PMDD: A Women’s Only Mental Disorder?

When the fifth edition of the Psychiatric Association’s Diagnostic and Statistical Manual (DSM) was issued, there was a newly classified mental disorder tucked away in the voluminous 991 page book. It’s called premenstrual dysphoric disorder (PPMD) and, up until the book’s publication, it was known merely as a condition. Now, however, because of its reclassification as a mental disorder, the potential implications are far reaching.

What is PPMD?
PPMD is a serious form of premenstrual syndrome with profound and debilitating symptoms ranging from irritability and marked depression to social withdrawal, headaches, anxiety, and hypersomnia or insomnia. Often called ‘PMS on steroids’, PPMD affects roughly 3% to 9% of women. It’s a cyclical condition that occurs approximately two weeks before a woman’s period.

Why the Controversy?
Mental disorders in the United States have historically had stigma attached to them. Some believe that if PPMD is labelled as a mental disorder, women will be socially stigmatized in that regard. According to PhD author and psychologist, Paula Caplan “It is really appalling that using PMDD for women who want recognition for discomfort is a very clear message that goes something like: ‘OK, OK, we’ll believe you are feeling bad if we get to call you mentally ill for feeling bad.’ Can you imagine if we did that to men?” In an online article, posted at www.apa.org, Dr. Caplan explains “It’s a label that can be used by a sexist society that wants to believe that many women go crazy once a month.”

But, there could be legal consequences as well. According to Sarah Gehlert, who studies health disparities at Washington University in St. Louis, it could even come down to custody disputes. In an October 21, 2013 online article posted at NPR.org, Sarah said “Say a poor woman is in court, trying to see whether she could keep custody of her child. Her partner’s or spouse’s attorney might say, ‘Yes, your honor, but she has a mental disorder.’ And she might not get her kids.” Considering the fact that the DSM is the psychological disorder authority, Ms. Gehlert’s assessment may not be too far off base.

Is the DSM Just a Conspiracy for Marketing and Profit?
Maybe all of the fiery dialogue is just par for the course. In an online article for The New Yorker, Gary Greenberg writes “Every revision of the DSM causes controversy; that’s what happens when experts argue in public about the nature of human suffering.” If the rhetoric surrounding the classification of PMDD as a mental disorder is just reflective of a natural response to change, maybe the social implications are much ado about nothing, and they will pass just as they usually do when a new DSM is issued.

The problem is, according to Greenberg, that there is something more sinister at work. Namely, the potential connection to pharmaceutical companies, and how they stand to profit greatly from these changes. In the April 9, 2013 article, Greenberg, author of the book The Book of Woe: The DSM and the Unmaking of Psychiatry, argues that the revised DSM is going to lead to an increase in the eligibility for people to receive a psychiatric diagnosis which, in turn, leads to more drugs being prescribed.

His statement carries weight, too. The last major revision of the DSM was in 1994, and, partly as a result, antidepressant prescriptions jumped from 5.84% in 1996 to 10.12% in 2005. In fact, prescription medication use has increased overall, with the CDC reporting that in 2008, $234.1 billion was spent on all prescriptions across the board, which was more than double the figure from 1999.

To take the point further, it is estimated that approximately 70% of Americans are currently taking at least one prescription drug and, of that number, 13% are antidepressants. That is according to findings published in the online medical journal Mayo Clinic Proceedings. The prescription records for Olmstead County, Minnesota were evaluated, and published online June 21, 2013. They showed that a total of 68.1% of the Olmstead County population had been given one prescription, 51.6% were on two prescriptions, and 21.2% of the population had five or more prescriptions.

The male-female gender divide in Olmstead County mirrors that of the United States. In the United States, women represent 50.8% of the population, and in Olmstead County, 51.1% of the population is female (2012).

Overall, the report concludes that “women received more prescriptions than men for several drug groups, in particular for antidepressants.” The Mayo Clinic’s findings stand up to the information contained in the Center for Disease Control’s report, which reflects that between 2005 and 2008, 12.7% of the United States female population had been prescribed an antidepressant within the preceding 30 days. That’s compared to only 5.0% of the male population during the same timeframe. What does all of that mean for women and pharmaceutical companies? And, what does it have to do with PMDD?

Rebranding for Profit

Maybe everything, according to the article at NPR.org. In the article, the prescription drug, Sarafem, is used as an example. Identical to Prozac, Sarafem has been approved to treat PPMD since 2000. It’s marketed as a PPMD-specialty drug, but the only difference between Prozac and Sarafem is the cost. While generic Prozac only costs about 25 cents a pill, Sarafem costs about $10 a pill. Aside from the cost, the only other difference between the two pills is their color. Prozac is green and Sarafem is pink. Other than that, they are chemically identical.

