The DSM Process: More Questions Than Answers?

Posted on February 3, I asked the question, CAUTION! Who Should Be the DSM5 Diagnostician? I suggested that we needed to pay as much attention to who would be designated as the diagnostician as on the revised diagnostic criteria. I recommended that psychiatrists be designated as the primary DSM5 diagnostician. This, of course, was different from the open-ended criteria stated in the Cautionary Statement of our current DSM-IV. The brief statement on the DSM on the Website of the American Psychiatric Association states:

“It can be used by a wide range of health and mental health professionals, including psychiatrists and other physicians, psychologists, social workers, nurses, occupational and rehabilitation therapists, and counselors.”

Left unsaid is what is meant by “used.”

I received many comments, including directly to me, to the blog, and in the cases of Drs Carlat and Pies, with their own formal blogs on the subject. I also tried to obtain a response or explanation from the leadership of my APA, to no avail. All these reactions, both pro and con, implied to me that there are even broader and more complex questions that need to be addressed, including the following:

1. Don’t We Still Need A Comparative Research Study on Diagnostic Skills?

As far as I know, we have never compared the different mental health disciplines as to diagnostic skills. Why not do that before we finish and publish a new manual? In addition, why not include a representative sample of primary care physicians in the process? That way, we will more surely know if the usual medical training of psychiatrists makes much significant difference. Or, are we really talking about different individual skills regardless of discipline? Or, are other variables a key to competent diagnosing? For instance, is it even more essential for a psychiatrist to be making the diagnosis in geriatric patients when medical considerations are even more likely?

2. Do We Need to Consider Publishing DSM5 as a Combined Interdisciplinary Project?

Though I strongly doubt it, let’s say that all mental health disciples are relatively equal as far as diagnostic skills. Why not then have the next DSM published by a consortium of mental healthcare organizations instead of just the American Psychiatric Association? This process would also be more likely to incorporate the unique areas of knowledge of each discipline. Profits from sales would be shared.

3. Don’t We Need a Monitoring Process for the Quality of the Diagnosis?

Though accountability, outcome measurement, and best practices have become expectations in medicine and psychiatry, that doesn’t yet seem to be applied to the diagnostic process in psychiatry. My extensive administrative experience since DSM-IV came out is that most clinicians ignore the criteria, even though they are so easy to use, and instead go by their own diagnostic process, which may or may not parallel DSM-IV. This variation includes the usual amount of time spent doing an evaluation, which might range form fifteen minutes to 2 hours. Perhaps monitoring would be another way to determine who is skilled enough. As the psychologist John Riolo, Ph.D commented to my blog:

“reducing the numbers who legitimately are able to do so will be a safeguard to patients and help minimize abuse.”

How might DSM5 be monitored? Consider a national panel of wise, conflict-free, and retired clinicians like him to be selected and designated as national “Qualitists” to monitor the quality of diagnosing.

4. Should We Consider a New Revision of DSM-IV Rather Than a New DSM5?

If DSM5 is not going to be a paradigm shift, as claimed, why not just another revision of DSM-IV, for as I wrote in the prior blog, and Dr. Carlat seemed to affirm in his:

“If we gradually obtain neuroimaging and/or genetic markers to improve diagnosing, it would seem that the diagnostic process will become even more of a medical one, most suitable for psychiatry... “

5. Should the Publication of DSM5 Be Indefinitely Delayed?

We’ve already delayed the expected publication in 2012 to 2013? Why not wait longer until we have time to address these and other issues? As psychiatric physicians, maybe a paradigm shift would allow us to call what we treat psychiatric diseases instead of mental disorders. Diseases are what the rest of medicine diagnose and treat. We then might have a Diagnostic and Statistical Manual of Psychiatric Diseases. Other disciplines would be welcome to devise criteria for mental disorders that are not deemed to be psychiatric diseases.

If diagnosis has important implications for treatment, research, and the roles of each professional discipline, answering such questions becomes important to the public and society. This is an opportunity that seems to come along only every 20 years or so.