午夜福利1000集合

Editorial 鈥�One manual shouldn鈥檛 dictate US mental health research鈥�

WELCOME to the future of psychiatric diagnosis. It will be based on science, and will look nothing like today鈥檚 . The DSM, the profession鈥檚 鈥渂ible鈥�, has dominated medicine鈥檚 approach to mental illness for 60 years.

On 29 April, , director of world鈥檚 biggest funding agency for research into mental illness, advocated a major shift away from categorising psychiatric disorders according to a person鈥檚 symptoms. This approach has given us labels like schizophrenia, bipolar disorder and major depression.

Insel, who heads the , wants mental disorders to be diagnosed more objectively using a combination of genetics, brain scans that show abnormal patterns of activity, and cognitive testing. In a , Insel said the agency would be reorienting its research away from DSM鈥榮 symptom-based approach. He delivered a blistering critique of DSM鈥榮 limitations, stating that 鈥減atients with mental disorders deserve better鈥�.

Coming just weeks before publication of the , Insel鈥檚 comments will be interpreted as a snub to the , which publishes the DSM 鈥� and a challenge to its hegemony over psychiatric diagnosis.

His comments certainly provide a powerful signal that psychiatry needs to be transformed for the 21st century. 鈥淚 think it is quite a monumental thing to happen, for the director of NIMH to be so blunt,鈥� says , director of the Welsh National Centre for Mental 午夜福利1000集合 in Cardiff, UK, and a prominent critic of the DSM. 鈥淚t鈥檚 a landmark.鈥�

Still, don鈥檛 expect the landscape of mental illness to change any time soon. Insel accepts that it will take at least a decade to conduct the research necessary to devise a new approach to diagnosis. In the meantime, patients鈥� illnesses will continue to be diagnosed using the DSM鈥榮 symptom-based categories.

鈥淲e鈥檝e been telling patients for several decades that we are waiting for biomarkers. We鈥檙e still waiting,鈥� says of the University of Pittsburgh, who led the DSM-5 revision. 鈥淭he new manual, due for release later this month, represents the strongest system currently available for classifying disorders.鈥�

Even the transition in research will be gradual 鈥� the NIMH isn鈥檛 going to stop funding projects based around DSM diagnoses overnight. But it is clear that new approaches will get priority in future, and with , the NIMH is in a position to call the shots.

鈥淭here is no question that NIMH has an unparalleled influence in shaping the research agenda in mental health,鈥� says Geoffrey Reed of the World 午夜福利1000集合 Organization in Geneva, Switzerland.

The DSM revision has been embroiled in controversy, with concerns that it will further expand the boundaries of mental illness, meaning more people will be prescribed powerful psychoactive drugs. Insel鈥檚 objections are much more fundamental, however. The main drawback is that rapidly expanding knowledge about the genes and brain circuits that underlie human behaviour is not generating major clinical advances, because it doesn鈥檛 readily map onto the conditions described in the DSM.

The obvious conclusion is that many of those conditions aren鈥檛 鈥渞eal鈥� diseases. Instead, people with different underlying problems are lumped together and those with fundamentally similar issues separated.

鈥淯nlike 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,鈥� Insel explained in his blog. 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�

Viewed from this perspective, DSM-5 seems like an exercise in rearranging the deck chairs on the Titanic. To accelerate the shift to biologically based diagnosis, Insel favours an approach embodied by an initiative launched 18 months ago by the NIMH, called the .

鈥�DSM-5 seems like an exercise in rearranging the deck chairs on the Titanic鈥�

This is based on the idea that mental disorders are biological problems involving brain circuits that influence patterns of cognition, emotion and behaviour. Rather than just studying people with major depression, for instance, the NIMH now wants researchers to involve patients from a broader range of diagnoses, and look for biomarkers that correlate with characteristics such as 鈥渁nhedonia鈥� 鈥� an inability to feel pleasure.

Similarly, Craddock believes researchers should be looking for an overlap between the underlying biological problems experienced by some patients currently diagnosed with schizophrenia, and others described as bipolar.

In the long run, Insel is convinced that studies like these will provide a better outlook for patients. 鈥淲e cannot succeed if we use DSM categories as the gold standard,鈥� he wrote in his blog.

Most psychiatrists contacted by New Scientist broadly support Insel鈥檚 bold initiative, but warn that there are some big challenges ahead to make his vision a reality. 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.

鈥淭hese are incredibly complicated disorders,鈥� agrees of the University of Cardiff, UK, a member of the DSM-5 work group on psychotic disorders. 鈥淭o understand the neuroscience in sufficient depth and detail to build a diagnosis process will take a long time,鈥� he says. Identifying specific brain circuits underlying complex phenomena such as paranoid delusions may prove particularly hard, says of Columbia University in New York City.

鈥淭o understand the neuroscience in sufficient depth to build a diagnosis process will take time鈥�

Some mental health professionals also worry that Insel鈥檚 biology-driven approach leaves little room for considering psychological processes, which they argue may still provide the best means of understanding the problems experienced by many people with mental illness.

Debate over the future of psychiatric diagnosis is likely to intensify when the in San Francisco, where DSM-5 will be officially launched.

This article appeared in print under the headline 鈥淎 revolution in mental health鈥