DSM-5: Potential Impact of Key Changes on Pharmacy Practice

Tammie Lee Demler, BS, PharmD, MBA, BCPP


US Pharmacist 

In This Article

Brief Review of Treatment Options for the Major Disorders

Although DSM is not a guideline for medication therapy, the diagnostic clarity that characterizes DSM-5 may influence prescribing trends. Pharmacists should not only be familiar with the DSM-5 changes, but also review general treatment guidelines for the major mental health conditions.

Neurodevelopmental disorders such as autism spectrum disorder do not have FDA-approved therapies to treat the core disorder. However, as is the case with a number of other mental health diagnoses, medication therapy targets the associated symptoms. Based on individual patient needs and past medical and/or psychiatric history, agitation and anxiety are symptoms that may be managed with antipsychotics, benzodiazepines, and sedating antihistamine products.

FDA-approved treatment for attention-deficit/hyperactivity disorder consists of stimulant and nonstimulant medications. DSM-5 highlights the expert consensus that this disorder may—and often does—encompass the patient's life span. Pharmacists must be mindful of therapeutic considerations in aging patients when stimulant medications are used. These considerations include, but are not limited to, increased cardiac risks. Newly branded older agents, such as clonidine and guanfacine, are now available. Pharmacists must also be familiar with pharmacologic and nonpharmacologic treatment options for common concurrent conditions, such as insomnia.

Schizophrenia spectrum and other psychotic disorders have a wide array of medication therapy options, including first- and second-generation antipsychotics. A wide arsenal of new medications have been launched in the last few years, owing to an unusually increased pace for new mental health medications brought to market during that time. As is the case with other mental health disorders, co-occurring symptoms such as agitation, anxiety, and insomnia are common and must be treated accordingly.

Of the mental health disorders with FDA-approved treatments, bipolar and related disorders can benefit from one of the largest arrays of treatment options. Mood stabilizers include lithium, antiepileptics, and second-generation antipsychotics. Additionally, medications may be required to treat symptoms of agitation, anxiety, and insomnia, as previously noted for other psychiatric diagnoses. Adasuve (loxapine) inhalation powder was approved by the FDA in December 2012 for the acute treatment of agitation associated with bipolar I disorder or schizophrenia in adults.[5]

Depressive disorders, anxiety disorders, and posttraumatic stress disorder are all distinct in their diagnostic criteria and therapeutic timeline; however, they share a common medication class as first-line treatment. Serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs) have emerged as the treatment of choice based on efficacy, lack of dependence, and tolerable side-effect profile. The FDA-approved uses may guide prescriber treatment choice; however, the mechanism of action is the same for all agents within each drug class (Table 2). When recommending these agents as a new treatment intervention or managing a patient currently on an SSRI/SNRI regimen, it is important for the provider to consider the side effects and drug interactions. The side-effect profiles of these agents may appear similar, but the degree of severity often differs with the agent chosen, the specific CYP450 profile of the drug, and potential individual genetic polymorphisms in individuals receiving treatment. In July 2013, the FDA approved levomilnacipran (Fetzima) as the newest SNRI for major depressive disorder in adults, making the drug the fourth SNRI to be approved in the U.S.[6]