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DSM-5 — Back to the Drawing Board?

MANAGED CARE September 2013. © MediMedia USA
Feature

DSM-5 — Back to the Drawing Board?

Mental illnesses are being redefined as science advances, but don’t believe reports of a war between the APA and the NIMH

Susan Worley

Emotions have been running high in the field of behavioral health care ever since two milestone events converged last spring. In May, the American Psychiatric Association (APA) published the fifth edition of its diagnostic system of classification, the Diagnostic and Statistical Manual (DSM), which had begun to receive mixed reviews more than a year before its release. And only a few weeks earlier, the National Institute of Mental Health (NIMH), already at work on a new system for classifying mental disorders based on genetics and neurobiology, announced that it will gradually shift funding away from research based on DSM categories. Since then, blogs, editorials, and articles laced with bellicose language and misinformation, many insisting that the APA and NIMH are at war, have left many professionals and lay people alike feeling deeply unsettled.

“With all of the controversy that’s been in the media lately, I can understand why these issues have been confusing for the lay public,” says Amir Kalali, MD, vice president and head of therapeutic strategy for neuroscience at Quintiles, a consultant to the pharmaceutical industry, “but there is no reason to panic. For the foreseeable future, clinicians will continue to use the DSM for practical reasons and, initially, the RDoC [the NIMH’s Research Domain Criteria project] will be most useful for research. I am sure the NIMH will not do anything to suddenly disrupt current research; they are really talking about future funding. I am hopeful that science will eventually get us where we need to be, but it is not going to happen overnight; it is going to take some time.”

At the core of the tumult is the intricate task of defining mental illness. The DSM, frequently referred to as psychiatry’s bible, is used above all for two very practical purposes: diagnosis and payment. It provides a common currency that enables providers, payers, and patients to engage in necessary transactions. But because defining mental illness raises a welter of profound political, economic, personal — and, most recently, scientific — issues, a single manual that claims to offer decisive answers to hugely complex questions is bound to attract criticism.

Common language

Before the publication of DSM–III in 1980, psychiatrists and other behavioral health care practitioners lacked a common language for diagnosing patients with mental disorders. Studies have shown that in earlier times, a fixation on questionable, and at the time unknowable, causes of mental disorders led to such confusion that one patient could easily receive distinctly different diagnoses from different clinicians. The release of DSM–III signaled the beginning of descriptive psychiatry, a relatively reliable diagnostic method that has zeroed in on signs and symptoms of psychiatric disorders, rather than on their causes.

Without yet-to-be-developed tools such as neuroimaging and genetic analysis, it made sense to base diagnoses on symptoms; however, the subjectivity and cultural biases that crept into various definitions of mental disorders pointed to some of the inherent weaknesses of a descriptive system (it was not until 1973, for example, that experts removed homosexuality from the DSM). Sophisticated technology has been revealing the arbitrary and fundamentally flawed nature of a classification that once served a useful purpose, and now points to the need for a new common language, one rooted in science.

Pamela Greenberg, president and CEO of the Association for Behavioral Health and Wellness (ABHW), stresses that many behavioral health care concerns are far more pressing than those related to the DSM — among them, the coming expansion of the insured population, a worrisome shortage of providers, and issues related to mental health parity. However, she adds that critical administrative tasks related to DSM–5 changes must be at the top of the agenda for every managed behavioral health organization (MBHO).

Pamela Greenberg

Evaluating the impact of the new manual is among the challenges facing managed behavioral health care organizations, says Pamela Greenberg, CEO of the Association for Behavioral Health and Wellness.

“There are a lot of redesign implications associated with the revised DSM, and right now many MBHOs are in an impact analysis phase,” says Greenberg, “They are looking at the impact on IT operations, on system operations, on benefit packages, and potential related expenses. With the way that some of the diagnostic criteria have expanded, we may see an uptick in diagnosis and utilization, and therefore pricing adjustments may be needed. Although the APA would like to have DSM–V implemented by January 1, 2014, with ICD-10 implementation coming later next year, many MBHOs will not be able to meet APA’s timeline. DSM codes have typically been used to help providers and others diagnose a behavioral health disorder and determine its severity, but the ICD codes are the ones payers use for billing purposes.

