In the past week, I’ve seen some incredibly sensationalistic articles published about the upcoming DSM-5 and a letter recently released by the National Institute of Mental Health (NIMH). In the letter by Dr. Thomas Insel, director of the NIMH, wrote in part, “That is why NIMH will be re-orienting its research away from DSM categories.”
Some writers read a lot more into that statement than was actually there. Science 2.0 — a website that claims it houses “The world’s best scientists, the Internet’s smartest readers” — had this headline, “NIMH Delivers A Kill Shot To DSM-5.” Psychology Today made the claim, “The NIMH Withdraws Support for DSM-5.” (The DSM-5 is the new edition of the reference manual used to treatment mental disorders in the U.S.)
So is any of this true? In a word, no. This is science “journalism” at its worse.
NIMH’s Research Domain Criteria
For the past 18 months, the NIMH has been working on a different categorization system to classify mental disorders, to help further its research efforts (the NIMH is primarily a research-driven organization). It’s called the Research Domain Criteria project:
NIMH has launched the Research Domain Criteria (RDoC) project to transform diagnosis by incorporating genetics, imaging, cognitive science, and other levels of information to lay the foundation for a new classification system.
The proposed classification system works under these assumptions:
- A diagnostic approach based on the biology as well as the symptoms must not be constrained by the current DSM categories,
- Mental disorders are biological disorders involving brain circuits that implicate specific domains of cognition, emotion, or behavior,
- Each level of analysis needs to be understood across a dimension of function,
- Mapping the cognitive, circuit, and genetic aspects of mental disorders will yield new and better targets for treatment.
In short, the NIMH is trying to find a new categorization system that takes into account more of the biology, genetics, brain circuitry and neurochemistry that we’ve discovered in the past three decades’ worth of research is becoming increasingly relevant to understanding mental disorders.
Does it Replace the DSM-5?
Will this replace the DSM-5? No, because as Dr. Insel notes, “This is a decade-long project that is just beginning.” If the NIMH effort ever replaces the DSM, it will be a long time from now.
Somehow, though, Science 2.0 and Psychology Today believe this letter suggests the NIMH has “withdrawn” support for the DSM-5, or has delivered a “kill shot” (whatever that is!). Are these kinds of characterizations accurate — or indeed, helpful?
We reached out to Bruce Cuthbert, Ph. D., the director of the Division of Adult Translational Research at the National Institute of Mental Health for clarification.
“As with most shifts in science, changes in research priorities require a transition,” said Dr. Cuthbert.
“Because almost all clinical researchers today grew up with the DSM system both clinically and in research, it will take some time to get a “feel” for the relationships between DSM disorders and various kinds of RDoC phenomena (both in terms of the types of symptoms, and in overall severity), learn how to write grant applications with the new criteria, and evolve new review criteria. So, there will be a period of some time while these crosswalks are worked out.
“I also should point out that these comments reflect [only] our translational research portfolios.
“Our Division of Services and Intervention Research mostly supports research conducted in clinical settings that is relevant to current clinical practice and services delivery. Thus, […] grants in these areas will continue to be predominantly funded with DSM categories for some time.”
That’s a far cry from the entire NIMH withdrawing support for the DSM-5. The NIMH is simply saying (in my opinion), “Look, we’re unhappy with the validity of the DSM and its lack of support for biomedical markers for mental disorders. We’re working on a different schema, especially targeted at researchers. It may have greater relevance someday — that’s our hope and vision.”
Why a New Diagnostic System?
But then again, researchers in mental illness have been promising biomarkers for at least two decades as well — with little notable progress to show for their efforts. ((David Kupfer, who chairs the DSM-5 Task Force, told Pharmalot: “The promise of the science of mental disorders is great. In the future, we hope to be able to identify disorders using biological and genetic markers that provide expreciseact diagnoses that can be delivered with complete reliability and validity. Yet this promise, which we have anticipated since the 1970s, remains disappointingly distant. We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting.”))
Why is a new diagnostic system needed?
“For psychiatric disorders, we cannot effectively use very much of the knowledge we have gained about the brain and behavior over the last 30 years because of our symptom-based diagnostic system. In other words, the categories defined by symptoms simply do not map onto all the knowledge that we have gained about brain circuits, genetics, and behavior,” replied Dr. Cuthbert.
“We know that many different mechanisms are involved in any one DSM disorder (heterogeneity), while any one mechanism (fear, working memory, emotional regulation) is typically involved with many different disorders. [This] heterogeneity frustrates attempts to develop new treatments.”
