The DSM-5: Will the New Manual Work in the Field?

Written by on May 3, 2012 in Research & Technology - No comments
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By Lloyd Sederer, MD

The debate rages on about the Diagnosis and Statistical Manual of Mental Disorders, fifth edition (DSM-5), due for release next year by the American Psychiatric Association (APA). Arguments abound over what disorders should be included (and what should be listed within each respective disorder, like autism or psychosis) and what should not be included; what is science and what is opinion; what stigmatizing dangers may exist from diagnosis; and the sheer volume of conditions that will find their way into the manual’s pages. Some conspiracy theorists claim that the APA is in bed with pharmaceutical companies, while others see a psychiatrist cabal that seeks wheelbarrows of money from the sales of this next edition.

A diagnostic manual of mental disorders cannot be eluded. Clinicians must have ways to declare their observations as specific conditions so they can communication with each other and to patients and families. Researchers depend on these reliable diagnoses to study the effectiveness of treatments, and the course and prognosis of diseases. Every insurance entity including Medicare, Medicaid, United, Aetna, Blue Cross Blue Shield (BCBS), Kaiser and countless others requires a diagnosis for payment – just as they do for heart and neurological conditions, asthma, diabetes, cancers and all the other maladies that impact the human race. International classifications of diseases, as well, must harmonize with the DSM to inform global public health practices and researchers: the DSM is not going away.
As the winds of controversy swirl, events are taking place that you might want to know about, and that might – might – settle some of the contention. The APA is field testing the DSM draft to see how it works.

The DSM-5 field trials

The draft DSM-5 is being tested in real-world clinical settings. Two studies will examine how the diagnostic criteria work with those who will actually use and be impacted by DSM-5, namely patients and clinicians. The first (and larger) of the two field trials involves 11 Academic Medical Centers (AMC) in the United States and Canada. These sites were selected from 65 applicants based on their capabilities to recruit and study a diverse group of participants (e.g., children, adults, seniors and ethnicities). This trial will allow the APA to compare the prevalence (rates of a condition in a population) of the disorders among AMC patients who would be given a DSM-IV diagnosis with those who would be given a similar diagnosis using the new criteria in the DSM-5.

The second type of field test involves routine clinical practice settings (RCPs). This DSM field trail will specifically examine small group or solo practices. The field work will involve a random selection of general adult psychiatrists and specialists in geriatric, child/adolescent and addiction psychiatry, and those that consult to medical colleagues as well as psychologists, advanced practice psychiatric nurses, licensed counselors, licensed marriage and family therapists, and licensed clinical social workers. This study will especially focus on how feasible and useful are the new criteria as well as the manual’s measures of severity of illness. The field trials will concentrate on conditions that are new (e.g., autism spectrum disorder), or that are significantly different than the preceding manuals (e.g., personality disorders), as well as conditions at the forefront of public concern such as post-traumatic stress disorder (PTSD). The field trial participants, however, will have all the new, proposed criteria for their use and input.

In addition to the proposed diagnostic criteria, the field trials will assess “severity measures” and cross-cutting symptom lists (new to the manual). Participants will use a severity rating scale and measures for a clinician to record symptoms such as anxiety, depressed mood, substance use, or difficulties with sleep or attention that occur across a wide variety of diagnostic conditions. For example, in everyday practice clinicians see people with depression who also suffer from anxiety, or individuals with bipolar disorder or PTSD who have insomnia. The field trials will assess whether the severity measures and symptom lists provide useful information and capture clinical change over time, which is essential to how clinicians determine response to treatments.

Previous DSM-III and DSM-IV field trials did not ensure that participating clinicians were not affiliated with the manual’s development; in fact, previous field trials were done by the experts who drafted the manual. The current DSM-5 field trials also use a larger and more diverse sample of participating clinicians and patients. These actions were taken to help to reduce bias and improve the generalizability of the findings. Patients and clinicians also have an unprecedented voice in shaping the proposed manual and its measures.

What happens then?

The results of the field trials will be reported at the APA annual meeting this May and shared with professional and consumer groups for their feedback. Reports will also be published in peer-reviewed scientific publications. The field trials and feedback received from patients, consumer advocacy groups, and the public will inform further revisions to diagnostic criteria or severity and symptom measures.
There has been a lot of smoke from the DSM fires. The field trials should help all concerned see through the smoke and into the embers of advancing the complex and continuous process of improving what we know about diagnosis in psychiatry.

For more information see the DSM-5 website: www.dsm5.org

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