"Transforming Diagnosis" of Mental Disorders

My excitement for science stems from a passion to help eliminate the social stigma surrounding mental disorders. Mental disorders plague 26% of adults and 13% of children (8-15 yrs) in the United States within a 12-month period. Some are treated quietly and recover quickly. Medications cannot control the symptoms of others and so they are labeled as lazy, rather than depressed, or crazy, rather than as someone suffering from schizophrenia. I’ve encountered many people who believe that if their depressed loved ones would just force themselves to get out of the house and stay busy, the depression would magically go away. But mental disorders aren’t a failure of motivation or of character, they arise from a disruption in brain function. Patients cannot will them away, just as a diabetic cannot regulate his/her own blood sugar and insulin levels by sheer force of will. There are drugs to treat most mental disorders but they don’t work for everyone all the time. Diagnosis isn’t as easy as taking a drop of blood and popping it into a blood glucose meter.

Figure 1: The DSM-5. (Source)

(That cover is really boring.)

For researchers and clinicians working in mental health areas, the standardized way to diagnose, treat, and study mental disorders has been based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) since 1952. That’s a long time. It’s been updated and revised since then and has changed dramatically since the 1950s. The fifth version has a release date of May 18 (Figure 1).

So when the Director of the National Institute of Mental Health (NIMH) made an announcement on April 29 that they won’t be backing the fifth edition of the DSM (DSM-5) people were shocked. From my view online following the announcement, it seemed as though researchers were excited and clinicians were not very thrilled. Within a few days, strange tweets and blog posts began surfacing about the announcement. People seemed confused (and maybe a bit panicked). The main concern seemed to be: how will people be diagnosed without the DSM?? But the announcement was focused on RESEARCH, not the clinic. Clinicians will still use the DSM for the time being, but the NIMH wants researchers to stop focusing on a system that, they say, lacks validity.

Essentially, this is what Insel said:

1. The DSM is a list of symptoms clustered under headings (disorders) which psychiatry defined with the best knowledge they had at the time.
2. New knowledge from neuroscience (brain) research is showing that symptoms, genes, brain function, and cognitive disruptions OVERLAP between some DSM-defined disorders.
3. We need to take these biological factors (genetics, imaging, cognitive assessments, etc) AND symptoms into account when diagnosing mental disorders.
4. The DSM-defined categories don’t allow for that.
5. We don’t have enough information yet to define new diagnostics BUT if we continue to do research using the DSM-defined categories we may miss things.
6. Therefore, researchers working at and applying for NIMH money will need to “re-orient their research away from DSM categories”. Essentially, rather than studying the cluster of symptoms known as schizophrenia, researchers will need to pick them apart and study their neural basis. For example, what genes and factors are involved in “hearing voices”. See the proposed RDoC for auditory hallucinations. 

The new diagnostic system will be based on the Research Domain Criteria (RDoC), which NIMH began developing in 2010. Insel specifically states in his announcement that “RDoC, for now, is a research framework, not a clinical tool” (emphasis mine).

Because my blog is aimed at the average person and all researchers (not just those in neuroscience), I’ll be publishing at least one more post to explain some concepts that I’ve glossed over here for simplicity.