Indeed, as John Horgan over at Scientific American wrote,
Ironically, some pharmaceutical companies that have enriched themselves by selling psychiatric drugs are now cutting back on further research on mental illness. The “withdrawal” of drug companies from psychiatry, Steven Hyman, a psychiatrist and neuroscientist at Harvard and former NIMH director, wrote last month, “reflects a widely shared view that the underlying science remains immature and that therapeutic development in psychiatry is simply too difficult and too risky.”
Pharmaceutical companies say that, on average, a marketed psychiatric drug is efficacious in approximately half of the patients who take it. Dr. Cuthbert from the NIMH suggests that, “One reason for this low response rate is the artificial grouping of heterogeneous syndromes with different pathophysiological mechanisms into one disorder.”
So the NIMH’s regrouping appears to be as much of an effort to spur new drug development as it is an effort to rethink the classification system of mental disorders. Which is a bit odd, if you think about it, since there is a rich research foundation showing that non-medication treatments — such as psychotherapy — work equally well (if not better) for the treatment of many mental disorders.
If these were pure medical diseases with clear and readily defined biomarkers, that shouldn’t be the case. After all, positive thinking can’t cure cancer. ((Although, to be fair, positive thinking can definitely help in its overall treatment.))
“Thus, mental disorders are an area where we must transcend the current symptom-based system if we are to advance,” concludes Dr. Cuthbert. “Among other things, if you have to wait until a full-blown set of symptoms is present before you can define a disorder (and there is no quantifiable data regarding risk states, as there is for, say blood pressure), then prevention is — by definition — impossible.”
This is simply untrue, in my opinion. There is a solid and growing research base already demonstrating that we can detect mental illness through a number of early screening and symptom measures and implement prevention measures. Other studies demonstrate significant correlations with certain characteristics — signs that can also be used to implement effective prevention.
“The research process will necessarily involve complex science to understand how we can relate more neuroscience-based measures to more specific and quantitatively-defined symptoms and clinical outcomes,” says Dr. Cuthbert from the NIMH. “This does not necessarily mean, however, that the diagnostic systems of the future will necessitate such a complex battery. As with biomarkers in other areas of medicine, a subsequent phase will be to find assessments that can be obtained feasibly in clinical settings (although this is unlikely to mean, as is the case now, that all disorders can be diagnosed simply sitting in a clinician’s office).”
Is It All About the Money?
Horgan suggests, perhaps, some ulterior motives for NIMH’s statement:
NIMH director Insel doesn’t mention it, but I bet his DSM decision is related to the big new Brain Initiative, to which Obama has pledged $100 million next year. Insel, I suspect, is hoping to form an alliance with neuroscience, which now seems to have more political clout than psychiatry. But as I pointed out in posts here and here on the Brain Initiative, neuroscience still lacks an overarching paradigm; it resembles genetics before the discovery of the double helix.
I’m not as skeptical as Horgan, but do believe the timing of Dr. Insel’s letter is a little curious — right before the launch of the DSM-5, and right after the public commitment of $100 million to brain research.
What is clear is that the NIMH is not withdrawing support for the use of the DSM-5 anytime soon. It is the reference manual all researchers and clinicians use today to speak the same language of mental illness. Without the same reference frame, research — and treatment — would become impossible.
Further Reading
Scientific American: Psychiatry in Crisis! Mental Health Director Rejects Psychiatric “Bible” and Replaces with… Nothing
Science 2.0’s article: NIMH Delivers A Kill Shot To DSM-5
19 comments
Thank you for this more measured response to the NIMH/APA dustup. After reading Insel’s statement, my impression was that he was describing a direction for research to take, not a wholesale abandonment of the DSM. The hysteria that came out of many websites seemed completely unfounded to me. Thanks for making such a rational case for calm.
On the money assessment! Lilly rep was at the CMHC I work at yesterday to note they have killed their psychotropic division, and how ironic the rep is going to the neuroscience division that seems to NOT include psychiatry.
This is being debated over at http://www.1boringoldman.com, and my comment at today’s post is harsh, but, so is the DSM 5. It is time to ignore or marginalize the same lame rhetoric by alleged leaders in psychiatry who are, as Dr Mickey is noting, just doing the APA version of Groundhog Day.
I would love to watch some faces get slapped, if you recall the scene from the movie!
I disagree with this take, and for the following reasons:
1. You ignore the crucial timing of the announcement, which is literally within days of the release of DSM-5, completely undermining that release.
2. You gloss (but don’t quote) the key statement by Insel that set all this off: “The weakness of the manual is its lack of validity.†That’s completely unambiguous. “Lack of validity” is extremely damning, esp. considering the NIMH’s previous support for DSM-III and -IV. Why didn’t you quote it?
