New mental health manual introduced for changing health field: DSM-5 released
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* Natalie McGill

Since 1952, mental health professionals have relied on the American Psychiatric Association’s *Diagnostic and Statistical Manual of Mental Disorders to diagnose and classify disorders*. In May, the manual’s first update in nearly 20 years was released, promising more precise diagnoses and research-based information on new disorders.

But in a field that has continued to evolve in the absence of the updated resource, only time will tell the manual’s impact.

David Kupfer, MD, chair of the *DSM-5* Task Force, said the new manual will help health workers better identify disorders and improve the diagnosis of mental health issues. One in four Americans ages 18 and older has a diagnosable mental disorder in a given year, according to the National Institute of Mental Health.

The revised edition — created after more than 10 years of work and more than 13,000 public comments — better characterizes symptoms and behaviors of affected people, he said, citing the addition of new disorders such as hoarding and binge eating as examples of disorders that are better defined.

“A major problem in using *DSM-IV* was when an individual (was) presented to a clinic for treatment for an eating disorder, in many cases the only diagnosis that could be used was an ‘eating disorder not otherwise specified,’” Kupfer told The *Nation’s Health. “DSM-5’s* descriptions are more precise, allowing patients to be reassigned from this broad category into more specific descriptive disorders that provide clinicians with more information about characteristics, course and outcome.”

One of the larger changes in the new manual is that it takes four autism disorders that had their own classifications — such as Asperger’s syndrome — and rolls them into a broader definition of autism spectrum disorder, said David Mandell, ScD, former chair of APHA’s Mental Health Section, a Section governing councilor and associate director for the Center for Autism Research at the Children’s Hospital of Philadelphia.

While such a change may seem simple, there are larger implications: Mandell said from a public health standpoint, health insurance coverage for families of people with autism could be affected. Medical expenses for people with an autism spectrum disorder, on average, were 4.1 times to 6.2 times more than for people without a disorder, according to the Centers for Disease Control and Prevention. One in 88 children has an autism spectrum disorder, according to CDC Autism and Developmental Disabilities Monitoring data.

“The big concern is that the diagnostic criteria have been tightened and people who currently qualify for services or would have qualified for services under the old criteria are not going to anymore, and that there will be a dramatic loss of services,” Mandell told *The Nation’s Health*. Mandell said 31 states have autism insurance mandates, meaning that plans have to include coverage.

“One question will be whether those payers take advantage of the diagnostic material to really crack down on who meets criteria,” Mandell said. “The way they can do that is administrative. ‘Were the proper tests administered?’”

However, Mandell said that because autism services have increased “dramatically” in the past decade, there is a benefit in the diagnosis criteria that there was not before.

“Frankly I think (practitioners) will continue to apply them liberally,” Mandell said. “I don’t think they’ll feel constrained in any way by the diagnostic criteria. The change can help us understand the biology of autism. By refining our definition of autism and making it more stringent, it may increase our chances of understanding the genetics and neurobiology of the disorder.”

*DSM-5* also removes subtypes of schizophrenia, such as paranoid schizophrenia. The change is one of the most important ones to the National Alliance on Mental Illness, because it is an honest assessment of the lack of precision when it comes to diagnosis, said Ken Duckworth, MD, medical director of the alliance. The disorder, which affects 1 percent of the U.S. population, is marked by delusions and hallucinations, according to the American Psychiatric Association.

Another change is the new diagnosis of disruptive mood dysregulation disorder in children, which is expected to curb overdiagnosis of bipolar disorder, he said. The dysregulation disorder is marked by persistent irritability in children, which includes severe outbursts occurring three or more times a week for a year or more, according to the American Psychiatric Association.

The change will prevent severely impaired children from “falling through the cracks” because they suffer from a disorder that was not defined, according to a *DSM-5* fact sheet.

Duckworth said that while he supports the manual changes as they relate to schizophrenia as an improvement, the overall public health impact is uncertain. He said it is hard to predict how the manual changes will affect insurance reimbursements and medical coding, a concern of the autism community.

While the new manual includes a wealth of new information, some public health issues, such as how socioeconomic factors affect mental health, need more attention, according to some researchers.

An article published online in April in *Health Affairs* calls for a review panel independent of the American Psychiatric Association to press for the social determinants of health to be considered in future *DSM* revisions, according to Helena Hansen, PhD, one of 12 article authors and an assistant professor of psychiatry and anthropology at New York University.

The panel could review differences in diagnoses according to factors such as income and race, and suggest research into whether there is an increase in a specific disorder, the article authors recommended.

Another early criticism of the manual came from NIMH, which questioned the accuracy of diagnoses that did not include the neurobiological science behind a disorder. The national agency later said that its work, the Research Domain Criteria, complements the *DSM-5* and that the manual should still be considered the standard for diagnosing disorders. The Research Domain Criteria is an ongoing initiative to map the biology behind mental health disorders.

“There’s a move toward precision medicine,” said Bruce Cuthbert, PhD, director of the Division of Adult Translational Research and Treatment Development at NIMH. “This is something that’s lacking in mental disorders, largely because the *DSM* is based on symptoms.”

Public health and population-level issues are critical mental health concerns, Hansen told *The Nation’s Health*.

One of her concerns is a medicalization of poverty, and that when it comes to disorders such as attention deficit disorder, children in low-income families who receive disability benefits tended to receive second generation antipsychotic drugs, compared to children from more financially stable households who received stimulants to help with their school performance.

“We’re bankrupting ourselves paying for psychotropic medications that don’t reduce disparities,” Hansen told *The Nation’s Health*. “We’re reaching a crisis point in mental health care in this country where the results are unacceptable. The public is not going to be supportive.”

Kupfer said that incremental updates identified with decimals, such as 5.1 or 5.2, may be necessary, as the new *DSM* is not expected to be relevant for the next 20 years.

“Since the research base of mental disorders is evolving at different rates for different disorders, such updates will allow diagnostic guidelines to be linked to scientific advances rather than a static publication date,” Kupfer said.

For more information, visit [www.dsm5.org](http://www.dsm5.org).

*   Copyright The Nation’s Health, American Public Health Association