DSM-5 Proposals for Mood Disorders: A Cost–Benefit Analysis

Michael B. First


Curr Opin Psychiatry. 2011;24(1):1-9. 

In This Article

Abstract and Introduction


Purpose of review The Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 revision is underway. The review examines draft proposals for changes in mood disorders (posted February 2010 on DSM-5 web site), explains their rationale, and considers relative costs vs. benefits.
Recent findings Proposals covered include recommendation for a comorbid anxiety dimension; addition of a new disorder, mixed anxiety depression; replacement of mixed manic episodes with a 'mixed features' specifier applicable to manic, hypomanic, and major depressive episodes; addition of severity dimensions for manic and major depressive episodes; and removal of the bereavement exclusion in major depressive episode. Although some proposals (particularly the anxiety dimension and the use of Patient Health Questionnaire-9 (PHQ-9) as depression severity dimension) may improve clinical and research utility, others have a high potential for false positives (e.g., addition of mixed anxiety depression, removal of bereavement exclusion), unclear clinical utility (e.g., mixed features specifier for depressive episodes), or problematic implementation (e.g., use of Clinical Global Impression (CGI), which requires prior experience of treating bipolar patients, for rating manic episode severity).
Summary A cost–benefit analysis of mood proposals yields mixed results, with some having significant benefits and others carrying the risk of significant problems. Only proposals in which benefits outweigh costs should be included in the final DSM-5.


The American Psychiatric Association is revising its Diagnostic and Statistical Manual of Mental Disorders (DSM), the first major revision of the manual since the publication of DSM-IV in 1994.[1] (In the present edition, DSM-IV-TR, published in 2000, only the accompanying text was revised; the disorder definitions were for the most part left unchanged[2]). According to the DSM-5 web site, the DSM-5 revision process is being guided by four goals: changes should improve clinical utility (the goal that is being given the 'highest priority'); recommendations should be guided by research evidence; whenever possible, DSM-5 should maintain continuity with previous editions; and there should be no a-priori restraints on the extent of the proposed changes.[3] However, in recognition of the contradictory nature of the third and fourth goals, DSM-5 Workgroups have been asked to 'carefully consider the impact that any changes would have on clinical practice, disorder prevalence and other important factors, while at the same time, considering the diagnostic advances that would be made through implementation of new scientific knowledge and clinical understanding'..[3] In other words, every proposed change to DSM-5 carries with it 'costs' and 'benefits', so that changes should be implemented only if the benefits offset the costs. Benefits of making changes to the DSM include improvements in its clinical utility,[4] its research utility,[5,6] and overall diagnostic validity. Costs of change include reductions in clinical utility owing to implementation of proposals that increase clinician burden, an increase in diagnostic false positives related to the lowering of diagnostic thresholds or addition of new disorders on the boundary with normality, and disruption of research efforts (especially for longitudinal studies) related to shifts in diagnostic definitions.[7,8]

In this review, we will consider proposals for changes being put forth by the DSM-5 Mood Disorders Workgroup, along with an analysis of their potential benefits and costs, according to the drafts that were posted on the DSM-5 web site (www.dsm5.org/) on February 2010. Because of space limitations, only a selection of the most important proposed changes is presented. These drafts were posted for the purpose of eliciting comments from the field and the public at large. Comments were received from mid-February to mid-April and presumably changes to the draft criteria have been made in response to these comments. Although changes made to the draft criteria for bulimia nervosa and the paraphilias in response to such comments have been posted on the web site,[9] it appears that no changes have been made to the Mood Disorders draft proposals at the time of this review (August 2010).


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