Guest editorial: 鈥�One manual shouldn鈥檛 dictate US mental health research鈥� by Allen Frances
The world鈥檚 biggest mental health research institute is abandoning the new version of psychiatry鈥檚 鈥渂ible鈥� 鈥� the Diagnostic and Statistical Manual of Mental Disorders, and stating that 鈥減atients with mental disorders deserve better鈥�. This bombshell comes just weeks before the publication of the fifth revision of the manual, called DSM-5.
On 29 April, Thomas Insel, director of the US National Institute of Mental 午夜福利1000集合 (NIMH), advocated a major shift away from categorising diseases such as bipolar disorder and schizophrenia according to a person鈥檚 symptoms. Instead, Insel wants mental disorders to be diagnosed more objectively using genetics, brain scans that show abnormal patterns of activity and cognitive testing.
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This would mean abandoning the manual published by the American Psychiatric Association that has been the mainstay of psychiatric research for 60 years.
The DSM has been embroiled in controversy for a number of years. Critics have said that it has outlasted its usefulness, has turned complaints that are not truly illnesses into medical conditions, and has been unduly influenced by pharmaceutical companies looking for new markets for their drugs.
There have also been complaints that widened definitions of several disorder have led to over-diagnosis of conditions such as bipolar disorder and attention deficit hyperactivity disorder.
Now, Insel has said published by the NIMH that he wants a complete shift to diagnoses based on science not symptoms.
鈥淯nlike our definitions of ischaemic heart disease, lymphoma or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure,鈥� Insel says. 鈥淚n the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain, or the quality of fever.鈥�
Insel says that elsewhere in medicine this type of symptom-based diagnosis been abandoned over the past half-century as scientists have learned that symptoms alone seldom indicate the best choice of treatment.
To accelerate the shift to biologically based diagnosis, Insel favours an approach embodied by a programme launched 18 months ago at the NIMH called the .
The approach is based on the idea that mental disorders are biological problems involving brain circuits that dictate specific patterns of cognition, emotion and behaviour. Concentrating on treating these problems, rather than symptoms is hoped to provide a better outlook for patients.
鈥淲e cannot succeed if we use DSM categories as the gold standard,鈥� says Insel. 鈥淭hat is why NIMH will be reorienting its research away from DSM categories,鈥� says Insel.
Prominent psychiatrists contacted by New Scientist broadly support Insel鈥檚 bold initiative. However, they say that given the time it will take to realise Insel鈥檚 vision, diagnosis and treatment will continue to be based on symptoms.
Insel is aware that what he is suggesting will take time 鈥� probably at least a decade, but sees it as the first step towards delivering the 鈥減recision medicine鈥� that he says has transformed cancer diagnosis and treatment.
鈥淚t鈥檚 potentially game-changing, but needs to be based on underlying science that is reliable,鈥� says of the Institute of Psychiatry at King鈥檚 College London. 鈥淚t鈥檚 for the future, rather than for now, but anything that improves understanding of the etiology and genetics of disease is going to be better [than symptom-based diagnosis].鈥�
Michael Owen of the University of Cardiff, who was on the psychosis working group for DSM-5, agrees. 鈥淩esearch needs to break out of the straitjacket of current diagnosis categories,鈥� he says. But like Wessely, he says it is too early to throw away the existing categories.
鈥淭hese are incredibly complicated disorders,鈥� says Owen. 鈥淭o understand the neuroscience in sufficient depth and detail to build a diagnosis process will take a long time, but in the meantime, clinicians still have to do their work.鈥�
David Clark of the University of Oxford says he鈥檚 delighted that NIMH is funding science-based diagnosis across current disease categories. 鈥淗owever, patient benefit is probably some way off, and will need to be proved,鈥� he says.
The controversy is likely to erupt more publically in the coming month when the holds its annual meeting in San Francisco, where DSM-5 will be officially launched, and in June in London when the Institute of Psychiatry holds a on the DSM.
