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May 20, 2013

It's here: How the new DSM will affect health care

Daily Briefing

The American Psychiatric Association (APA) last week released the highly anticipated update to the Diagnostic and Statistical Manual of Mental Disorders (DSM), which was designed as a "living document" that changes as research evolves rather than once every 20 years.

Released nearly 20 years after the DSM-IV, the manual's fifth edition was created over a 14-year period with input from more than 1,500 clinicians and researchers, according to the APA.

The new, digital guide is designed to be updated regularly as a "living document," according to David Kupfer, head of the DSM task force. As such, the guide will not be referred to as the "DSM-V." Instead, it will be the "DSM-5" and future updates will be noted as "DSM-5.1," "DSM-5.2," and so on. 

Altogether, DSM-5 includes about 160 disorders, roughly the same number as the DSM-IV. However, those disorders are "sliced" differently, according to APA President-Elect Jeffrey Lieberman. Some of those changes—including the expanded list of addictions, which now includes gambling and online shopping, and the exclusion of the Asperger's syndrome—have been highly controversial.

In addition, some experts warn that the new DSM lowers the criteria for most mental illness, requiring fewer symptoms for a shorter period of time to obtain a diagnosis. Allen Frances—who lead the development of the DSM-IV—warns of a "hyperinflation" of diagnosis.

Meanwhile, some experts have critiqued the new DSM for its lack of scientific backing. According to National Institute of Mental Health Director Thomas Insel, the guidelines may be the best tool currently available to clinicians treating patients, but they suffer from a scientific "lack of validity."

Lieberman notes that the DSM-5 "can only reflect the research we have."

How the DSM-5 will impact treatment

Writing in the New York Times earlier this month, psychiatrist Sally Satel argues that psychiatrists likely will not alter treatments to fit the DSM-5. "The media will trumpet the release of the new DSM, but practicing psychiatrists will largely regard it as a nonevent," she writes.

However, Satel notes that the guide remains important because insurance companies cover services "only if there is a diagnosis." The DSM-5 "offers discrete categories" that "provide a common language practitioners can use to discuss patients."

Meanwhile, Wall Street Journal notes that the DSM is used to identify study participants, to make decisions on grant funding and research publication, and to guide drug approvals.

Some experts—including Insel—argue that the DSM now should be used primarily in clinical settings. "It's no longer the best guide for research," Insel says (Begley, Reuters, 5/17; Wang, Wall Street Journal, 5/17; Satel, New York Times, 5/11; Gever, MedPage Today, 5/16).

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