Jeffrey A. Lieberman, MD


May 18, 2013

This week, my good friend and colleague Tom Insel and I issued a rare joint statement clarifying the National Institute of Mental Health's (NIMH) support of the Diagnostic and Statistical Manual of Mental Disorders (DSM) as the gold standard of care for 2013 and for years to come, and the American Psychiatric Association's (APA) support of the NIMH's Research Domain Criteria (RDoC) as our best hope for a better gold standard for 2023 and beyond. We did this because of a blog post on the NIMH Website about our collective frustration with the progress of brain science, the paucity of new treatments for brain diseases to help our patients, and the need for future-looking researchers to think outside the box.

We were concerned that comments about how to move beyond some of our traditional, symptom-based methods of diagnosis -- which are, at the moment, the gold standard of science -- were widely misreported as NIMH changing its position on the newly revised DSM-5. This is, of course, a preposterous notion. The NIMH was involved in all phases of the revision of the DSM, including the moments during the 10-year process when we all realized that the science that we hoped by now would have given us laboratory, imaging, and electrophysiologic procedures to help diagnose mental illnesses, was still coming up short. We all agree with Tom's exhortation to the field that patients "deserve better" than using symptoms alone to treat these illnesses, and they "deserve better" than our current standard of knowledge about the brain and the causes and cures of mental illnesses.

But some took his "cheerleading the future" comments to suggest that there is a better or different way to treat our patients in the present than diagnosing with the DSM. There is not. And too many patients aren't yet receiving our current gold standard of treatment. Tom and I agree on that, which is why, as Director of the NIMH and President-Elect of the APA, we issued this statement which, unfortunately, got much less media coverage than his original blog post.

The NIMH's position on the DSM and need for scientific progress in understanding the genetic and neurobiologic basis of mental disorders has not changed. The DSM is an essential guide to clinicians to facilitate accurate diagnosis and treatment. At the same time, biomedical research cannot be confined by traditional diagnostic constructs and their boundaries. Tom and I, and the APA and NIMH, are in complete agreement on this. The DSM is a valuable guide that helps clinicians in the evaluation of patients to establish an accurate diagnosis and facilitate the most effective treatment. It is designed to reflect the latest scientific knowledge and translate this into a "user-friendly" instrument for clinicians and patients. Although the DSM-5 does have a new section with proposed diagnoses that need further study, the manual is not meant to guide all of mental health research -- that's NIMH's job -- or constrain research in any way.

The fact that we have not seen sufficient progress in scientific research to enable greater change in psychiatric diagnosis is not the fault of the DSM. Psychiatrists would like nothing more than to see laboratory tests and imaging -- routine in diagnosing other diseases -- incorporated into the DSM and clinical practice.

The New York Times had it right in its May 2, 2013, editorial:

The underlying problem is that research on mental disorders and treatment has stalled in the face of the incredible complexity of the brain. That is why major pharmaceutical companies have scaled back their programs to develop new psychiatric drugs; they cannot find new biological targets to shoot for. And that is why President Obama has started a long-term brain research initiative to develop new tools and techniques to study how billions of brain cells and neural circuits interact; the findings could lead to better ways to diagnose and treat psychiatric illnesses, though probably not for many years.
Meanwhile, the diagnostic manual remains the best tool to guide clinicians on how to diagnose disorders and treat patients. Consensus among mental health professionals will have to suffice until we can augment it with something better.


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