DSM-5 a Year Later: Clinicians Speak Up

DSM-5 Turns 1
On May 18, 2014, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) turned 1. Clinicians have now had over a year to familiarize themselves with the new manual and decide whether to incorporate it into their practice. To get a sense of how DSM-5 has been embraced by the medical community, Medscape surveyed its members — including both psychiatrists and other clinicians involved in mental health diagnosis and care — on the major and more controversial diagnostic revisions, as well as on their overall satisfaction with the update, and invited them to provide comments.

A Look at Usage
In all, over 6000 clinicians began our survey. However, because the questions pertained to use and experience with DSM-5, the 55% of those responding that they have not incorporated it into practice could not complete the survey and were queried on their reasons for not adopting the manual.

Reasons for Not Adopting the Manual
Despite starting the survey, implying interest in DSM-5, 21% of the 3454 noncompleters cited a lack of relevance to their practice and dropped out. The most common reasons for not adopting the manual, despite its relevance to the respondent's practice, were lack of familiarity with the update (22%; many haven't had time to review the revisions or didn't know the update had been released) and that it isn't necessary for billing (21%), as often the International Classification of Diseases (ICD) is sufficient. This appears especially true among non–mental health specialists such as family practitioners, who tend to see psychiatric conditions for which the DSM criteria have not changed considerably. Five percent of clinicians who've opted not to use DSM-5 feel that the manual's symptom checklists are lacking in clinical or scientific validity. This skepticism was especially evident among psychologists, many of whom cited economic incentives and a great deal of political jockeying by various interest groups as hindering the manual's credibility. Three percent of respondents feel that not enough has changed from DSM-IV to justify switching.

Who Completed Our Survey?
Nearly 3000 clinicians completed our survey, indicating that they do have experience using DSM-5 in clinical practice. The majority of completers were mental health specialists.

Who Is Using the Manual?
Perhaps not surprisingly, of the 2828 survey completers, psychiatrists and psychologists have been most apt to embrace the update, with approximately 60% of each group reporting that they've incorporated it into their practice. One half of the pediatricians surveyed report using DSM-5, followed by 44% of neurologists and primary care physicians, and just 21% of nurses.

A Unified ASD
Survey participants were asked about several DSM updates or diagnoses new to the manual, namely those representing major or controversial revisions. One of the most contentious updates was the move to a single autism spectrum disorder (ASD) category that does not differentiate among the multiple pervasive developmental disorder diagnoses in DSM-IV (eg, autistic disorder, Asperger's disorder). Leading up to DSM-5's release, detractors worried that the new classification would result in many patients formerly diagnosed with an ASD now falling outside of diagnostic criteria and thus being ineligible for certain support and treatment resources. However, per our survey, two thirds of respondents encountering ASD patients report that the new criteria have not changed the percentage of their patients qualifying for the ASD diagnosis, or that not enough time has passed to tell. Others report both reductions — most small, but some significant — and increases in the number of their patients meeting the new criteria. Many commenters feel that the new criteria allow more accurate diagnosis.

Rethinking Autism: Clinicians Weigh In
Per the new ASD classification, the majority of survey respondents have not noticed a change in the rate of diagnosis. Of those who answered "No," some did report that they perhaps didn't see enough relevant patients to notice a change, whereas many report negligible changes. Among those who mentioned altered diagnostic rates, some commenters reported an increase, although most reported modest decreases. Numerous respondents feel that the new criteria are more accurate and better represent the continuum of neurodevelopmental disorders.

Grief or Depression?
Another controversial update to DSM-5 was the removal of the bereavement exclusion as part of the major depressive disorder (MDD) diagnostic criteria. In DSM-IV, individuals experiencing depressive symptoms lasting less than 2 months after the death of a loved one were excluded from a diagnosis of MDD. Critics worried that removing this exclusion could lead to the overpathologizing of a normal human response, whereas proponents argued that the new criteria acknowledge bereavement as a severe psychological stressor that can predispose to or cause full-blown depression. Less than one quarter of survey respondents reported a change in clinical decision-making as a result of the revision.

The Bereavement Exclusion: Clinicians Weigh In
Despite the debate surrounding this update, over three quarters of respondents did not report a change in clinical decision-making in response to the removal of the bereavement exclusion. Of those who did, the majority reported an increase in depression diagnoses in patients who formerly would not have met MDD criteria. Of those answering "No," but who also acknowledge caring for patients with depression or bereavement, many commented that regardless of diagnostic criteria, they consider distinguishing between the two to be a clinical judgment call.

Disruptive Mood Dysregulation Disorder
New to DSM-5, the disruptive mood dysregulation disorder (DMDD) diagnosis included children with persistent irritability and severe behavioral outbursts 3 or more times per week for more than 1 year. The inclusion was intended to prevent the overdiagnosis of bipolar disorder in young patients with prepubertal onset of these symptoms. Nearly three quarters of survey respondents have not noticed a change in clinical decision-making as a result of the addition.