The manufacturer of Serafem, Lilly Pharmaceuticals, lost its patent on Prozac in 2000, and market analysts recognize that Lilly engaged in a marketing ploy when it attempted to repackage Prozac as something more socially acceptable. It took $30 million in advertising to do it, but it worked. With Sarafem, pharmaceutical companies again found a way to take advantage of women and the DMS classifications.

What’s next for pharmaceutical companies now that PPMD is officially a mental disorder, and not just a condition? Based on their history of rebranding (Sarafem was just one example of many), and how women’s antidepressant prescriptions outnumber men’s by more than 2 to 1, as well as the fact that prescriptions surge when a new DMS revision is issued, it’s safe to assume that the pharmaceutical companies will likely seize the opportunity to rebrand other drugs. They’ll paint them pretty colors, inflate the price and market them as ‘new’. The problem? Regardless of how pretty they package it, for women who will now be facing the stigma of being classified with a mental disorder, it will be a hard pill to swallow.

The Digital Drug Trade: Shutting Down the Silk Road, Will More Follow?

Closed for Business, or Not?
Vice ecommerce are online marketplaces and much like the familiar Amazon and Ebay they exist to provide products to anxious customers. Unlike your typical ecommerce sites, however, these sites specialize in selling illegal products. Selling products ranging from drugs to counterfit documents and weapons, these illicit websites are the virtual equivalent of the real world black market.

The most prominent of these black market sites was The Silk Road, which launched in February 2011. In late September, 2013, however, after a two-and-a-half year investigation, The Silk Road was shut down by the FBI, and its alleged kingpin, William “Dread Pirate Roberts” Ulbricht was arrested.

Online Kingpin
The Silk Road was no small endeavor and was far from being a common street corner drug peddler. According to the FBI, total Bitcoin sales (‘anonymous’ virtual currency) for the Silk Road was $1.2 billion. Sales commission alone was $80 million. The FBI has so far seized about $33.6 million in Bitcoin assets belonging to Mr. Ulbricht, making it the biggest crypto-currency seizure ever.

The takedown by the FBI was no small endeavor either. It cost them well over two years’ worth of manpower and resources to get to this point, and the investigation isn’t even over yet. The prosecution of the case against Mr. Ulbricht is being handled by the DOJ’s Complex Fraud Unit with Assistant U.S. Attorney Serrin Turner leading the charge.

The FBI and the DOJ aren’t working alone though. Britain’s newly formed National Crime Agency, as well as other international organizations, is also participating in the global effort to end black market internet sales. In a statement related to the seizure of Bitcoins and the arrest of U.K. dealers, Keith Bristow, the agency’s general director, said “The latest arrests are just the start; there are many more to come.”

The Silk Road Continues
Even as the governmental agencies issue warnings and push forward to bring down all of the players involved with the Silk Road, as it turns out, they have merely scratched the surface of the black market internet underbelly. Just over a month after the shutdown of the Silk Road, the Silk Road 2.0 was already up and running. It was as if the Silk Road was merely closed for renovations while consumers lined up outside waiting for the big “Grand Reopening”. Just as they did with the original Silk Road, Reddit users simply picked up where they left off, openly posting information such as product and vendor reviews. For them, it was as if nothing ever happened.

Not only do the FBI and the DOJ now have the new Silk Road enterprise to deal with but, in the true spirit of capitalism and supply-and-demand economics, the Silk Road 2 (“Under New Management”), just like its predecessor, has its share of competition. The two biggest competitors to the Silk Road 2 are Black Market Reloaded and Sheep Marketplace.

Enter the Competition
Black Market Reloaded (BMR) is possibly the Silk Road’s biggest competition. It did have its own hiccup to contend with early on but, after being shut down for two days in early October (somebody published some of the source code), BMR was up and running again in no time. Black Market Reloaded changes its URL fairly often and, like all of the other major players, can only be accessed via .onion through Tor. On the BMR Reddit page, just like with the Silk Road, customers can post product reviews and advice on which vendors sell the best product, and who has the best customer service and shipping timeframes.

Sheep Marketplace, like Silk Road 2 and Black Market Reloaded, is accessible only via .onion, and only through the anonymizing network, Tor. Sheep Marketplace also sells a variety of illegal merchandise, but just like the other black market internet ventures, the bulk of its trade is through illicit drug sales. Reddit users also post vendor and product reviews and consumer advice.

There are even sites on the ‘regular’ internet that provide step-by-step instructions on how to safely and anonymously access Silk Road 2.0, Sheep Marketplace and Black Market Reloaded, and they’ll even tell you where to find the URL. It seems that, with the reviews being openly posted on Reddit and the other mainstream sites offering information on how to tap into the black market sites, no one is taking the actions of the FBI and the DOJ seriously.

