The American Psychiatric Association is set to release the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) this month. These new guidelines will have a profound effect on how clinicians diagnose mental disorders, how health insurers reimburse for treatment, how drug makers market their products, and how the government determines benefits for public programs. It is no understatement that the DSM-5 will once again reshape the social and clinical understanding of mental disorders. (If you want a summary of big changes in this DSM-V this short article in JAMA is great).
In a new article in Health Affairs, a group of sociologists and epidemiologists make a strong argument for adding an independent oversight panel to the DSM process. The panel would monitor social and environmental factors that shape diagnosis and treatment of mental disorders, and make recommendations for tweaking diagnostic guidelines or for initiating future research on the determinants of mental illness.
These recommendations are offered as a counterweight to some troubling trends. Diagnosis rates for some mental disorders have been soaring since the last revision of the DSM in 2001 – and the prevalence of these disorders has been unequal across social groups in the United States. I recently discussed the growth of ADHD diagnosis as an important example, where I argued that fundamental issues of causation and even prevalence are still unknown. It is known, however, that the risk of diagnosis is very different in the United States than in the United Kingdom, where the diagnostic criteria are generally more stringent. Diagnostic expansion is an important way in which the labeled and treated population grows over time.
Social context also matters. The DSM is fundamentally concerned with the neurobiological bases of mental disorders, and the authors of the DSM are mainly academic clinicians. Independent of biology, there are a multitude of factors that receive much less emphasis in the classification of mental disorders: cultural understandings of mental illness, changing social exposures (such as experience with combat that could lead to a proliferation of post-traumatic stress disorder), and the influence of major corporate interests, including the pharmaceutical industry. Anybody who watches television in the direct-to-consumer era realizes what a big business treating clinical depression has become for drug makers.
To what extent is the DSM to blame for these problems? And is there a better alternative to the current framework?
Problems: Diagnosis or treatment?
There are good reasons to worry about the influence of the DSM. After the release of DSM-IV, drug makers created checklists of the new ADHD symptoms for elementary school teachers, which encouraged them to identify children with the disorder. Teachers are the main pathway into a doctor’s office, but they are not particularly good judges of ADHD symptoms (nor probably other behavioral disorders).
On the other hand, it’s not clear that the changing guidelines are to blame, so much as how the guidelines are applied by clinicians. Primary care physicians, rather than psychiatrists and psychologists, are now on the frontlines of mental health treatment in the United States. While most primary care doctors have a general familiarity with the symptoms of common mental disorders such as unipolar depression, ADHD, and anxiety, they do not have the resources or time to fully and effectively evaluate mental disorders. Again, sticking with the example of ADHD, the DSM-IV advises that children must be assessed across multiple domains (such as school, home, etc.). A thorough ADHD evaluation should include observation-based work, paired with validated rating scales given to parents, teachers, and older children. These are simply not tasks that pediatricians are set-up to administer, and so the default method of diagnosis is often a short interview with a symptom checklist.
These are problems rooted in limited clinical capacity, so we need to ask how much a more socially contextualized perspective on mental illness would be able to help.
What’s the role of an oversight panel?
Granting that diagnostic guidelines do contribute in some way (and it may be more indirect, but no less important), what could an oversight panel accomplish?
In addition to suggesting new directions for research, of the most ambitious roles such an oversight panel could fulfill would be in recommending revisions to the DSM – which the taskforce would be required to consider – based on the appearance of over- or under-diagnosis of disorders within subgroups in the population.
They would also mediate controversies about the cross-cultural issues in psychiatry: “By attending to the impact of social environments on biology in ways that can cause local variations in the incidence of mental disorders, the review body would help develop diagnostic criteria that would be useful internationally and cross-culturally.”
My impression is that the mental health treatment community is looking to embrace alternatives to a purely neurobiological model of mental disorders. Even the DSM-IV made some progress in that arena. But they are likely to resist the incursion of “outsiders” such as epidemiologists that would like to rein in the development of new diagnoses based on the social and cultural ramifications of those diagnoses.
This debate is going to rage on for some time, because at its core it asks the question whether the classification of mental disorders should try to accommodate all the “messiness” of how clinicians actually practice in diverse, multicultural settings under considerable pressures from special interests. Getting the theory of diagnosis to align with the practice of diagnosing is the next frontier of psychiatry.