NS 2916: How a scientific DSM will transform psychiatry http://www.newscientist.com/article/mg21829164.000-how-a-scientific-dsm-will-tra nsform-psychiatry.

html * 08 May 2013 by Peter Aldhous , Andy Coghlan and Sara Reardon The decision of the leading US mental health institute to move away from the psychiatrists' "bible" means years of transition to biologically based diagnoses [Editorial "One manual shouldn't dictate US mental health research" added.] WELCOME to the future of psychiatric diagnosis. It will be based on science, and will look nothing like today's Diagnostic and Statistical Manual of Mental Disorders. The DSM, the profession's "bible", has dominated medicine's approach to mental illness for 60 years. On 29 April, Thomas Insel, director of world's biggest funding agency for research into mental illness, advocated a major shift away from categorising psychiatric disorders according to a person's symptoms. This approach has given us labels like schizophrenia, bipolar disorder and major depression. Insel, who heads the US National Institute of Mental Health, wants mental disorders to be diagnosed more objectively using a combination of genetics, brain scans that show abnormal patterns of activity, and cognitive testing. In a blog post on the NIMH website, Insel said the agency would be reorienting its research away from DSM's symptom-based approach. He delivered a blistering critique of DSM's limitations, stating that "patients with mental disorders deserve better". Coming just weeks before publication of the latest revision of the manual, known as DSM-5, Insel's comments will be interpreted as a snub to the American Psychiatric Association, which publishes the DSM - and a challenge to its hegemony over psychiatric diagnosis. His comments certainly provide a powerful signal that psychiatry needs to be transformed for the 21st century. "I think it is quite a monumental thing to happen, for the director of NIMH to be so blunt," says Nick Craddock, director of the Welsh National Centre for Mental Health in Cardiff, UK, and a prominent critic of the DSM. "It's a landmark." Still, don't expect the landscape of mental illness to change any time soon. Insel accepts that it will take at least a decade to conduct the research necessary to devise a new approach to diagnosis. In the meantime, patients' illnesses will continue to be diagnosed using the DSM's symptom-based categories. "We've been telling patients for several decades that we are waiting for biomarkers. We're still waiting," says David Kupfer of the University of Pittsburgh, who led the DSM-5 revision. "The new manual, due for release later this month, represents the strongest system currently available for classifying disorders." Even the transition in research will be gradual - the NIMH isn't going to stop funding projects based around DSM diagnoses overnight. But it is clear that new approaches will get priority in future, and

with a budget of almost $1.5 billion per year, the NIMH is in a position to call the shots. "There is no question that NIMH has an unparalleled influence in shaping the research agenda in mental health," says Geoffrey Reed of the World Health Organization in Geneva, Switzerland. The DSM revision has been embroiled in controversy, with concerns that it will further expand the boundaries of mental illness, meaning more people will be prescribed powerful psychoactive drugs. Insel's objections are much more fundamental, however. The main drawback is that rapidly expanding knowledge about the genes and brain circuits that underlie human behaviour is not generating major clinical advances, because it doesn't readily map onto the conditions described in the DSM. The obvious conclusion is that many of those conditions aren't "real" diseases. Instead, people with different underlying problems are lumped together and those with fundamentally similar issues separated. "Unlike our definitions of ischemic heart disease, lymphoma or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure," Insel explained in his blog. "In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain, or the quality of fever." Viewed from this perspective, DSM-5 seems like rearranging the deck chairs on the Titanic. To to biologically based diagnosis, Insel favours by an initiative launched 18 months ago by the Research Domain Criteria project. an exercise in accelerate the shift an approach embodied NIMH, called the

This is based on the idea that mental disorders are biological problems involving brain circuits that influence patterns of cognition, emotion and behaviour. Rather than just studying people with major depression, for instance, the NIMH now wants researchers to involve patients from a broader range of diagnoses, and look for biomarkers that correlate with characteristics such as "anhedonia" an inability to feel pleasure. Similarly, Craddock believes researchers should be looking for an overlap between the underlying biological problems experienced by some patients currently diagnosed with schizophrenia, and others described as bipolar. In the long run, Insel is convinced that studies like these will provide a better outlook for patients. "We cannot succeed if we use DSM categories as the gold standard," he wrote in his blog. Most psychiatrists contacted by New Scientist broadly support Insel's bold initiative, but warn that there are some big challenges ahead to make his vision a reality. "It's potentially game-changing, but needs to be based on underlying science that is reliable," says Simon Wessely of the Institute of Psychiatry at King's College London. "These are incredibly complicated disorders," agrees Michael Owen of the University of Cardiff, UK, a member of the DSM-5 work group on

