Most people who walk into a psychiatrist’s office have never heard of the Diagnostic and Statistical Manual of Mental Disorders (DSM), and yet it is one of the most important and widely used texts in all of medicine. According to the National Institute of Mental Health, more than 50 million adults in the United States have a diagnosable mental disorder in a given year. All psychiatric disorders recognized by the U.S. healthcare system – from ADHD and Alzheimer’s, to Substance Use and Schizophrenia – are included in the DSM, and without the manual, proper detection and treatment of mental illnesses simply could not occur.
The DSM provides a listing of the symptoms and diagnostic criteria that psychiatrists and other mental health and healthcare professionals use to determine whether someone has a psychiatric disorder. It also includes descriptive information to help clinicians arrive at the correct diagnosis, such as text that clarifies how to differentiate a particular disorder from other similar disorders. Furthermore, the manual provides important statistics about mental disorders, such as how common a disorder is and how often it occurs among males and females. While clinicians make up the majority of DSM users, it is an important tool for other professionals, such as researchers, who conduct studies about the occurrence and treatment of psychiatric disorders, health insurance workers, who use DSM to decide whether a treatment is “medically necessary” and reimbursable, as well as U.S. lawmakers and government executives, who refer to DSM in determining insurance coverage in the public healthcare system.
The first edition of the manual, DSM-I, was published in 1952. Since that time, four editions have been produced, with the most current version, DSM-IV, released in 1994. The American Psychiatric Association (APA) is in charge of overseeing the revision and publication of DSM. Why are revisions needed? Simply put, to ensure that patient care keeps pace with science. As advances in research create a clearer picture of factors such as how mental disorders develop; why certain disorders, like depression and anxiety, tend to occur together; and the symptoms that patients experience, we need to refine the diagnostic criteria to make sure that patients are diagnosed correctly. The use of this manual also helps assure that patients receive the appropriate and most effective treatments.
The process to develop the next edition of DSM – DSM-5 – has been underway for nearly 10 years. Experts hope that potential changes in DSM-5 will bring about improvements in patient care. For instance, we know from research and from working with patients that certain symptoms are very common in most individuals with psychiatric disorders. These symptoms include depressed mood, anxiety, sleep problems, changes in thinking or memory, and several others. However, busy clinicians do not always ask patients about these common problem areas – which means some patients do not always receive the treatment they need. One of the proposed changes for DSM-5 is to include questionnaires that clinicians will use to more thoroughly review these common symptoms. This is similar to the “review of systems” your physician uses when he or she is assessing your general medical health. Given that nearly half of all people who have one mental disorder also meet criteria for two or more mental disorders, DSM-5’s “mental review of systems” approach will hopefully aid clinicians in determining whether a patient is experiencing symptoms that need treatment, in addition to identifying any number of psychiatric diagnoses that he or she might also have.
Other proposed changes to DSM-5 are more specific to actual diagnoses, such as changing the wording of diagnostic criteria to more accurately describe patients’ symptoms. These also include proposing new psychiatric disorders that are not currently a part of DSM-IV, as well as suggesting that some disorders be included in existing disorders or are removed from the manual altogether.
The process for determining whether a change should occur is lengthy and complex but is designed to produce revisions that are based on science and intended for the betterment of patients. There are 13 DSM-5 Work Groups, each representing expertise in a specific area of psychiatry, such as mood disorders, anxiety disorders, eating disorders, etc. Since the groups were officially appointed in 2007, they have been reviewing published research studies, examining data from previous studies, and conferencing with colleagues and with each other to draft their proposed revisions for each disorder. No decision will be made without careful and thoughtful consideration of the evidence, and whether a given change is truly necessary. In every case, the impact on patient care will be of utmost importance.
As work group members are completing their draft criteria, DSM-5 developers are now preparing to enter the next major stage of the revision process: field testing. Proposals that involve significant changes (e.g., new disorders) will be tested in a series of small studies that allow DSM-5 developers to “evaluate” the potential impact of new criteria in real-world settings. This includes academic institutions and large hospitals, as well as private practitioners and smaller clinical offices. The field trials will allow the work group members to determine whether their proposals are helpful for patients, useful to clinicians, and can be reliably used by different healthcare professionals across different systems of care. After these field trials are complete, work group members will make additional modification to proposed revisions, and there may be a second round of field tests to further evaluate proposed changes. The APA will begin drafting the text for DSM-5 within the next two years, and the final version of DSM-5 will be published and released at the APA’s Annual Meeting in San Francisco, Ca., in May 2013.
As part of DSM-5 development, in February of 2010, the APA developed a web site (www.dsm5.org) where all of the diagnostic criteria and proposed changes for DSM-5 are listed. A two-month period of public comment followed, with work groups using the online feedback as part of subsequent deliberations on potential changes to criteria. Although no longer open to submissions from the public, I would encourage you to visit the site to learn more about how this process is proceeding. The public will have another opportunity to provide commentary through DSM-5.org in the summer of 2011, after initial field tests are complete and further revisions to the draft criteria are posted online.
Proper diagnosis and treatment are vital to reducing the burden caused by psychiatric diagnoses. The impact of mental illness can be felt in nearly every aspect of society, from healthcare and legislation, to education and the economy. Continued revisions and improvements to the DSM are critical to assuring that those suffering from psychiatric disorders receive the most scientifically based and clinically beneficial treatment possible.
Carol A. Bernstein, M.D., is President of the American Psychiatric Association and is an associate professor of psychiatry, Vice Chair for Education, and Associate Dean for Graduate Medical Education at New York University School of Medicine, a part of NYU Langone Medical Center.