Is a New DSM Necessary, and How Should It Look?

As the American Psychiatric Association has started sharing early recommendations for the future of the Diagnostic and Statistical Manual of Mental Disorders (DSM), discussion about a new DSM are coming to the forefront. Editor in chief of Psychiatric Times, John J. Miller, MD, shared his thoughts in a series of exclusive interviews.

Is the DSM Helping or Hindering Patient Care? Rethinking Diagnosis, FDA Approval, and Access to Treatment

Miller framed a future DSM through what he called the “DSM house of cards,” a metaphor meant to capture both the influence and fragility of the diagnostic system.^1,2 Across multiple iterations, he noted, DSM diagnoses have often been treated as fixed representations of psychiatric reality rather than as provisional constructs designed to facilitate communication, research, and clinical decision-making. “Each iteration is viewed as the dogma or the concrete diagnostic reality of psychiatric disorders rather than as an approximate tool,” he said, emphasizing that the DSM was intended to support dialogue, not constrain it.

One of the most consequential downstream effects, Miller argued, is the way DSM diagnoses become tightly coupled to drug approvals by the FDA—and, by extension, insurance coverage decisions. Although the FDA appropriately requires a clear diagnostic target when evaluating medications, DSM diagnoses themselves are fluid and subject to change as scientific understanding evolves. “The problem is the DSM diagnoses are fluid,” Miller said, noting that they are “not absolute and will change over time.”

He suggested that the field may need to “knock down this house of cards” and reembrace the DSM as a living framework—one that evolves alongside neuroscience and clinical evidence, without becoming rigidly embedded in regulatory and reimbursement structures. For practicing psychiatrists, the discussion underscores a familiar tension: balancing diagnostic precision with clinical reality in a system where labels, approvals, and coverage decisions remain deeply intertwined.

References

1. Duerr HA. A New and Improved DSM? The American Psychiatric Association Shares Strategy and Roadmap. Psychiatric Times. January 28, 2026. Accessed January 29, 2026. https://www.psychiatrictimes.com/view/a-new-and-improved-dsm-the-american-psychiatric-association-shares-strategy-and-roadmap

2. Miller JJ. Updating the DSM: Reviewing the New APA DSM Recommendations. Psychiatric Times. January 29, 2026. Accessed January 26, 2026. https://www.psychiatrictimes.com/view/updating-the-dsm-reviewing-the-new-apa-dsm-recommendations

Why Global Integration Is Essential for the Future of DSM

Dr Miller continued raising a fundamental question for psychiatrists as the field looks ahead to the next iteration: Should the DSM remain a US-centered diagnostic manual or evolve into a truly global classification system?

“It makes sense to me to work with the World Health Organization (WHO) and actually integrate or transition DSM into the next iteration of the [International Classification of Diseases] ICD, which will be the ICD-12,” Miller commented. One recommendation from the DSM workgroup that Miller strongly endorsed was the proposal to add a section on “contextual factors.” This section would include socioeconomic factors, cultural factors, and environmental factors, reflecting a broader understanding of how mental illness presents and is treated in real-world clinical settings.

Miller highlighted the paper, “The Future of DSM: A Report from the Structure and Dimensions Subcommittee,” which is 1 of the 5 that were released from the APA regarding plans for a new addition.^1-3 Interesting, he noted of the 14 authors, most are from the United States but 2 bring in international diversity, representing Canada and the Netherlands.

Miller also drew attention to a growing disconnect between the DSM and the ICD. DSM-5-TR , which was released in 2022, currently uses ICD-10 codes. Coincidentally, the WHO released ICD-11 in 2022. “The timing was unfortunate,” Miller said, noting that a commentary in the Journal of the American Medical Association estimated the United States may not transition to ICD-11 until at least 2027.

The disconnect between the 2 manuals highlights structural differences between a US-based diagnostic manual and a global classification system used across medical specialties worldwide. For psychiatry, integration could carry both practical and symbolic weight. “The advantage of this is we’re moving from a United States-based manual to a world-based manual,” Miller explained, adding that integration into ICD-12 could help reduce stigma. “It’s another step in the direction of destigmatizing mental illness.”

References

1. Ongur D, Abi-Dargham A, Clarke DE, et al. The future of the DSM: Areport from the structure and dimensions subcommittee. Am J Psychiatry. 2026 Jan 28:appiajp20250876.

2. Wainberg ML, Alpert JE, Benton TD, et al. The future of DSM: A strategic vision for incorporating socioeconomic, cultural, and environmental determinants and intersectionality. Am J Psychiatry. 2026 Jan 28:appiajp20250875.

3. Drexler K, Alpert JE, Benton TD, et al. The future of DSM: Are functioning and quality of life essential elements of a complete psychiatric diagnosis? Am J Psychiatry. 2026 Jan 28:appiajp20250874.

Updating the DSM: Reviewing the New APA DSM Recommendations

Miller reviewed the historical context of the DSM, noting its first publication in 1951, the release of DSM-5 in 2013 with major revisions from DSM-IV, and the DSM-5-TR in 2022, which currently serves as the working manual and incorporates ICD-10 billing codes. In 2024, the APA Board of Trustees established the Future DSM Strategic Committee in recognition of rapid scientific and clinical changes affecting psychiatry.

Miller explained that the publications proposed 4 domains to serve as a potential organizing template for the next DSM.^1,2 He reflected that the proposed framework evoked elements of the multiaxial system used in DSM-IV and DSM-IV-TR, which had previously been eliminated in DSM-5. He highlighted parallels between the new contextual factors domain and the former axes addressing medical comorbidities, psychosocial stressors, and global functioning. In particular, he emphasized the value of Axis V and the Global Assessment of Functioning as a longitudinal measure of patient functioning.

References

1. APA releases roadmap for the future of the DSM. American Psychiatric Association. January 28, 2026. Accessed January 29, 2026. https://www.psychiatry.org/News-room/News-Releases/APA-Releases-Roadmap-for-Future-of-DSM

2. Oquendo MA, Abi-Dargham A, Alpert JE, et al. Initial strategy for the future of DSM. Am J Psychiatry. 2026.

Dr Miller is Medical Director, Brain Health, Exeter, New Hampshire; Editor in Chief, Psychiatric Times; Voluntary Consulting Psychiatrist at Seacoast Mental Health Center, Exeter/Portsmouth, NH; Consulting Psychiatrist, Insight Meditation Society, Barre, Massachusetts.