psychotic disorders. "To understand the neuroscience in sufficient depth and detail to build a diagnosis process will take a long time," he says. Identifying specific brain circuits underlying complex phenomena such as paranoid delusions may prove particularly hard, says Michael First of Columbia University in New York City. Some mental health professionals also worry that Insel's biology-driven approach leaves little room for considering psychological processes, which they argue may still provide the best means of understanding the problems experienced by many people with mental illness. Debate over the future of psychiatric diagnosis is likely to intensify when the American Psychiatric Association holds its annual meeting in San Francisco, where DSM-5 will be officially launched. This article appeared in print under the headline "A revolution in mental health" Sounding off Psychiatrists are divided over the biggest challenge yet to the manual that defines their field "DSM is a nightmare and it's been reified... [Diagnoses] have the miraculous bad property of being too broad and too narrow at the same time" Steven Hyman, former director, NIMH "[This] may someday culminate in the genetic and neuroscience breakthroughs that will revolutionise our field. In the meantime, should we merely hand patients another promissory note that something may happen sometime?" David Kupfer, chair, DSM-5 task force "It holds the potential of mental illnesses being on a par with the rest of healthcare, in having a number of biomarkers and being more objective in doing assessments" Wayne Lindstrom, president, Mental Health America "This could eventually lead to an abandonment of much psychiatric research that recruits subjects on symptom-based diagnostic criteria" Geoffrey Reed, World Health Organization "[It] is based on an assumption that everything of interest in understanding psychological conditions is reducible to biology. That is not a scientific finding" Jonathan Shedler, University of Colorado --Editorial: One manual shouldn't dictate US mental health research http://www.newscientist.com/article/dn23490-one-manual-shouldnt-dictate-us-menta l-health-research.html * Updated 19:06 08 May 2013 by Allen Frances The new edition of the DSM "bible" is so flawed that the US National Institute of Mental Health is right to abandon it, says eminent psychiatrist Allen Frances The controversies swirling around the imminent update of the Diagnostic and Statistical Manual of Mental Disorders, produced by the American Psychiatric Association, have badly hurt confidence in

psychiatric diagnosis. The problem arises from the fact that the update, called DSM-5, includes new diagnoses and reductions in thresholds for old ones, that expand the already stretched boundaries of psychiatry and threaten to turn diagnostic inflation into hyperinflation. In my opinion, the DSM-5 process has been secretive, closed and sloppy - with confidentiality restraints, constantly missed deadlines, botched field testing, the cancellation of an important quality control step, and a rush to publication. A petition for independent scientific review endorsed by 56 mental health organisations was ignored. There is no reason to believe that DSM-5 is safe or scientifically sound. And now we have the announcement of a major shift away from DSM by the US National Institute of Mental Health (NIMH) when it comes to deciding how it allocates its considerable research resources (see "How a scientific DSM will transform psychiatry"). The research problem in psychiatry actually goes much deeper than the aberration that is DSM-5. In 1980, when DSM-III was published, there was great optimism that its provision of a reasonably reliable diagnostic system would rapidly lead to a revolution in psychiatric research. No impact on diagnosis In one way, this did indeed happen - but in another it did not. Psychiatric research quickly went from stepchild to darling; in most medical schools it is now just behind internal medicine in attracting external funding. The happy result has been an explosive advance in basic neuroscience. But, disappointingly, 30 years of advancing knowledge has had no impact whatever on psychiatric diagnosis or treatment. Translational research - work that bridges the gap between basic research and clinical application - has been distressingly slow in all of medicine, and it is particularly difficult in psychiatry because the brain is so much more complicated than any other organ. Within a few years, we will likely have accurate tests for Alzheimer's disease, but there is nothing in the pipeline for any other psychiatric disorder, and it may take decades before we have accurate biological tests for them. DSM-5 hoped to include biological markers that might reflect past research and promote future research. This was a premature and unrealisable ambition: the science simply isn't there now. And it has become increasingly clear that the DSM descriptive system may be a research dead end because its syndromes are too diverse and overlapping to be good research targets. So the NIMH has wisely chosen another approach that is more likely to bear fruit - picking simpler targets for study and bringing to bear all of its enormous resources to determine their causal mechanism. What we call schizophrenia does not present in one uniform way, and there will not be one cause - there probably are hundreds. Simplify the question

It makes more sense to simplify the research question by studying the genesis of hallucinations than to expect to understand the diverse causes of complex construct schizophrenia. The brain is likely to remain frustratingly elusive in providing answers, but focusing the target is our best hope. Where does all this leave current clinical work? Schizophrenia remains an immensely useful construct - imperfect for sure, but very helpful in clinical communication and in guiding treatment. The DSM disorders are all fallible and subjective constructs, but most are useful as temporary way stations until we learn more and can develop better ones. The mistake of DSM-5 was to attempt to go beyond current knowledge. Its new disorders are a dream list for researchers, but will be a nightmare to the patients who are misidentified and treated unnecessarily. Anything that goes into the manual should already have passed rigorous research testing; the manuals are far too important to include untested hypotheses. DSM-5 is not, and cannot be, an appropriate guide to future research. Correction: Since this article was first published, the word "other" has been inserted before "psychiatric disorder" in the sixth paragraph. Profile Allen Frances is a professor emeritus at Duke University, North Carolina, and was chairman of the DSM-IV task force. He is author of Saving Normal and Essentials of Psychiatric Diagnosis