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Director of top research organization for mental health criticizes DSM for lack of validity

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f2954 (Published 08 May 2013) Cite this as: BMJ 2013;346:f2954
  1. Michael McCarthy
  1. 1Seattle

Just weeks before the release of the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM), the director of the country’s leading research organization on mental health has criticized its inadequacies.

Thomas Insel, director of the United States National Institute of Mental Health, wrote in a blog posted on the institute’s website that the manual had been useful because it provided labels and definitions that created a common language for describing psychopathology.1

“The strength of each of the editions of DSM has been ‘reliability’—each edition has ensured that clinicians used the same terms the same ways,” Insel wrote. “The weakness is its lack of validity.”

The problem, Insel said, was that “DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure.

“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,” instead of an electrocardiograph or a blood test. “Patients with mental disorders deserve better,” he added.

Just as other fields of medicine have abandoned symptom based diagnosis, psychiatry must as well, Insel said, and going forward the institute will no longer use DSM categories to guide research.

“We need to begin collecting the genetic, imaging, physiologic, and cognitive data to see how all the data—not just the symptoms—cluster and how these clusters relate to treatment response,” Insel said.

To achieve that goal, the institute has launched the Research Domain Criteria project, a decade long initiative to “lay the foundation for a new classification system” for mental disorders by incorporating data from genetics, imaging, cognitive science, and other sources, he said.

Although Insel admitted that there were not yet enough data from such sources to create a new classification system, he said: “We cannot succeed if we use DSM categories as the ‘gold standard.’”

Instead, the institute will favor research projects that look across DSM categories, he said. Studies looking at biomarkers for depression, for example, should not only look at patients who meet the DSM’s strict criteria for major depressive disorder, but also at those with anhedonia, emotional appraisal bias, psychomotor retardation, and related disorders, he said.

Although the Research Domain Criteria project is only a research framework and not a clinical tool, Insel argued that “the project is a step towards ‘precision medicine,’ the movement that has transformed cancer diagnosis and treatment.”

In a response to Insel’s post, the American Psychiatric Association released a statement from David Kupfer, chair of the DSM-5 task force, that pointed out that doctors have been anticipating for the long promised benefits of precision medicine since the 1970s.2

“We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting,” Kupfer said.

In the interim, it has been “clinical experience and evidence, as well as growing empirical research, that have advanced our understanding of disorders such as autism spectrum disorder, bipolar disorder, and schizophrenia,” he said.

Efforts such as the Research Domain Criteria project are vital to progress and could revolutionize the field of psychiatry someday, Kupfer said. He added, “In the meantime, should we merely hand patients another promissory note that something may happen sometime? Every day, we are dealing with impairment or tangible suffering, and we must respond. Our patients deserve no less.”

Notes

Cite this as: BMJ 2013;346:f2954

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