Psychiatry Practice Changers 2014

Bret S. Stetka, MD; Cristoph U. Correll, MD


December 08, 2014

In This Article


Editor's Note: In 2014, psychiatry progressed. Numerous genomic breakthroughs hint at a future of personalized psychiatric care, existing therapeutic approaches to mental illness were honed, and new treatments are showing promise. Based primarily on Medscape News coverage and input from our expert advisors, what follows are notable important advances in psychiatry from the past year, starting with the sluggish adoption of the field's updated diagnostic manual. The list is far from comprehensive, so please tell us in the comments section what 2014 developments you feel were most important to psychiatry.


What might actually be considered more of an "anti-practice changer" is the seemingly slow adoption of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).[1]

The update of psychiatry's go-to diagnostic reference was released in May 2013 amid controversy that there wasn't enough solid evidence to justify a new manual. One year later, Medscape surveyed its members—including both psychiatrists and other clinicians involved in mental health diagnosis and care—to see if they'd adopted it in their practice. Respondents were queried on some of the more major and/or controversial revisions, along with their overall satisfaction with the update, and invited to provide comments.

Over 6000 clinicians began the Medscape survey, 55% of whom reported not having incorporated the DSM-5 into their practice and dropped out. Despite having started the survey, indicating an interest in DSM-5, 21% of the noncompleters dropped out due to a lack of relevance to their practice; 22% reported that they hadn't had enough time yet to review the new manual or that they didn't even know it had been released. A total of 21% of nonusers cited not needing the DSM-5 for billing, as often the International Classification of Diseases (ICD) is sufficient, while only 5% reported not using the DSM-5 due to lack of clinical and scientific validity.

Despite the sluggish incorporation of the DSM-5 into care, a number of the new or updated diagnoses appear to be holding up clinically, according to the results of the Medscape survey. Per the data, initial concerns that the DSM committee's move to a single autism spectrum disorder (ASD) would result in many patients formerly diagnosed with an ASD no longer qualifying for a diagnosis, thus being ineligible for certain support and treatment resources, appear at least for now to be unfounded. Two thirds of those encountering ASD patients reported that the new criteria have not changed the percentage of their patients qualifying for the ASD diagnosis or that not enough time has passed to tell.

The vast majority of respondents reported not having seen a change in clinical decision-making in response to other controversial updates, including the removal of the bereavement exclusion, the new disruptive mood dysregulation disorder diagnosis, and the decision to combine the substance abuse and substance dependence diagnoses. A total of 30% of respondents supported the new "with mixed features" specifier for depression and mania or hypomania, reporting that it better characterizes the often mixed nature of mood disorders.

Finally, 60% of survey respondents using the DSM-5 find it more accurate than DSM-IV, while nearly 75% reported being satisfied with its real-world performance.

As with any change to classification or diagnostic systems, adoption will pick up with time and depend also on health systems requiring the adoption of DSM-5 into clinical practice. The more widespread application of DSM-5 will be welcome, as using two classification systems, even if they are for the most part very similar, can cause confusion. Moreover, one intention in designing DSM-5 was to increase the specificity of the diagnostic criteria, for example by requiring the presence of two category A criteria belonging to the core illness concept for the diagnosis of schizophrenia or mania.


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