The diagnostic manual known as "the Bible of psychiatry" is about to get a major overhaul.
The American Psychiatric Association (APA) puts out the tome known in the field as the DSM-5. That stands for the Diagnostic and Statistical Manual of Mental Disorders, 5th edition.
The APA outlined its thinking and approach for the next revision in five studies published Wednesday in The American Journal of Psychiatry.
Instead of a weighty volume, the next DSM will be "a living document" online and easier to update. The APA hasn't set a strict timeline and hasn't decided yet if it will be called the DSM-6 or some new name. But it is seeking input from a broad range of both mental health professionals and people who have psychiatric conditions.
"The DSM is really the foundational framework for mental health diagnosis," said Dr. Maria Oquendo, chair of the Strategic Committee in charge of the future of the manual, speaking at a press conference announcing the research supporting the new approach.
The DSM is used by psychiatrists, psychologists, physicians, researchers, and insurance companies.
"It's very useful in the sense that it helps you think about what is going on with the patient in a hopefully accurate way," says Dr. Jennifer Havens, chair of child and adolescent psychiatry at NYU Grossman School of Medicine. "Because the essential thing you have to do in any illness is diagnose it. And if you make the right diagnosis, you prescribe or initiate the right treatments."
Keeping it current
In the past, the DSM has been revised every 15 years or so, with the DSM-5 published in 2013. "Each revision reflects advances in science, clinical practice and sociocultural understanding," said Oquendo.
But that lengthy process and making it available in a print format has had limitations, according to Dr. Nitin Gogtay, deputy medical director of the APA, who also spoke at the virtual press conference.
"Clinicians and other stakeholders may lack uniform and timely access to the most current evidence that might delay translation of new discoveries into the practice," he said. "We want this process to be as current as possible."
Keeping the next edition primarily online means it can be updated more regularly to reflect recent scientific developments in diagnosis and treatment of mental illnesses.
Addressing critiques of the DSM
Many of the other changes to the manual are intended to incorporate scientific advancements in understanding of mental disorders, their diagnoses and treatment, and address common criticisms of the current DSM.
"There are many critiques out there," said Oquendo. "And perhaps the most salient one is the fact that the DSM doesn't reference what the causes of mental disorders are."
"It's a fairly standard approach in medicine to try to understand the causes of an illness," says Havens, who isn't involved in revising the manual. "If you understand the causes of the illness, maybe you can prevent it. It absolutely affects your treatments."
But because the underlying causes of mental illnesses are complex — involving an interplay of genetics, biology, one's environment and life experiences — and there were conflicting ideas about causes in past decades, past DSMs left them out. (The DSM-5 acknowledged potential causes under "Risk and Prognostic Factors.". )
Not accounting for causes can harm diagnoses and treatment plans, says Havens. Take for example, the lasting impact of childhood traumas on people's mental health.
"Trauma causes a significant amount of the mental illness that we see in everybody," she says. "And it increases the vulnerability of people who are going to have serious, persistent mental illness like schizophrenia tremendously. And it's part of the problem in the field that we don't understand that enough as a cause and we don't intervene enough. "
Today, researchers know a lot more about the factors that cause or exacerbate mental illnesses. And that will be factored into future DSMs and approaches to prevention of 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 who faces additional daily stressors can all affect mental health negatively.
So, future DSMs will emphasize factors that influence mental health symptoms and outline approaches to prevention of symptoms in different populations.
This would be a "sea change in psychiatry," says Havens.
The role of biological markers
Since the publication of DSM-5 there have been significant advances in understanding the biological roots of mental health disorders. Those advancements have brought scientists closer to discovering biological markers for various disorders.
"They might be blood tests; they might be neuro imaging tests. They might even be digital tests from wearable devices or cognitive testing that are meant to measure biological processes that might underlie mental disorders," says Dr. Jonathan Alpert, vice chair of the Future DSM Steering Committee of the APA and head of psychiatry at Montefiore Medical Center in New York City.
One area where the Food and Drug Administration has already approved tests for biomarkers is for Alzheimer's disease, he says.
"There are blood tests and tests of cerebrospinal fluid that look at some of the proteins," Alpert says.
Another kind of biological marker in the near future may be certain markers of inflammation for people with major depression.
"A subset of people with major depressive disorder, also called clinical depression, have elevated measures of inflammation, and that can be picked up even by a blood test of C-reactive protein (CRP)," says Alpert. CRP is a marker for inflammation.
"Those people seem to respond preferentially well to anti-inflammatory agents either by themselves or in addition to more standard antidepressants like SSRIs," like Prozac and Lexapro.
Discussions of who can benefit from such testing within the population of people with major depression may be in a future version of the DSM.
Lived experience voices
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 illnesses. They want this next version to be informed by a wider circle of people than just psychiatrists.
"There's a strong recognition that there were not enough voices included in our prior iterations of this document," says Dr. Tami Benton, who leads child and adolescent psychiatry at the Children's Hospital of Philadelphia, and is a member of the DSM strategic committee. "There's going to have to be greater inclusion of individuals who are affected — people with lived experience, including adolescents and their families and children and their families."
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