While there is no formal mandate requiring MBHOs to complete these administrative tasks by a certain date, the APA is encouraging full implementation of DSM–5 before January. However, because the DSM was last updated in 1994, Greenberg says, MBHOs are new to many of the administrative tasks involved.

“There should be a recognition that these updates take time and money,” says Greenberg “I’ve been with ABHW for 15 years, and this is the first time I’ve ever gone through this process. By the time the next DSM is released, we’ll understand right away how to go about the implementation process.”

How do MBHOs feel about a new system of classifying mental disorders based on science?

“Just like everyone else, we’ve been hearing about the controversy in the media, but from the perspective of our members, the more information, the better. We believe that new scientific information will only be helpful — in terms of bringing potentially new treatments to the field and new resources to our providers. It should help us to better understand diagnoses and better determine medical necessity criteria.”

Where things stand now

For those wondering why the APA stopped affixing roman numerals to the DSM, there’s a simple answer: More frequent revisions are expected.

According to the APA, this change reflects the organization’s intention to make future revisions more responsive to breakthroughs in scientific research.

Incremental updates will be tied to scientific advances and will be identified with decimals (e.g., DSM–5.1, DSM–5.2) until a new edition is warranted.The APA and the NIMH, far from being feuding enemies, will be working together to lay the groundwork for a future diagnostic system. For now, the organizations agree that current DSM and ICD categories provide the best information for guiding the clinical diagnosis of mental disorders. They also agree that while RDoC will help guide the classification of patients for research studies, it will not be immediately useful as a clinical tool.

PBMs and health plans, far from being caught in a crossfire, seem poised to make benefit decisions as new evidence becomes available.

Susan Worley is a freelance writer who specializes in science and medicine.

Reconsidering the boundaries between mental disorders

The fact that we are having a debate about how to think about mental disorders is a good thing,” says Jordan W. Smoller, MD, ScD, associate vice chairman of Massachusetts General Hospital’s department of psychiatry and professor of psychiatry at Harvard University. “When we began to rely on categories that were essentially a product of expert consensus, beginning with the development of the modern DSM, it was understood that these were provisional diagnoses, and that as information came on board, as research progressed, we would work to make these more sophisticated, more valid, and more grounded in what we’ve come to understand about the mind and the brain. I am optimistic that it is exactly the process that we are seeing play out here.”

Jordan W. Smoller, MD

“Psychiatry is not alone, says Harvard’s Jordan W. Smoller, MD, ScD, in having its categories thrown into question by new knowledge.

Smoller is a member of the large international consortium of investigators that earlier this year published findings that five different psychiatric illnesses — schizophrenia, autism, bipolar disorder, major depressive disorder, and ADHD — have common genetic underpinnings. In particular, they found that variations in genes that affect calcium channel activity play a role in all five disorders. For the first time, research has provided evidence that distinct disorders may have what Smoller refers to as a “shared biology.”

“This research has challenged our older ideas regarding discrete categories of mental disorders,” says Smoller. “We learned that disorders that we thought of as quite different may not have sharp boundaries.”

While this study suggests that genetics may eventually help to predict and even prevent psychiatric disorders, Smoller says that research is still in the very early stages.

“The genetic variations identified in the study are considered relatively common, and they confer, by themselves, only a tiny increase in risk. So you could have all the variants mentioned in the study and still not develop a disorder, just as having high cholesterol may increase your risk for heart disease but won’t guarantee that you will have a heart attack. As researchers identify more variants that confer risk, it may be possible to combine these risk factors into genetic risk scores or genetic risk profiles that may actually be more predictive.”

Research also may lead to the identification of new molecular targets for psychotropic drugs, but it’s unlikely that new treatments will emerge right away.

“We are beginning to lay out a basic map with regard to genes and brain functions involved in psychopathology. Research will continue to tell us more about important risk factors for particular psychiatric disorders. Some may turn out to be environmental.”

