For the first time in nineteen years, mental health professionals are working today with a new set of diagnostic criteria for mental illness. What does this all mean for the kids and families we serve? Throughout the month of June, we’ll examine in more depth the implications of the changes in criteria for specific disorders, including changes in criteria for:

• ADHD
• Autism spectrum disorders
• Bipolar Disorder
• Disruptive Mood Dysregulation Disorder (DMDD)
• Intellectual Disability
• Social Communication Disorder

With the official launch of the DSM-5 today, here are some first impressions of the new manual…

The DSM-5 represents psychiatry’s past and not its’ future. The diagnostic criteria are not (for the most part) based upon any clear understanding of the underlying pathology of the conditions described in the manual. Dr. Thomas Insel, Director of the National Institute of Mental Health (NIMH) has announced in his blog that the NIMH will be reorienting the research they fund away from DSM criteria. Quoting Dr. Insel…

The weakness is its lack of validity. Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the 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. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

We’ll talk more about the implications of the NIMH’s decision to shift away from use of the DSM-5 in a future post.

The new diagnostic criteria still produce unacceptably high levels of disagreement on diagnosis for individual patients. In the DSM-5 field trials, the odds of two different clinicians reaching the same diagnosis with the same patient were only 28% better than chance across all diagnoses, and only 8% better than chance for DMDD. The coefficient of agreement (Kappa statistic, K) for the diagnosis of Major Depression was 0.33. To put it differently, the odds that a parent will get the same diagnosis for their child if they take them to two different mental health professionals is less than 50-50.

In the short run, the new criteria are likely to have little impact upon the quality of care kids and families receive from mental health professionals. Old habits are hard to change. In a reimbursement-driven mental health system, many clinicians don’t take the time to do diagnostic assessments in enough depth to make meaningful use of the criteria. For that matter, the US Government isn’t requiring insurers to use the new diagnostic codes until 2014. It remains to be seen whether clinicians will adopt the rating instruments for assessment/severity of specific disorders included in the DSM-5, especially primary care physicians who provide much of the mental health care for children and teens.

On the whole, the DSM-5 is a diagnostic manual developed by a very, very big committee that considered lots of factors other than the original intent of developing common criteria for accurate and consistent diagnosis and meaningful research.

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