You may have already heard our big news in psychiatry: The first major revision of the Diagnostic and Statistical Manual (DSM) since the mid-1990s has just been approved by American Psychiatric Association's Board of Trustees. And the new DSM-5 will be published in May. Getting to the finish line has taken a decade of arduous work and tens of thousands of pro-bono hours from more than 1,500 experts in psychiatry, psychology, social work, psychiatric nursing, pediatrics, neurology, and other related fields from 39 countries.
The goal of the DSM-5 process has been to develop a scientifically based manual of psychiatric diagnosis that is useful for clinicians and our patients. APA's interest in developing DSM dates back to the organization's inception in 1844, when one of its original missions was to gather statistics on the prevalence of mental illness. In 1917, the association officially adopted the first system for uniform statistical reporting, called the "Statistical Manual for the Use of Hospitals for Mental Diseases," which was adopted successfully by mental hospitals throughout the country. It was expanded into the first Diagnostic and Statistical Manual (DSM) in 1952 and first revised (DSM-II) in 1968. Like the rest of the field in that era, these first two versions were substantially influenced by psychoanalytic theories.
With advances in clinical and scientific knowledge, changes in diagnostic systems are inevitable. The World Health Organization's International Classification of Diseases (ICD) -- the standard diagnostic tool for epidemiology, health management, and clinical care used around the world, which covers all medical diagnoses -- has been through 10 editions since the late 1800s and is now preparing its 11th edition, due in 2015. Likewise, DSM has undergone changes to take into account progress in our understanding of mental illnesses. DSM-III, published in 1980 under the leadership of Dr. Robert Spitzer, and DSM-IV, published in 1994 under the leadership of Dr. Allen Frances, represented the state of science of psychiatry at those times and significantly advanced the field.
In the two decades since the publication of DSM-IV, we have witnessed a wealth of new studies on epidemiology, neurobiology, psychopathology, and treatment of various mental illnesses. So, it was time for APA to consider making necessary modifications in the diagnostic categories and criteria based on new scientific evidence. But there were, of course, challenges inherent in revising an established diagnostic system.
The primary criterion for any diagnostic revisions should be strictly scientific evidence. However, there are sometimes differences of opinion among scientific experts. At present, most psychiatric disorders lack validated diagnostic biomarkers, and although considerable advances are being made in the arena of neurobiology, psychiatric diagnoses are still mostly based on clinician assessment.
Also, there are unintended consequences of psychiatric diagnosis. Some arise from the unfortunate social stigma and discrimination in getting jobs or even obtaining health insurance (notwithstanding the mental health parity law) associated with a psychiatric illness. There is also the double-edged sword of underdiagnosis and overdiagnosis. Narrowing diagnostic criteria may be blamed for excluding some patients from insurance coverage and needed services, while expanded efforts to diagnose (and treat) patients in the early stages of illness to prevent its chronicity are sometimes criticized for increasing its prevalence and potentially expanding the market for the pharmaceutical industry. (It should be noted, however, that DSM is not a treatment manual and that diagnosis does not equate to a need for pharmacotherapy.)
APA has carefully sought to balance the benefits of the latest scientific evidence with the risks of changing diagnostic categories and criteria. We realize that, given conflicting views among different stakeholders, there will be inevitable disagreements about some of the proposals -- whether they involve retaining the traditional DSM-IV criteria or modifying them.
The process of developing DSM-5 began in earnest in 2006, when APA appointed Dr. David Kupfer as chair and Dr. Darrel Regier as vice-chair of the task force to oversee the development of DSM-5. The task force included the chairs of 13 diagnostic work groups, who scrutinized the research and literature base, analyzed the findings of field trials, reviewed public comments, and wrote the content for specific disorder categories within DSM-5. To ensure transparency and reduce industry-related conflicts of interest, APA instituted a strict policy that all task force and work group members had to make open disclosures and restrict their income from industry. In fact, an examination of the latest information shows that the vast majority of the task force and work group members have no financial relationship with industry.
To obtain independent reviews of the work groups' diagnostic proposals, the APA Board of Trustees appointed several review committees. These reviews were used to revise the proposals, as necessary.
There has been much more public interest and media scrutiny of DSM-5 than any previous revisions. This reflects greater public awareness and media interest in mental illness, as well as widespread use of the Internet and social media. To facilitate this transparent process, APA created a website where preliminary draft revisions were available for the public to examine, critique, and comment on. More than 13,000 website comments and 12,000 additional comments from emails, letters, and other forms of communication were received. Members of the DSM-5 work groups reviewed the feedback submitted to the APA and, where appropriate, made modifications in their proposed diagnostic criteria. Finally, the Board of Trustees considered all the reviews and the public comments in making its decisions on various diagnostic proposals.
We believe that DSM-5 reflects our best scientific understanding of psychiatric disorders and will optimally serve clinical and public health needs. Our hope is that the DSM-5 will lead to more accurate diagnoses, better access to mental health services, and improved patient outcomes.
For more by Dilip V. Jeste, M.D., click here.
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