It’s possible that these buyers have a ‘catch me if you can’ attitude because they feel a certain level of invincibility since their identities are supposed to be protected through Tor. Unfortunately, that’s what Mr. Ulbricht may have thought. Of course, as it states at the bottom of the FBI’s Ulbricht-related press release, “the defendant is presumed innocent unless and until proven guilty.” As such, the ending to Mr. Ulbricht’s story has yet to be written.

Regardless of the flourishing virtual black market and the indifferent attitude of its consumers, it really is a “buyer beware” industry. In a Forbes.com interview discussing the arrest of the alleged Silk Road mastermind, William Ulbricht, an anonymous FBI spokesman said “This is supposed to be some invisible black market bazaar. We made it visible. When you interviewed [Ulbricht], he said he would never be arrested. But no one is beyond the reach of the FBI. We will find you.”

Shameless Social Security Disability Scams

In Utah a video was discovered that depicted a 40-year old man rocking out to music while playing an air guitar. Another video showed a 31-year old woman playing the drums at one of her band’s concerts. These videos would be amusing or entertaining if they were not evidence of social security disability fraud. The 40-year old man had been collecting thousands of dollars in disability payments claiming that his sore muscles would not allow him to work or leave his house. The 31-year drummer had been collecting social security disability checks for 4 years based on suffering from a mental impairment that resulted in “low energy.” Fraudulent social security disability scams are not new. The media regularly reports videos and other evidence of purportedly disabled people engaged in vigorous activities that would be difficult if not impossible if the worker was truly injured or in some other way incapable of earning an income. However, a recent scam that was uncovered by the federal government is particularly shocking as it involved an attorney and a judge.

Conn and Daugherty
Attorney runs a private law practice in Stanville, Kentucky that focuses on helping clients secure Social Security Disability Insurance (SSDI) benefits. According to a report issued by the Senate Homeland Security and Governmental Affairs Committee, the Social Security Administration (SSA) paid Conn over $4.5 million in attorney’s fees from 2006 to 2010. This made Conn the 3rd highest paid disability lawyer in the country. All of these fees were from cases heard by Judge David B. Daugherty, a SSA administrative judge. Of the 1375 cases brought before Daugherty by Conn only 4 were denied, giving Conn 99.7% approval rate. A South Carolina disability attorney notes that this is astounding considering that on average the social security disability approval percentage of cases reviewed by administrative judges is only 62%.

The Conn-Daugherty scheme was brought to the attention of officials by whistle-blowers. The ensuing investigating uncovered the use of physicians with suspended licenses, $96,000 in unexplained deposits to Daugherty’s bank accounts, the use of disposable cell phones, shredding of tons of documents, and the destruction of computer hard drives. Daugherty has since retired and Conn is being investigated by the Department of Justice.

Rampant Social Security Fraud
While the facts and figures associated with the Conn-Daugherty scam are surprising, this scam is only a small part of the overall problem of fraud involved in SSDI benefits. SSDI fraud takes several different forms including making false statements on an SSDI application, using falsified documents such as an altered social security card, or concealing information, such as failing to report an improvement in a medical condition or failing to report the death of a recipient. A report recently released by the Senate Permanent Subcommittee on Investigations discovered that fraud is so rampant that the Social Security Disability Trust Fund could run out of funds in 18 months. In recent years the number of people receiving SSDI benefits has skyrocketed from 6 million in 2002, to 9.4 million in 2010 and as of August, 2013, 13 million. SSA officials attribute the increase to the aging population. However, a simple gleaning of records show sloppy work in the review and processing of applications and a clear effort to quickly work through the backlog of cases. As a result it has become relatively easy to get away with fraud. For example, the SSA is supposed to conduct Continuing Disability Reviews (CDRs) to determine the status of claimants. Due to lack of sufficient staff CDRs are not routinely completed. Because of this scams such as the one perpetrated by an Oregon woman who collected her father’s SSDI checks for 26 years after he died, are widespread and often go undetected.

How to Stop the Fraud
The Social Security’s Office of the Inspector General set up a hotline for people to phone in tips on SSDI fraud. A report can be anonymous, but the SSA encourages people to disclose their names as it makes it easier to investigate the possible fraud. For the 5 month period from October 1, 2011 through March 30, 2012, the OIG received 63,368 allegations of fraud. Based on these allegations the SSA opened 3,969 cases that resulted in 703 criminal convictions.

While the hotline, CDRs, and other procedures that the SSA has in place are necessary, they are clearly not the complete answer to the problem. The SSA has an annual budget of over $12 billion with a deficit of $47 billion at the end of 2012. Clearly more emphasis needs to be focused on ridding the system of fraudulent claimants. Do you think new procedures need to be implemented? Or should more of an effort be made to make current systems, such as the CDRs, effective?