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Topping up the tipplers
Do you crave a drink after a hard day? Be warned. You may soon be labelled an 'addict'. A broader definition of the word by America's psychiatry bible is likely to inflate the number of alcoholics worldwide by 60 per cent.
One year from now, the number of Indians addicted to alcohol will skyrocket from 44 million (4. 4 cr) to 70 million (7 cr). And this won't be because hordes of stressed-out citizens are hitting the bottle. This drastic jump in the figure will happen because a revised medical definition of 'addiction' is going to bring many more casual drinkers into its ambit.
Next May, the Diagnostic and Statistical Manual of Mental Disorders (DSM), which serves as the US arbiter of mental illness, will revise the definition of an addict. According to the new definition, an alcohol addict will be a person who "craves for alcohol", takes "large amounts" or consumes the substance over a "longer period than intended". The new definition is expected to inflate the number of alcohol addicts by about 60 per cent. Even though DSM, published by the American Psychiatric Association (APA), is considered the bible of psychiatry, mental health experts across the world are questioning the move to widen the list of symptoms for addiction to alcohol as well as internet, shopping, gambling and sex while cutting down the number of symptoms required for diagnosis.
Dr Allen Frances, who led the taskforce that drafted DSM-4 in 1994, told TOI-Crest that DSM-5 had "lost touch with common sense". Expressing the fear that the new definition would cause embarrassment to millions of people, Frances says, "It's almost always better to under-diagnose than to over-diagnose. Once a 'mislabel' is given, it takes on a life of its own - it is much easier to step up to a needed diagnosis than to step down from an inaccurate one. "
The doctor's protest has found many supporters: 13, 000 people, including psychiatrists from around the world, have written an open letter to APA demanding that no new diagnoses should be included in the definition of addiction without an independent external review. But the APA has said that DSM-5 is not yet final and the draft proposals by its task force are being evaluated by two independent groups: a scientific review committee, which will look at the supporting data for proposed changes, and a clinical and public health committee, which will assess the potential impact of changes on clinical practice and public health.
Back in India, the ground realities are different. The majority of alcohol addicts are never diagnosed or treated properly, leading to health and social problems. Even being officially declared an addict does not change things. For example, in the US, if someone is declared an addict by DSM standards, he is likely to get medical benefits and even legal clemency in some cases. But in India, insurance companies do not cover psychological illnesses, and mental patients are stigmatised. Many Indian psychiatrists say the government should work towards weaning people away from high-alcohol drinks. In India, 88 per cent of drinkers consume hard spirits compared to only 31 per cent in the US. Low-alcohol drinks, like beer and wine, are possible substitutes. "Anything beyond social drinking is complicated and can lead to a disorder. Even if there is a risk of overdiagnosis, early diagnosis can prevent a lot of problems in the long run, " says Dr TSS Rao, editor, Indian Psychiatric Journal.
According to Dr Samir Parikh, director of mental health and behavioural sciences, Fortis Healthcare, DSM is mainly for the reference of mental health professionals and even if some criteria are generic in nature, they will not necessarily lead to over-diagnosis. "A patient is not declared an addict by the mere presence of symptoms, " he says. "There must be functional impairments for the diagnosis of disorders. What's more important is that the idea is not to label someone as an addict but to let him know what's causing the problem and help with the treatment. " APA president Dr Dilip V Jeste told TOI-Crest, "There are many potential benefits in diagnosing mental disorders early, but there can also be drawbacks. I think what you are seeing is a public debate on these two viewpoints. The members of the DSM-5 workgroups are weighing the benefits and challenges to determine the appropriate threshold for each disorder to more accurately diagnose mental disorders at the early stages. " The DSM-5 task force says the new manual will help in early diagnosis of disorders, leading to a lowering of healthcare costs and a healthier society in the long run. "The broader language involving addiction is intended to promote more accurate diagnoses, earlier intervention and better outcomes. "
Critics demand that the process of drafting the manual should be more transparent. They say that the nearly 25, 000 comments that have been posted on DSM5. org should be made public. While APA has turned down this demand, it has accepted two major changes suggested in the draft by rejecting a proposal that might have turned the existential worries and sadness of everyday life into a mental disorder, and another to expose non-psychotic children to antipsychotic medication.
WHEN USE BECOMES ABUSE
Another subject in DSM 5 is being widely debated: forms of addiction that are not caused by the use of substance, but where there is a compulsion to repeatedly engage in a particular action like gambling, sex, shopping and internet gaming. While gambling is being added as an addiction for the first time, internet use disorder has been proposed for Section III, a section of DSM-5 in which conditions that require further research will be included. Critics say these are "vague" and "catchall categories" under which almost everyone can be declared an addict. "The false positive rates are too high and none of the suggestions has a proven treatment, " says Frances. But no one is denying that cases of such addictions are on the rise and that there is need for more research in these areas. Even though internet addiction cases in India are not as high as in high-speed broadband nations like South Korea and China, psychiatrists say they are increasingly dealing with patients who report such symptoms. A recent Stanford University study found that one in every seven computer users reported neglecting school, work, family, food, and sleep in order to remain online.
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