Expert Remarks on the Revision
As stated in the APA Board of Trustees' press release announcing the release of the approved final diagnostic criteria for DSM-5, "The trustees' action marks the end of the manual's comprehensive revision process, which has spanned over a decade and included contributions from more than 1,500 experts in psychiatry, psychology, social work, psychiatric nursing, pediatrics, neurology, and other related fields from 39 countries." David J. Kupfer, MD, Task Force chair, answered some questions for U.S. Pharmacist.
Q: How Were the Task Force and Work Group Members Selected?
A: The president of the APA nominated individuals with expertise in their fields to be Task Force members. The nominees were reviewed by a subcommittee of the APA Board of Trustees to evaluate their relevant expertise and potential for real or perceived conflicts of interest. Final approval was granted by the full Board of Trustees. The Work Group members were also nominated by the president of the APA in consultation with the Task Force leadership and the Work Group chairs. Again, the nominees were reviewed and approved by the Board of Trustees in the same manner as Task Force nominees.
DSM-5's Task Force and Work Group members included more than 160 world-renowned scientific researchers and clinicians with expertise in mental disorders, neuroscience, biology, genetics, statistics, epidemiology, and public health. Numerous experts also served as advisors to the DSM-5.
Q: Can You Share the Types of Comments You Received During the Public Comment Period? Were These Influential in Some Decisions to Change?
A: The first draft of proposed changes was posted publicly on the DSM-5 website in February 2010, and the site also posted two subsequent drafts. With each draft, the site accepted feedback on proposed changes, receiving more than 13,000 comments on draft diagnostic criteria from mental health clinicians and researchers, the overall medical community, and patients, families, and advocates. Following each comment period, the DSM-5 Task Force and Work Groups reviewed each comment and made revisions where warranted.
In addition to the three public comment periods, Task Force members worked closely with advocacy groups, consumers, and other non–psychiatric care providers in face-to-face meetings and regular briefings. For example, in the autism community, there was some concern that diagnostic changes would result in individuals losing their diagnosis and, thus, being left without critical services. By the time the criteria were approved in late 2012, autism advocates listed the changes among the top 10 autism research advances of 2012.
Q: What Was the Main Reason for Moving Away From the Global Assessment of Functioning Score? Pharmacists Found Axis III Very Helpful in Ensuring that Patients' Medical Needs Were Addressed.
A: Over the years, problems emerged with the multiaxial approach, suggesting that the use of axes was unnecessarily complex and outdated and served to complicate the diagnosis process and impede global health information-sharing.
With the new single-axis approach, clinicians will still take note of the same mental, physical, and social considerations as under the multiaxial system to provide comprehensive assessments. They'll just go about it differently. For example, in DSM-5, we recommend the World Health Organization's Disability Assessment Schedule (WHO-DAS) as a global measure of disability. Using the WHO-DAS, disorders and their associated disabilities are conceptually distinct and assessed separately. This measure is based on an international classification of functioning and disability that is currently used throughout the rest of medicine, thereby bringing DSM-5 into greater alignment with other medical disciplines and into greater harmonization with international measures.
Q: What is the Reason You Stopped Using Roman Numerals?
A: This change represents APA's goal of creating a clinical manual that incorporates timely updates based on a preponderance of supportive research evidence. Incremental updates will be identified with decimals (i.e., DSM-5.1, DSM-5.2, etc.) until a new edition is required.
Q: Is There Anything Else You Want to Add Now That the Negative Bloggers Are Out There?
A: I would add that DSM reflects the state of our scientific knowledge. When we started the process of developing this manual 14 years ago, I think we were all optimistic that there would be biomarkers and other breakthroughs of that magnitude. That hasn't happened yet, but DSM-5 provides the best guidebook possible to diagnosing mental disorders. As breakthroughs occur, they will be incorporated into next editions to further strengthen patient care.
Q: Were Any Medication Guidelines Changed or Recommended?
A: DSM has never been a manual guiding treatment or medication guidelines. As with past editions, DSM-5 is intended to be a manual for assessment and diagnosis of mental disorders and will not include information or guidelines for treatment of any disorder. That said, determining an accurate diagnosis is the first step toward being able to appropriately treat any medical condition, and mental disorders are no exception. DSM-5 will also be helpful in measuring the effectiveness of treatment, as dimensional assessments will assist in evaluating changes in severity levels as a response to treatment.
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