For a long time now there has been a debate about what the release of the American Psychiatric Association's new Diagnostic and Statistical Manual -- the DSM-5 -- will do to the field of mental health care. This debate has spread to all quarters -- psychiatrists, psychologists, primary care physicians, parents, advocates, self-advocates. The list goes on. Because of new diagnoses and changes in criteria, there is real anxiety: Will normal behavior be pathologized? Will psychiatric diagnoses be doled out to those who don't need them? Will diagnosis be denied to those who do?
No one, however, questioned a central assumption: DSM-5 would be used far and wide. That is, until now. Last week, in a blog post that has generated much interest and handwringing, National Institute of Mental Health (NIMH) director Dr. Thomas R. Insel announced that his organization would effectively ignore the DSM-5 when funding mental health research going forward.
Many think this is a huge development. The announcement was described in some blogs as the NIMH "abandoning" the DSM, and as "a potentially seismic move." Let's take a look.
Essentially, Dr. Insel said the DSM has created a coherent landscape of psychiatric diagnosis, but that its categories of disorders do not stem from any measurable causes or underlying biological conditions in the brain. His words:
The strength of each of the editions of DSM has been "reliability" -- each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.
It is no secret that the DSM is a clinical tool more than a scientific one, designed to compensate for the often unknown "etiology" or cause of psychiatric illness. This has been true since we began perceiving mental illnesses as real diseases of the brain. Lacking objective diagnostic tests -- for now -- the manual creates a set of clinical categories so that doctors are on the same page, and so that research into treatments could be effectively compared.
Dr. Insel's "abandonment" of the DSM is in fact a symptom of his optimism that we are now or will soon be able to discover the "real," biological causes of mental illness. The DSM is inconsistent with this science. "We cannot succeed if we use DSM categories," he writes. "The diagnostic system has to be based on the emerging research data, not on the current symptom-based categories."
In summary: For what we need to do in mental health research -- for what it is becoming clear we can do -- the DSM approach is not appropriate. Even if it is still the best way to diagnose disorders and deliver treatment and knit the mental health care system together, it must begin to be supplanted by a new science-based framework.
Dr. Insel has a framework in mind, and the NIMH will move toward funding research based on a new paradigm called Research Domain Criteria, or RDoC, first mentioned online by NIMH two years ago. "RDoC is a framework for collecting the data needed for a new nosology," or classification scheme, Insel writes. "That is why NIMH will be re-orienting its research away from DSM categories. Going forward, we will be supporting research projects that look across current categories -- or sub-divide current categories -- to begin to develop a better system."
After the somewhat alarmist response to his online posting, Dr. Insel spoke to the New York Times to clarify his views. The DSM is still of vital importance to mental health clinicians, he said. However, "biology never read that book." To put this another way: RDoC aims to represent what the brain really has to say about its own dysfunctions and what causes them. The goal is to listen to the brain with the tools of emerging science and to let it dictate new categories and associations that will lead to the new and better diagnostic tools and treatments. This is heady stuff, but it's also possible, which is why we should greet the development of RDoC and Dr. Insel's announcement with enthusiasm, not fear.
What does this mean for the family in the doctor's office this weekend? What we are seeing is shift toward two different approaches in psychiatry, one focused on clinical effectiveness, another on the needs of scientific inquiry. As Dr. Nassir Ghaemi writes in Medscape Psychiatry, the NIMH has decided "that we need two sets of diagnostic criteria: one for practice (DSM-5) and one for research (RDoC). The one for practice can be based on 'pragmatic' decisions about diagnostic criteria; the one for research should be 'real.'"
Dr. Insel concludes his posting on a optimistic, even ambitious note: "RDoC is nothing less than a plan to transform clinical practice by bringing a new generation of research to inform how we diagnose and treat mental disorders."
But whatever the promise of biological psychiatry is -- and I believe it is immense, and have dedicated the Child Mind Institute to exploring the brain with all the available tools -- its transformative effect on clinical practice is years distant. Only time will tell how these two systems will eventually work together. But it is heartening that the field is proactively preparing for this future.
Harold S. Koplewicz, MD, is a leading child and adolescent psychiatrist and the president of the Child Mind Institute, whose website, childmind.org, offers information on childhood psychiatric and learning disorders.
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