NIMH, APA Clash Over Upcoming DSM-5

'Patients Deserve Better,' NIMH Director Says

Deborah Brauser

May 07, 2013

Two of the biggest organizations in the field of psychiatry are clashing over the soon-to-be-released Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), which will be released by the American Psychiatric Association (APA) on May 18 at its annual meeting in San Francisco, California.

In a blog post published on the National Institute of Mental Health (NIMH) Web site, the organization's director, Thomas Insel, MD, states that the upcoming manual is reliable but lacks validity and that "patients with mental disorders deserve better."

"Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure," said Dr. Insel.

"Symptom-based diagnosis...has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment," he added.

Dr. Insel also reported that the NIMH is launching the new Research Domain Criteria (RDoC) project as a possible replacement diagnostic tool sometime in the future and as "a first step towards precision medicine." It will incorporate genetics, imaging, and other data into a new classification system.

In addition, the organization noted that it "will be re-orienting its research away from DSM categories."

In a formal response, David Kupfer, MD, chair of the APA's DSM-5 Task Force, stated that although using biological and genetic markers to reliably identify disorders would be wonderful, "this promise, which we have anticipated since the 1970s, remains disappointingly distant."

Dr. Thomas Insel

"In the absence of such major discoveries, it is clinical experience and evidence, as well as growing empirical research, that have advanced our understanding of disorders," said Dr. Kupfer, adding that this progress will be recognized in the upcoming DSM-5.

Need for "Precision Medicine"

The DSM-5 will be released at the upcoming APA Annual Meeting in San Francisco, California.

Dr. Insel notes that although the final version of the manual has tweaked several diagnostic categories, it actually involves "mostly modest alterations of the previous edition," based on research conducted since 1990.

"The goal of this new manual, as with all previous editions, is to provide a common language for describing psychopathology. While DSM has been described as a 'Bible' for the field, it is, at best, a dictionary, creating a set of labels and defining each," he said.

On the other hand, the NIMH set out to try to better define several major categories during a set of workshops conducted during the past year and a half.

"It became immediately clear that we cannot design a system based on biomarkers or cognitive performance because we lack the data. In this sense, RDoC is a framework for collecting the data needed for a new nosology," said Dr. Insel.

"But it is critical to realize that we cannot succeed if we use DSM categories as the 'gold standard.' We need to begin collecting the genetic, imaging, physiologic, and cognitive data to see how all the data — not just the symptoms — cluster and how these clusters relate to treatment response."

Because of this goal, the NIMH will, going forward, only be supporting research projects that "look across current categories." For example, instead of assessing only patients meeting strict criteria for major depressive disorder, NIMH-funded trials may need to examine all patients in a mood disorder clinic.

Dr. Insel stressed that the RDoC is not yet a clinical tool but is instead a research framework.

"This is a decade-long project that is just beginning," he said. "Some will see RDoC as an academic exercise divorced from clinical practice. But patients and families should welcome this change as a first step towards 'precision medicine,' the movement that has transformed cancer diagnosis and treatment."

Still Waiting for Biomarkers

In his response statement, Dr. Kupfer noted that the DSM-5 "represents the strongest system currently available" for classifying psychiatric disorders.

"We've been telling patients for several decades that we are waiting for biomarkers. We're still waiting," he said.

On the other hand, the new manual will act as a guidebook, providing a common language to clinicians while helping them to describe and diagnose their patients.

Dr. Kupfer added that both the APA and the NIMH do agree that more research is needed. Content in the DSM-5's new Section III will encourage future studies, and the RDoC is a part of vital efforts aimed at advancing the collective understanding of mental disorders, he noted.

However, these efforts are not ready yet, "and they cannot supplant DSM-5," said Dr. Kupfer.

"RDoC is a complementary endeavour to move us forward, and its results may someday culminate in the genetic and neuroscience breakthroughs that will revolutionize our field. In the meantime...we are dealing with impairment or tangible suffering and we must respond. Our patients deserve no less."

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