3. You ignore the crucial fact in Insel’s statement that the NIMH will no longer rely exclusively on the DSM in future research. That *does* represent a significant shift in policy.
4. You write, “The NIMH is simply saying (in my opinion), ‘Look, we’re unhappy with the validity of the DSM and its lack of support for biomedical markers for mental disorders.'” Glad you acknowledge that this is indeed merely your opinion, but, no, given the full statement and its timing and what it actually says the NIMH will do, this is way too mild a reading, especially in light of Insel’s follow-up remarks in the NY Times. The statement *does* indicate a move away from DSM criteria and a marked softening of support for the manual–as lots of media are indeed reporting correctly.
1. Actually addressed just that point when talking about my lack of cynicism regarding the timing, considering it was also published just a few weeks after $100 million was announced for more brain science.
2. The (lack of) validity of the DSM is no secret. Any researcher in this space knows that, given the hundreds of studies conducted on the validity of DSM diagnoses over the past 30 years. For the director of the NIMH to state a fact already known to scientists and researchers isn’t really news — except to people not in the field.
But it’s a broad, sweeping generalization — and like most generalizations, isn’t very helpful. Some diagnoses have good validity; others have poor validity. To condemn the entire book as though it were one entity is to simply over-simplify and over-generalize.
3. Is it? The NIMH has never said it was relying on the DSM exclusively for diagnoses in the first place. It’s just the common language of researchers and clinicians. If they want to expand on that common vocabulary by pursuing an agenda that independent researchers have been pursuing for decades, well, that’s their prerogative… but it’s not an enormous or significant change. If you’re a researcher and looking for an NIMH grant, you’ll still get funded if you use DSM diagnostic categories.
4. The NIMH is welcomed to “soften” it’s support of a diagnostic system it believes doesn’t capture yet-to-be-identified biomarkers, but it’s hardly a “kill shot” or “withdrawal” of support across the entire agency. As I noted in my entry, this is only one part of the large NIMH bureaucracy — the other parts of the NIMH are still supporting the DSM 100 percent.
Interesting how media reports are missing that point.
“Kill shot” is indeed an overstatement. But how could one reconcile “support” for the DSM with Insel’s clear verdict on its “lack of validity”? Difficult, to say the least — unless you’re happy to bend yourself into a pretzel. No, he was indeed perfectly clear about the NIMH moving away from the DSM and its criteria–and that’s what the majority of the media correctly are reporting.
Not a single journalist has described what it means to “move away” from the DSM in realistic terms. So I honestly don’t know what Dr. Insel’s statement means, until the rubber meets the road.
We’ve been studying biomarkers for decades. The failure to find biomarkers is attributed to the failure of the current diagnostic system.
But an equally valid conclusion is that there are no biomarkers for what are largely socially-constructed and -defined disorders. I don’t know and I don’t have any answers, except to throw it out there… that mental illness has always been a biopsychosocial phenomenon. Throwing out two components of that — the psychosocial — and focusing on the “bio” seems like tunnel-vision to me. And goes against all the research demonstrating the effectiveness of psychosocial treatments (like psychotherapy).
I can’t think of any other area of medicine where something like psychotherapy could be shown to cure a disease.
Maybe the emphasis on biomarkers will result in something new a few decades from now. Who knows? But that’s decades from now… nothing that’s going to impact yours or my life this year, much less tomorrow.
The breathlessness in which some mainstream media outlets are reporting on this shift, however, is entirely unwarranted. For some time, the NIMH has not been the driving force in mental illness research. Their desire and hope to take a big chunk of that $100 million committed is simply being reflected here. You certainly couldn’t hope to compete for $100M in research funding by saying the status quo was fine, right?
Many thanks to Dr. Grohol for exposing the shoddy reporting and “hype” on this issue. The NIMH approach to diagnosis–which is likely years away from having the required neuroscience–was hardly a “kill shot” to the DSM-5. Yes, it is important to search for neurocircuits and underlying biological correlates for our diagnoses, but many conditions in clinical medicine are diagnosed on the basis of signs, symptoms and the patient’s history (e.g., migraine headaches, fibromyalgia, atypical facial pain).
Also, the claim that the DSM-5 lacks “validity” because it is not anchored in biology (e.g., there are no verified “biomarkers” for the diagnostic categories)is vastly oversimplified. Biomarkers help define one type of diagnostic validity, usually called “etiological validity.” But there are many other kinds of validity in science, such as convergent validity, discriminant validity, and
predictive validity.
