Is it time for a new approach to mental health diagnoses?

[Greg Bernhardt]

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)—slated for release this month—has lost a major customer before even going to print. Thomas Insel, director of the National Institute of Mental Health (NIMH), declared last week on his blog that the institution will no longer use the manual to guide its research. Instead, NIMH is working on a long-term plan to develop new diagnostic criteria and treatments based on genetic, physiologic, and cognitive data rather than symptoms alone.

http://news.sciencemag.org/scienceinsider/2013/05/nimh-wont-follow-psychiatry-bibl.html

Do you think neuroscience has advanced beyond this "Bible"?

 

[Evo]

I always considered the DSM to be primarily a diagnostic tool.

And apparently it isn't the official diagnostic tool for the US.

The International Statistical Classification of Diseases and Related Health Problems (ICD), produced by the World Health Organization (WHO), is another commonly used manual which includes criteria for mental disorders. This is in fact the official diagnostic system for mental disorders in the US, but is used more widely in Europe and other parts of the world

http://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disorders

See http://en.wikipedia.org/wiki/Intern...ated_Health_Problems#Usage_and_current_topics

 

[DiracPool]

http://news.sciencemag.org/scienceinsider/2013/05/nimh-wont-follow-psychiatry-bibl.html

Do you think neuroscience has advanced beyond this "Bible"?

That sure would be nice. The problem is what to do in the meantime...

Instead, NIMH is working on a long-term plan to develop new diagnostic criteria and treatments based on genetic, physiologic, and cognitive data rather than symptoms alone.

How long is this this going to take?

 

[edward]

The NIMH appears to have a well defined goal aimed at research.

Over the past several decades, an increasingly comprehensive body of research in genetics, neuroscience, and behavioral science has transformed our understanding of how the brain produces adaptive behavior, and the ways in which normal functioning becomes disrupted in various forms of mental disorders. In order to speed the translation of this new knowledge to clinical issues, the NIMH included in its new strategic plan Strategy 1.4: “Develop, for research purposes, new ways of classifying mental disorders based on dimensions of observable behavior and neurobiological measures.” (For the full text, see http://www.nimh.nih.gov/about/strategic-planning-reports/index.shtml#strategic-objective1). The implementation of this strategy has been named the Research Domain Criteria Project (RDoC). The purpose of this document is to describe the RDoC project in order to acquaint the field with its nature and direction, and to facilitate commentary from scientists and other interested stakeholders regarding both general and specific aspects of the RDoC approach.

Currently, diagnosis in mental disorders is based on clinical observation and patients’ phenomenological symptom reports. This system, implemented with the innovative Diagnostic and Statistical Manual-III (DSM-III) in 1980 and refined in the current DSM-IV-TR (Text Revision), has served well to improve diagnostic reliability in both clinical practice and research. The diagnostic categories represented in the DSM-IV and the International Classification of Diseases-10 (ICD-10, containing virtually identical disorder codes) remain the contemporary consensus standard for how mental disorders are diagnosed and treated, and are formally implemented in insurance billing, FDA requirements for drug trials, and many other institutional usages. By default, current diagnoses have also become the predominant standard for reviewing and awarding research grants

bold mine

http://www.nimh.nih.gov/research-priorities/rdoc/nimh-research-domain-criteria-rdoc.shtml

I can only assume that the NIMH wants more emphasis put into research in neuroscience and less research on drugs that just treat psychiatric symptoms.

The diagnostic codes in the DSM are almost endless with many individuals fitting into numerous codes.

http://en.wikipedia.org/wiki/Diagnostic_and_Statistical_Manual_of_Mental_Disorders

 

[Evo]

I don't think NIHM will have much bearing on the ICD or even the DSM. What they decide to use for research grants is neither here nor there as far as the diagnosing of patients that is accepted in the medical and insurance fields. I think they should distance themselves.

 

[dimensionless]

...the institution will no longer use the manual to guide its research.

Do you think neuroscience has advanced beyond this "Bible"?

Research normally delves into subjects more deeply than textbooks. And, for that matter, the textbooks themselves are based on the research. I would answer yes. Neuroscience, along with other subjects, are and always have been ahead of the DSM.

 

[Tzikin]

Nope, I do not get it. Any approach to mental health has to be based on the mental health context and symptoms. The subject is far too complex for the linear approach of science and requires its integration alongside the subjective evidence of human perception.
A good example of this is that schizophrenia is barely distinguishable in its inheritance and chemistry to creative genius.

 

[jc156392]

Psychiatry has a long way to come, but it is still not as a stage where conditions can be categorised based on objective tests rather than the interpretation of symptoms. I applaud the NIMH for taking this step, hopefully it will stimulate more research in this field. We are becoming more aware that mental illnesses do not fall into discrete categories but lie somewhere on a spectrum. There was a good article on the topic in Nature recently (http://www.nature.com/news/mental-health-on-the-spectrum-1.12842).

The history of the DSM is fascinating. In 1952, it was 130 pages long and listed 106 mental disorders. In 1994, it was 886 pages long and listed 297 disorders. I think a lot of doctors tend to use it as a guide rather than a rigid diagnostic instrument. In Australia we use the ICD-10.

 

[sgrondahl]

We discussed the DSM-V in abnormal psychology this year. The discussion revolved around the 180 degree changes in the DSM-V regarding aberrant behaviors (among other things), and the fact that many therapists see a disconnect in the diagnoses in V verses previous serial versions of the DSM.

I have no idea whether it is right or wrong, just an observation of mine that it was a lively debate! Ciao.

 

[Monique]

Already in 2010 the NIMH announced that psychotic disorders should be classified differently (Toward New Approaches to Psychotic Disorders: The NIMH Research Domain Criteria Project). In fact, that was also the goal of the DSM-5: to not classify disorders based on distinct classifications (Kraepelin approach), but to use a continuum. This however met with a lot of criticism from clinicians who were skeptical that such an approach could be implemented as a diagnostic tool in the clinic.

Clearly research is headed in the direction of characterizing the continuum (example: Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis). Neuroscience is definitely advancing beyond the bible, but changing the mindset of doctors who have used it as a diagnostic tool will take a large effort.

 

[jc156392]

It would be a complete paradigm change. There's a lot of clinical other than doctors who work in mental health. A change to diagnoses on a continuum would require a long transition period and considerable costs in implementation. Nevertheless, given the evidence for this model, it seems to be the right path to take.