Meanwhile, research has underscored the need to re-examine the boundaries between disorders.

“The need to revisit definitions of disorders is not really unique to psychiatry,“ says Smoller. “We have a system of classifying cancer, for example, that dates back to the late 19th century, and recently experts have agreed that it’s time we updated it.

“And cancer experts are recognizing something that we also recognize in psychiatry — that just the words that are used to create diagnostic categories can have a tremendous impact on people.

“Diagnostic categories are important in the real world because they are the foundation of reimbursement, but they also have a weight of their own, and impact the way we look at ourselves and each other.

“We have to be as careful and as responsible as we can be as we begin to evolve new categories. The NIMH is appropriately taking a lead in moving the field in the right direction.”

As the new DSM draws fire, an argument for common sense

I know the updates in DSM-5 have spawned quite a bit of debate, but for the day-to-day workings of a typical psychiatric practice, I’m not sure they amount to major changes,” says Marvin S. Swartz, MD, head of social and community psychiatry at Duke University. “This new revision, which features the elimination of Asperger’s syndrome, has had a much bigger impact on autism advocacy groups, for example.”

Marvin S. Swartz, MD

“Critics squawk sometimes when human behavior is pathologized, says Duke’s Marvin S. Swartz, MD, — and sometimes when it isn’t. He’d liked to see more of a focus on prevention.

The very vocal reaction to the removal of Asperger’s syndrome from DSM-5 may be seen as somewhat ironic in light of previous objections to DSM changes. In the past, the invention of new categories of mental disorders has led critics to charge psychiatry with “disease mongering” and pathologizing normal human behavior. But now, with the removal of Asperger’s syndrome, patients, providers, and advocacy groups are outraged by the loss of the category.

“That’s the other side of the coin,” says Swartz. “Retaining the diagnosis of Asperger’s is important to patients and families because it affects reimbursement. The loss of this category may mean the loss of access to treatment. The diagnosis is necessary for coverage — it’s a good illustration of the administrative uses of a diagnosis in the realm of health insurance.”

Other contested changes to the manual have raised concerns about excessive costs, unnecessary testing and treatment, and a range of forensic and other issues. Among the most talked-about changes is the recent removal of the bereavement exclusion from the diagnosis of major depressive disorder. Swartz says he is able to see both sides of this issue (removing this exclusion may lead to an increase in treatment and costs) — but does that mean he is or isn’t in favor of the recent change to the DSM?

“I’m in favor of common sense,” says Swartz, “If you see a person who has all the signs and symptoms, all the hallmarks of depression, the fact that it began as a loss should not prevent a patient from pursuing treatment. One of the benefits of descriptive psychiatry was the common-sense recognition that we don’t know all the causes and risk factors for any disorder. Making certain presumptions about etiology at this point is unwise. We don’t know that bereavement can’t cause major depression.”

Also engendering debate are new criteria in DSM-5 that now qualify individuals as having post-traumatic stress disorder (PTSD) when they merely learn about a traumatic event secondhand. Swartz understands why clinicians and other experts oppose this change, but he sees some justification.

“After 9/11 the greatest risk factor for traumatic symptoms was repeatedly watching the event on television, so should patients who exhibit symptoms after vicariously experiencing an event be excluded? You have to apply common sense to any judgment, you have to sort out people who are malingering, but if a person has the signs and symptoms of PTSD, if someone seems to have had a credible traumatic experience, should that person forgo treatment?”

The vagueness with which certain disorders have been reworded in DSM-5 is another cause for concern. Allen Francis, MD, editor of DSM-IV and a prominent and vocal critic of the new edition, has stated that the wording of mild neurocognitive disorder is now so vague that he and his wife and all of their friends could be diagnosed with the disorder.

A related concern is a trend toward earlier diagnosis.

Both types of change could lead to unnecessary testing and treatment.

“Experts have expressed concerns about the early diagnosis of a lot things,” Swartz says. “The question really should be about how best to focus prevention efforts. Misguided prevention efforts could inflate insurance costs — but, on the other hand, does that mean you can’t justify prevention for anything? In some cases prevention will save money in the long run.”