The APA Annual Meeting: A Brief Review

As posted previously, last month I attended the American Psychiatric Association’s (APA’s) annual conference. I thought I’d offer a brief review of the meeting here. This year the meeting took place in Moscone Center, a conference center complex located just south of Market Street in downtown San Francisco. As in prior years, anti-psychiatry protesters held a peaceful rally in front of the main entrance. There was also an exhibit of psychiatry’s cruelties (psychosurgery, shock treatment, inhumane conditions in asylums, etc) running all five days in a tent across the street from the conference. A few of us ventured into the tent, the great majority did not. I imagine many meeting attendees felt as I did about the political criticism: That all medical, surgical, and psychiatric treatments look crude in retrospect, and that we don't personally identify with current parts of the field that we find distasteful or wrongheaded. That's how I feel, anyway.

The conference was also a block from Yerba Buena Gardens, where I caught a very pleasant Balinese gamelan concert at the same time as the protest rally on the first day. This simultaneity — two events scheduled to coincide, forcing a choice — was a constant in the conference as well. The “scientific program” consisted of numerous overlapping talks, such that attending any presentation meant missing five or more other good ones. I’m not sure why the APA opted for such frustrating redundancy. Nor can I explain why predictably popular talks were scheduled into small rooms, with the result that dozens of registrants were turned away once the room filled. For instance, the crowd for Otto Kernberg’s psychoanalytic talk on love and aggression was several times larger than the assigned room. In this unusual case we were all moved to a cavernous hall at the last moment, where Dr. Kernberg gave a warm and very engaging presentation on the necessity and creative consequences of aggression in romantic love. I liked how the renowned psychoanalyst Kernberg, standing at the podium on a huge stage, momentarily seemed to represent the APA in an era of biological ascendancy.

The same huge auditorium was to hold the keynote address by Bill Clinton. However, Mr. Clinton was ill and could not be there in person. Several hundred (a couple thousand?) conference-goers nonetheless waited over an hour to see him on video. Mr. Clinton was pleasant, thoughtful, and charismatic, but didn’t offer much specifically about psychiatry or mental health. Mostly he spoke about public health needs in general.

The quality of the presentations was high — I mostly chose “mainstream” ones this time, not the many off-beat and generally smaller meetings. I attended presentations on suicide, personality disorders, PTSD, sexual compulsions, DSM-5 and mood disorders, the controversy over antidepressant efficacy, psychiatrists writing and blogging for the general public, teaching psychotherapy to residents, and assessing the capacity of demented patients to make medical decisions for themselves. There were dozens of others I would have liked to attend, had they not coincided with the ones I chose.

I skipped the industry-sponsored, non-CME presentations that lured attendees with a free lunch or dinner. But I did wander through the exhibit hall, both to see the “new investigator” scientific posters, and to peruse the brand-new DSM-5. In contrast to the last time I went to this conference several years ago, the industry sales booths seemed less garish and “over the top.” Of course, there were still a lot of them. Several had raffles where valuable prizes such as an iPad Mini could be won by those who gave the company their contact information. One booth offered a pocket digest of the new DSM-5, MSRP about $60, to everyone who watched a 12 minute presentation and coughed up a mailing address. I was tempted… but no. (It’s interesting to ponder how much a single psychiatrist contact is worth to a drug company. Much more than $60, I’d venture.)

The DSM-5 itself is $200 in hardcover, $150 in paperback — an unabashed moneymaker for the APA. Despite the incredible controversy it stirred up, my impression is that the changes from DSM-IV-TR are relatively minor. In particular, the personality disorder section hasn’t changed much, although the new edition is no longer multi-axial, i.e., there is no “Axis 2″. Some language has been made more precise, as well as more “biological” in some passages, and some disorders have been expanded to include more that would previously have been considered normal. Whether this is good or bad depends on one’s perspective in several respects; mostly I find it unfortunate. DSM classifications often matter more to insurers and disability officers than to practicing psychiatrists, who in David Brooks’ words are “heroes of uncertainty” (echoing an earlier post of mine, but I’ll forgive him for not quoting me). We deal with individuals, not disease categories. The wisdom of embracing uncertainty was also highlighted by Dr. Allen Frances recently.

I will end by quoting part of the talk on antidepressant efficacy that summarizes this tension in my field. As I’ve discussed previously, randomized controlled trials (RCTs) are considered the gold standard for scientific rigor in psychiatry; however, a lot of psychiatry is not scientific in this sense. DSM categories help define the “average” patient with a particular disorder, leaving a lot of wiggle room since the categories are not based on etiology. RCTs say which treatments best help this “average” patient. However, as stated in the presentation at the APA meeting:

Evidence Based Medicine has become synonymous with RCTs even though such trials invariably fail to tell the physician what he or she wants to know which is which drug is best for Mr Jones or Ms Smith — not what happens to a non-existent average person.

Thus, for me, the new DSM was a sideshow at the conference. The most insightful presentations, whether on PTSD, suicide, or capacity assessment, combined science and the nuanced human communication of meaning. They recognized that our work is informed by science but goes well beyond it. Anti-psychiatrists don’t like this, insurers don’t like this, neuroscientists don’t like this, even many psychiatrists don’t like this. But it’s true and inevitable for the foreseeable future. I like it. As for the APA annual meeting, I’m glad I went, and equally glad I won’t feel the need to go back for several years at least.

© 2013 Steven Reidbord MD. All rights reserved.