DSM-V: Suggestions for Change

With the recent announcement (PDF) by the American Psychiatric Association of a one year delay for the latest revision of the Diagnostic and Statistical Manual of Mental Disorders (the DSM, as it’s known), a new round of commentary and articles have appeared questioning the usefulness of the DSM.

The DSM is used by clinicians in the mental health field to diagnose mental disorders according to the symptom lists contained in the book. The DSM is also used by researchers to ensure that when one researcher is talking about treatments for “major depression,” another researcher will use the same definition for “major depression.”

I’m no defender of the DSM revision process, as previous blog entries have noted. But I’ve noticed that sometimes the criticism moves from well-couched concerns (e.g., the lack of transparency into the process; the signing of non-disclosure agreements by those involved, etc.) into hyperbole and an endless series of “what-if’s.”

I haven’t seen critics address how the DSM is any different than the World Health Organization’s ICD-10 (PDF), which is the international book of health diagnoses. It, too, undergoes regular revisions, a process which at times has been controversial. And like the DSM, it does so at very long intervals (the ICD-10 was first published 23 years ago and is only now undergoing a revision that will result in the ICD-11).

But that’s the nature of these efforts. There’s no way you can update or make changes to what are largely described by subjective, behavioral symptoms (in the case of the DSM) — e.g., things you self-report about the way you are feeling or behaving — without engaging in some controversy. And it takes time to work out all of the issues. Trying to shoehorn what is supposed to be a thoughtful, research-focused process into a fast-moving, constantly-changing process seems ill-advised and short-sighted.

If you disagree with the validity of this diagnostic process, that’s a fine and legitimate argument to make. Many do, and call for alternative methods for classifying behavioral dysfunction (although none have ever taken off). But that’s a very different argument than the argument I see most critics making, like this one from New Scientist:

It doesn’t have to be this way. With the advent of the internet, there is no longer any compelling need to rewrite the diagnostic criteria for the whole of psychiatry in one go.

Outside of the well-known Wikipedia, I don’t know of a single reference book that has gone the way of constant, electronic updates only. Is this really a wise suggestion on how to run a mental health care system, where diagnoses are constantly changing and being “updated?” Realistically, what clinician or researcher is going to keep up with such a system? And how would that take the controversy out of updating the diagnoses themselves?

Which brings us back to the stability of diagnostic categories and definitions. Most diagnoses should be as most clinicians and researchers use them — stable and unchanging, for the most part. Today, nearly any mental health clinician can rattle off the diagnostic criteria for major depression and the differential for bipolar disorder. If these are changing every year, or even every five years, that means a constant re-learning of knowledge clinicians and researchers thought they knew (and need to use on a daily basis).

Which isn’t to say that diagnoses shouldn’t be updated when the preponderance of research evidence suggests the current set of symptoms is incomplete or somehow wrong. Just that diagnoses shouldn’t be these constantly-changing, moving targets.

Some of the blame for the current controversy can be attributed to poorly thought-out comments made by David Kupfer, the chair of the DSM-V task force. Kupfer doesn’t seem to understand the significance of the diagnostic system and how it’s actually used by hundreds of thousands in daily use. You can’t just throw out comments about how “there are no constraints on the degree of change” that can be made in the DSM-V and expect that to sit well with the people who actually depend and rely on the DSM. As I’ve said previously, despite Kupfer’s comments, there will not be significant, game-changing alterations to the current DSM-IV. How do I know this? Because to do so would call into question the continued use of DSM-V in clinical and research practice. Clinicians, researchers and insurance companies in the U.S. could fairly easily switch to the ICD-10 criteria (which are largely the same as the DSM-IV criteria) and just ignore the DSM-V.

Workgroups need privacy to work on their business, but then that business should be made public in a timely manner. Bills in Congress, for instance, are written and wrangled out behind closed doors, which is the way most nonprofit organizations, universities, companies and even some researchers conduct their ordinary business. To try and conduct significant business in a group of more than a dozen or two people is not only difficult, it can be downright impossible. But minutes of meetings and transparency is a part of the governmental process, and we expect the same from our nonprofit organizations tasked with such an important update.

Fixing the DSM Revision Process

All of which suggests some obvious ideas for improving this process in the future:

1. Workgroup meetings should be more transparent. While not necessarily needing absolute 100% transparency in real-time, minutes of meetings should be made available to the public (not just cleaned-up summaries). Updates should occur more often than twice a year (we’ve only had a single workgroup update in all of 2009, with only 2 weeks left to go in the year).

2. The book should be released in draft form and open for comments and revisions for at least 6 months. What better way to fix the most obvious concerns or problems that come from a revision like this than to open it up to public scrutiny before its final release?

3. Editors should respond publicly to relevant, targeted criticism, questions and concerns about the draft in a set of ongoing, respectful conversations. If the BMJ can take and publish rapid responses to research papers, why can’t other organizations follow their lead?

4. New diagnoses to be added must meet a set of minimal criteria, published and agreed upon ahead of time. What better way to ensure special interest diagnoses don’t make it into the book than to have a set of objective, research-based criteria ahead of time?

5. DSM task force chairs should refrain from speaking to the media during this process. Media are in a different business than researchers working on updating a diagnostic manual, and they have very different goals. Media sometimes exists to generate controversy and stories, even at the expense of actual knowledge. “Trying diagnoses” in the court of public opinion is no way for a scientifically-based reference book to be written.

6. Give up on old ideas never embraced. The DSM task forces can learn a lot from history. The concept of trying to tie diagnoses to severity scales has been tried somewhat (e.g., the GAF), and basically failed. Forcing it upon clinicians (and researchers) when it’s clearly not a concept clearly and widely accepted is untenable and unwise. It also has the potential to create dysfunction and disorders where there are none.

7. Ensure workgroups are a balanced mix of real-life clinicians and researchers and conflicts of interest are declared. Many people believe the current workgroups are too biased toward academic researchers, who ordinarily don’t practice. Easily fixed by a careful balancing and vetting process ahead of time. Conflicts of interest should be noted ahead of time and workgroups should be organized taking these into account (e.g., no more than 25 or 30% of members should have such past — not current — conflicts).

8. Dump the non-disclosure agreements. There’s no need for them in this process. Simple common sense should be substituted instead. If workgroup minutes are made regularly available, they will speak for themselves (and won’t need others to interpret what is actually being discussed).

Sadly, I know none of these suggestions will be adopted for the current revision, because of the size of egos involved and the belief that “nothing’s broken” in the current process. But perhaps the American Psychiatric Association is listening and will work toward implementing some of these ideas for future revisions of the DSM. Because if the process doesn’t change, the DSM may indeed go the way of the dodo bird.

You’re welcomed to read the lengthy background about the current troubles with the DSM-V revision process here: Psychiatry’s civil war and the accompanying editorial, Time’s up for psychiatry’s bible.