For some DSM diagnoses, these types of validity are supported; e.g., one study found the DSM-III-R and ICD-10 diagnoses of schizophrenia had high predictive validity for long-term outcome, and both provide relatively stable diagnoses.
[Mason et al, Br J Psychiatry. 1997 Apr;170:321-7.]
To be sure: we can do much better than the DSM system, in my view, but we could also do worse!
Best regards,
Ron Pies MD
Well-stated, Dr. Pies, thank you.
It is a biopsychosocial model to mental health, and the simple fact that if you take 10 random people who meet a genuine criteria of a common psychiatric illness, you could treat all 10 people differently from one another and get sizeable remission features in all. And I am not talking about prescribing 10 different medications. The rank and file from the APA by in large would offer that alone!
Sorry, I really don’t care if I alienate more colleagues than not in this next comment: psychiatrists think with their prescription pads until proven otherwise these past 10 or more years at least, and I know in my heart that almost half do not make any effort to ask about upbringing issues in some form in the first evaluation visit.
Not that I am a big fan of Freudian concepts as a whole, but the man must be rolling in his grave if he could see what his profession has degraded to in the past couple of decades alone.
Oh, by the way, big Pharma is pretty much abandoning psychiatry, just look at what Lilly is doing with their Psychopharm division as of July. This from one of the biggest “contributors” of impact psychotropics for almost 25 years, starting with Prozac and ending with Cymbalta.
I would love to see the hypocrisy and plain denial that will be going on in San Francisco next week, but, I have better things to do with my time and money then. The question is, why do members not know better by now?
Just like the Democrats in Federal Government are circling the wagons in preparation of the Benghazi hearing tomorrow. Denial, rationalization, minimization, and projection will rain like a monsoon by tomorrow night.
Funny, basically what will happen in SF after the opening ceremony at the APA conference for DSM5.
“Do you hear laughter Ramesses, yes, it is the laughter of slaves (the public).” Judgment is coming, believers of the APA, and it will not be a happy ending for the organization, if truth prevails. Just my opinion!
Well, I have to admit for me this is like the Iraq-Iran war or a Ravens-Bengals football game (with apologies to Joel). I hope both sides lose, at least on the intellectual merits of their argument.
NIMH is correct that DSM lacks validity. Dr. Frances went a step further and called it what most of us would after a few beers.
However, NIMH is WAY ahead of itself in promoting biological markers because few reliable ones exist. This is as much an infant science as psychodynamics was in Freud’s day. In fact, if you want a reliable predictive marker for the course of a mental disorder, you look at statistical factors including psychometrics, which Paul Meehl and others have solidly proved since the 1950s.
Most of what we see in the office is Axis 2 (dimensional) crashing into Axis 4. Both NIMH and DSM fail to recognize this.
Like I said, do a thought experiment. Imagine insurance companies and school districts paid for Axis 2 and 4, many of the Axis 1 diagnoses would go away.
It still blows my mind that a question about sleep or mood asked by a GP counts as evidence of major depression, but >65 MMPI-2 two scale which includes dozens of questions and corrections for validity counts for nothing diagnostically, even though the latter is clearly more reliable and valid. My hope is that the other APA (psychologists) offers a competing manual to DSM-5. Or even better yet, that a disciple of Meehl who really understands taxonomy/scientific method/statistics/falsifiability writes one on his/her own.
NIMH is correct to criticize DSM on constructional validity but is way ahead of itself in the promise of biological markers which is an infant science. We still need descriptive psychiatry, just a better manual.
Why is the science of psychometrics being ignored in this debate? A valid elevated 2 scale on the MMPI-2 which reflects several dozen questions is clearly more reliable and valid than having a GP ask about sleep or mood.
I am surprised psychology hasn’t been more vocal about this.
I liked the article
I am a non tech rather was is a patient
It is good if people can understand better and treat funds are good motivator
started to read basic psychology some places able to understand differently in my context …
Thank you for sharing your take. There are few journalist or blogger voices that I trust more.
Regardless of whether NIMH said this or that, the bottom of this whole “debate” is not being looked at.
Mental health is an area that has been foisted off on MDs through psychotropic drug prescriptions by Big Pharma using the DSM as an insurance billing guide, all in a sly move to push their “legal” drugs for profit and not the benefit of or actual help of the individual.
Further, the APA as gone so far away from the original Freudian theory, which Freud said himself was far from complete. The only reason the APA is still functioning is due to the false claims of the DSM being based upon scientific fact – although they do say in their own DSM manual that it does not – but it is promoted verbally otherwise. And the APA gets their funding through government programs and Big Pharma and insurance companies that are mandated by law to pay claims, which by the way is also orchestrated by the APA and Big Pharma.