DMDD: Clinicians Weigh In
Clearly a subject that draws opinions, nearly 3000 survey respondents submitted comments regarding the new DMDD diagnosis. Many commenters reported not seeing enough relevant patients to have an opinion, whereas a majority of those answering "No" reported that they'd always been careful not to overly apply a bipolar disorder diagnosis in children — with many pointing out that just because the nomenclature has changed, it doesn't mean that the patients have. A majority of the commenters who did report a change in practice support the update.

A Personality Continuum
In developing diagnostic criteria for personality disorders, the DSM-5 work group proposed a major overhaul: Remove 4 of the 10 DSM-IV personality disorder diagnoses and move from a categorical to a trait-based, dimensional classification system. The new system was intended to better capture the nuances of human personality by measuring a variety of traits on a continuum. The system ultimately didn't make it into the body of the manual but was included in Section 3 as deserving of further research. Whereas nearly 40% of clinicians reported considering the new approach in practice, the majority reported not using it.

Personality Disorders: Clinicians Weigh In
Given that the dimensional classification of personality disorders was not included in the body of the DSM-5, it's not surprising that most clinicians aren't embracing the approach just yet. However, 39% is not insignificant, and it appears that the diagnosis of personality disorders is moving in this direction, with numerous commenters either already considering dimensional traits in their practice or acknowledging that it is a more accurate means of assessing human personality.

The Mixed Mood Specifier
Also following a dimensional approach to diagnosis, DSM-5 includes a "with mixed features" specifier that can be applied to bipolar I disorder, bipolar II disorder, bipolar disorder NED (previously called "not otherwise specified" [NOS]), and MDD. The update was intended to address the clinical phenomenon of "mixed" mood states that do not meet full criteria for a mixed episode of bipolar I disorder, reflected by co-occurrence of full mania and MDD. Nearly 30% of survey respondents did report a change in clinical decision-making as a result of this update.

Mixed Moods: Clinicians Weigh In
The majority of respondents citing a change in clinical decision-making as a result of this change feel that it makes diagnosing patients with mixed symptoms easier. As one psychologist put it, "This gives us freedom to interpret what is frequently encountered clinically: Somebody isn't fully manic at presentation, but you can see where they're headed and act proactively." The majority of respondents answering "No," but to whom this update is relevant, feel that it doesn't have major implications for management, because patients will still be handled in the same manner.

A Rise in Substance Use Disorders?
DSM-IV included criteria for both substance abuse and substance dependence. In DSM-5, the 2 diagnoses have been combined within an "addictions and related disorders" category; each specific substance use disorder can be divided into mild, moderate, and severe subtypes. The new criteria increase the number of symptoms required to qualify for a diagnosis; however, leading up the DSM-5's release, critics argued that it would result in many more people qualifying for a substance-related disorder. Medscape's survey data suggest otherwise, with three quarters of respondents reporting not seeing a change in the incidence of substance use disorders.

Substance Use Disorders: Clinicians Weigh In
Most survey respondents who reported seeing patients with substance use disorders did not report a change in incidence due to the revised criteria, though many still support distinguishing between substance abuse and dependence, citing that these groups are clinically distinct. Of those reporting a change in substance disorder incidence, the majority reported an increase.

The Rocky Release
As previously mentioned, more than one half of clinician respondents to Medscape's DSM-5 survey dropped out because they've opted not to incorporate the manual into their practice. Although the majority of noncompleters stated that they are not yet familiar with DSM-5 or that it is not necessary for billing as their main reasons for not using it, numerous commenters did cite the various controversies surrounding the development and release of the manual as contributing to their avoidance of it. Nearly three quarters of respondents using the manual reported not being influenced by its tumultuous release.

The Controversy: Clinicians Speak Up
Some respondents cited early hesitation to adopt DSM-5 owing to political and financial special interests influencing the manual's content and release. However, many of these survey completers who were initially reluctant to use the new manual reported that they have since started using DSM-5, and now feel that the controversies were blown out of proportion.

DSM-IV or DSM-5?
Also of concern among survey respondents is the clinical accuracy of DSM-5; many cited questionable field trial results. Among the most concerning trial findings was the fact that 2 unchanged and common disorders, MDD and generalized anxiety disorder, were among 6 disorders found to have questionable reliability. "I'm extremely concerned about the low kappa values. I do not believe [DSM-5] should've been released," commented one psychiatrist. Despite the skepticism, nearly 60% of respondents using DSM-5 find it more accurate than DSM-IV.

Clinician Satisfaction
Our survey suggests that plenty of clinicians encountering mental health patients are, for a variety of reasons, not using DSM-5. However, the majority of those who have adopted the manual seem relatively satisfied. More and more clinicians will no doubt begin using the manual as it is increasingly adopted by employers and electronic health record systems. Hopefully, future DSM-5 revisions will further improve clinical accuracy and utility, while addressing shortcomings revealed by increasing experience with the manual.