DSM-V expected to explore physical, mental health links

The Diagnostic and Statistical Manual of Mental Disorders is about to get a makeover -- it will be the focus of a detailed overhaul that experts hope will reflect emerging scientific understanding and expect to take years to finish.

Those involved in the process predict that the completed revision will place a greater emphasis on how psychiatric illnesses change throughout a person's life and how different mental health issues interact. Gender and cultural issues also are expected to play a bigger role, along with a greater examination of the connection between mental and physical health.

"It's very important to have a better paradigm than what we've been using to look at somatic presentations of mental disorders, and the relationship to disorders in other organ systems," said Darrel Regier, MD, MPH, vice chair of the task force on the revision and the American Psychiatric Assn.'s director of research.

The last full revision, the DSM-IV, came out in 1994, although a text update was issued in 2000. The DSM-V is due out in 2012, but there is a lot of work to be done before then.

Last month the APA announced the members of the revision task force. Working groups addressing specific mental health issues will be appointed later this year.

A draft will be available for public comment in 2009. This step also will allow researchers to undertake clinical trials to determine the usefulness of the diagnostic categories.

"As the nation's dictionary of mental illnesses, the Diagnostic and Statistical Manual plays a vital role in assuring that patients get proper diagnoses and treatments for their mental health concerns," said David J. Kupfer, MD, task force chair. "The APA has entrusted the revision of the DSM to world-renowned scientists who have vast experience in research, clinical care, biology, genetics, statistics, epidemiology, public health and consumer advocacy."

In light of the increasing attention being paid to conflict-of-interest issues, the organization also announced rules governing this issue for task force members. Participants are required to reveal all potentially conflicting relationships and are restricted to no more than $10,000 in annual income from industry sources except for unrestricted research grants.

"Patients deserve a diagnostic manual based upon the latest science and free of conflicts of interest," said APA President Carolyn Robinowitz, MD.

Input sought

The organization also will be accepting input through its DSM-V Prelude Project, which can be accessed online (link), and many organizations and individuals already have weighed in on possible changes. For example, the American Medical Association will be forwarding for consideration a report adopted at its June Annual Meeting on the possible emotional and behavioral effects of video games.

But while this book is influential, it is not without controversy, and critics hope diagnostic criteria will be less expansive. Some feel it currently can lead to people being categorized as having a mental health issue such as depression that could be more related to a temporary situation such as the death of a loved one rather than a psychiatric illness. Questions also have been asked about whether some diagnoses are useful.

"The emphasis on symptoms without context probably needs to be rethought," said Leonard Sax, MD, a family physician in Poolesville, Md., who also holds a PhD in psychology. "And I wonder whether conduct disorder is really a meaningful diagnosis. Maybe the child needs a change in parenting or a change in the peer group? This diagnosis makes it easier for parents to believe that medication is appropriate, but it's not." His book, Boys Adrift: The Five Factors Driving the Growing Epidemic of Unmotivated Boys and Underachieving Young Men, is due out this month.

Meanwhile, some of the experts involved in previous revisions are concerned that 2012 may be too tight of a deadline.

"That's five years to review all the issues and review suggestions for changes and collect data in field trials. I don't see how that can be done in five years," said Robert Spitzer, MD, who was involved in previous revisions and is a professor of psychiatry at Columbia University in New York.