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

As the American Psychiatric Association begins outlining early recommendations for the future of the Diagnostic and Statistical Manual of Mental Disorders (DSM),^1,2 questions about how the manual is used—and misused—are again coming to the forefront. In a recent video commentary, John J. Miller, MD, editor in chief of Psychiatric Times, reflected on what he described as the DSM’s evolution from a shared clinical language into a rigid structure that can unintentionally hinder patient care.

In an exclusive interview with Psychiatric Times, Miller framed the issue through what he called the “DSM house of cards,” a metaphor meant to capture both the influence and fragility of the diagnostic system. 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 FDA drug approvals—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.”

This disconnect creates challenges in everyday clinical practice. Medications approved for one diagnosis may demonstrate benefit across multiple conditions, yet insurers often deny coverage if the prescribed use does not align precisely with the FDA-approved indication. Miller pointed to selective serotonin reuptake inhibitors as a familiar example: initially approved for unipolar major depression, these agents are now widely used across a range of psychiatric disorders. Despite this, coverage may still be denied because “the drug’s not FDA approved for that” indication.

The result, he explained, is a system that places stress on all parties involved—patients, families, clinicians, and payers alike—while delaying or preventing access to optimal treatment. “Ultimately, what happens is our patients do not get access to the best possible treatments,” Miller said.

Although he stopped short of proposing a specific solution, Miller emphasized the importance of clearly defining the problem. He suggested that the field may need to “knock down this house of cards” and re-embrace 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.

Your Thoughts?

We want to hear from you. What are your current frustrations with the DSM? How do DSM diagnoses influence your real-world clinical decision-making? We welcome brief commentaries and/or short video submissions from practicing clinicians you’re your perspectives, challenges, or potential solutions to help shape the ongoing conversation about the future of psychiatric diagnosis.

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.

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

How You Can Make a Difference: The PRiSM Challenge

Psychiatric Times is accepting submissions for the PRiSM writing challenge, which invites clinicians and researchers to explore PRiSM as a potential alternative framework to traditional DSM-based diagnosis. Full guidelines and submission details are available here.