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.
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).
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.”
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.