When you base an entire subject and “profession” such as the APA on lies, nothing that is discussed in regards to them will be logical nor can it be reasoned to agreement. Hence this blog.
The APA and DSM will not be with us much longer from all indications and statistics.
All we should look at are facts and not opinion. But one would have to set aside personal profit and special interest to see the truth, unfortunately hardly ever seen nowadays.
-JS
i fully agree with james there sure is something
fishy in insels statement
A pox on both your houses! Neuroscience is the future, perhaps, but DSM 5 is rehashing the past. At this point i the progress in psychiatric diagnosis resembles a cookbook – you mix the symptoms to make a diagnosis just as a cook compounded ingredients to make a meal. No two meals are in fact alike even with the same ingredients, and if you don’t know how to cook you won’t succeed with the recipe. No two patients are alike even with the same symptoms. I just saw a patient with symptoms of ADHD, but when her story was teased out that was not what she had. Schizophrenia and DID have most symptoms in common, but they are radically different disorders.I could go on. Moreover, each member of the DSM committee has a different agenda, just as different cooks lean to different ingredients. I heard one member of the task force assert that affect and emotion are the same!
The truth of the matter is that the aim to construct a diagnostic manual that everyone can agree on is a pipe dream. Such a manual seeks to objectify conditions that are not objects. It’s like building castles in the air. Dr. Insel seems to say that DSM 5 will do until something better comes along. I doubt anyone can come up with something better – ever. I hate the DSM system, even though I was involved in the validation of DSM III and its initial introduction. Still, I use the compendium, while defining what is actually going on, so at least I know what that is. But I don’t believe psychiatric diagnosis can be manualized.
There is no point to and there should be no desire to construct a diagnostic manual to satisfy all constituencies and special interests. That is pork barrel politics, not real science. Maybe climate science started this whole annoying trend of government bodies voting on the truth, but the fact is that a theory or a concept is valid (or at least temporarily valid as the best we can do given the state of knowledge) whether or not it is testable and falsifiable, period.
The whole idea of a large committee writing a book like this is absurd. It’s too bad that someone who really understood the subject of mental illness classification such as Paul Meehl didn’t write it when he was alive, as I have no doubt it woud have been better than the brain-deadness that arises out of committees.
Think about any of the “NOS” disorders. Basically, these are nonentities reclassified as nosological entities. Viola, “science” by fiat! For one purpose-so people can get paid. No one can defend these scientifically. Or logically. Assume A is a taxonomically valid construct. DSM insists that not A is A. Even in its prefaces, DSM (4) reminds the reader that A may not necessarily be A anyway, so what is the point? At some point, this turns into a Monty Python sketch.
The truth is we can easily make DSM better by tightening up the categories and eliminating the nonsense. If that makes monied interests angry, too bad, that’s not a reason to be unscientific. Let them argue that Axis 2 and Axis 4 disorders should be reimbursed.
Talk about being manipulated by inappropriate forces into professional alterations to be assimilated! We have been effectively converted by Managed Care/Big pharma who are the Borg!
Think about the one fact that that Managed Care refused to acknowledge Axis 2 as a disorder worthy of reimbursement for treatment, how has the APA handled this over the years to this DSM insult now? First psychiatry made everyone with “mood swings” Bipolar, then added Adult ADD into the lability process along with PTSD for any and all traumas as explanations for people, yet could not explain why all those med trials kept failing to impact on the symptoms. Couldn’t bill for characterological factors, so cram that aquare peg away in the round hole. Ouch!
Now, just do away with the role of Personality, period! This is leadership, this is academic problem solving, this is responsible diagnostic assessment?! Nah, this is ultimate sell out.
When medicine as a profession allowed the frank antisocial element that pervades profit seeking in this country to intrude into care, it destroyed itself, and psychiatry is that ugly poster child of the Gordon Gekko character in “Wall Street. Greed was not only accepted as good, but as the sole drive to the profession per what leadership wanted.
If you as a provider buy DSM 5, you are only aiding and abetting the destructive process endpoint. Hey, while just my opinion, tell me I am wrong and give honest rebuttal to how the hierarchy made healthy and responsible decisions these past 15 years with managed care and big pharma lurking behind them!
You can’t if you are honest and attentive.
Psychiatric diagnoses are fungible depending on whether insurance will or will not reimburse for them. And some folks still wonder why psychiatry, psychology and the social sciences are considered a laughingstock by many.