The ‘Bible of Psychiatry’ will get a new format and philosophy for its next edition : NPR

The diagnostic manual known as the “Bible of Psychiatry” is about to get a major overhaul.

The American Psychiatric Association (APA) publishes a work known in the field as the DSM-5. This means the Diagnostic and Statistical Manual of Mental Disorders, 5th edition.

The APA outlined its thinking and approach for the upcoming review in five studies published Wednesday in the American Journal of Psychiatry.

Instead of a bulky volume, the next DSM will be a “living document” that is online and easier to update. The APA has not set a strict timetable and has not yet decided whether it will be called DSM-6 or under a new name. But it seeks advice from a wide range of mental health professionals and people with psychiatric disorders.

“The DSM is truly the foundational framework for diagnosing mental health,” said Dr. Maria Oquendo, chair of the strategic committee overseeing the manual’s future, speaking at a news conference announcing research supporting the new approach.

The DSM is used by psychiatrists, psychologists, doctors, researchers and insurance companies.

“It’s very useful in the sense that it helps you think precisely about what’s going on with the patient,” says Dr. Jennifer Havens, chair of the department of child and adolescent psychiatry at NYU Grossman School of Medicine. “Because the essential thing to do with any disease is to diagnose it. And if you make the right diagnosis, you prescribe or initiate the right treatments.”

Keep it up to date

In the past, the DSM was revised approximately every 15 years, with DSM-5 being released in 2013. “Each revision reflects advances in science, clinical practice and sociocultural understanding,” Oquendo said.

But this lengthy process and making it available in print form had limitations, according to Dr. Nitin Gogtay, APA deputy medical director, who also spoke at the virtual press conference.

“Clinicians and other stakeholders may lack uniform and timely access to the most recent evidence, which could delay the translation of new findings into practice,” he said. “We want this process to be as current as possible.”

By keeping the next edition primarily online, it can be updated more regularly to reflect recent scientific developments in the diagnosis and treatment of mental illness.

Responding to Critics of the DSM

Most of the other changes to the manual are intended to incorporate scientific advances in the understanding of mental disorders, their diagnoses and treatment, and to address common criticisms of the current DSM.

“There are a lot of critiques,” Oquendo said. “And perhaps most striking is the fact that the DSM does not refer to the causes of mental disorders.”

“It’s a pretty common approach in medicine to try to understand the causes of a disease,” says Havens, who is not involved in revising the manual. “If you understand the causes of disease, you may be able to prevent it. It absolutely affects your treatments.”

But because the underlying causes of mental illnesses are complex – involving an interaction between genetics, biology, environment and life experiences – and there were conflicting ideas about the causes in recent decades, the old DSMs left them aside. (The DSM-5 has recognized potential causes under “Risk and Prognostic Factors.”)

Failing to consider causes can harm diagnoses and treatment plans, says Havens. Take for example the lasting impact of childhood trauma on people’s mental health.

“Trauma causes a significant portion of the mental illness we see in everyone,” she says. “And that significantly increases the vulnerability of people who are going to have a serious and persistent mental illness like schizophrenia. And that’s part of the problem on the ground that we don’t understand this cause enough and we don’t intervene enough.”

Today, researchers know much more about the factors that cause or exacerbate mental illness. And this will be considered in future DSMs and approaches to preventing mental health symptoms in different populations.

Oquendo says things like living in poverty, or near environmental toxins, or being part of a religious or cultural minority facing additional daily stressors can all negatively affect mental health.

Thus, future DSMs will emphasize factors that influence mental health symptoms and present approaches to symptom prevention in different populations.

It would be a “radical change in psychiatry,” says Havens.

The role of biological markers

Since the publication of the DSM-5, significant progress has been made in understanding the biological roots of mental health disorders. These advances have brought scientists closer to discovering biological markers for various disorders.

“It could be blood tests, it could be neuroimaging tests. It could even be digital tests done from wearable devices or cognitive tests to measure biological processes that may be causing mental disorders,” says Dr. Jonathan Alpert, vice chair of the APA Future DSM Steering Committee and chief of psychiatry at Montefiore Medical Center in New York.

One area where the Food and Drug Administration has already approved biomarker testing is in Alzheimer’s disease, he says.

“There are blood tests and spinal fluid tests that look at certain proteins,” Alpert says.

In the near future, certain inflammation markers may be another type of biological marker in people with major depression.

“A subset of people with major depressive disorder, also called clinical depression, have elevated measures of inflammation, and this can be detected even by a C-reactive protein (CRP) blood test,” says Alpert. CRP is a marker of inflammation.

“These individuals appear to respond preferentially to anti-inflammatory agents, either alone or in addition to more standard antidepressants such as SSRIs,” such as Prozac and Lexapro.

Discussions about who might benefit from such testing within the major depression population may take place in a future version of the DSM.

Voices of lived experiences

For now, the APA is putting its thinking and overall strategy out into the world for feedback from the public, including health care providers, advocates, and people living with mental illness. They want this next version to be informed by a wider circle of people than just psychiatrists.

“There is clear recognition that there were not enough voices included in our previous versions of this document,” says Dr. Tami Benton, who directs child and adolescent psychiatry at Children’s Hospital of Philadelphia and is a member of the DSM strategic committee. “There will need to be greater inclusion of those affected – people with lived experience, including adolescents and their families and children and their families.”