The American Psychiatric Association’s latest edition of the Diagnostic and Statistical Manual (DSM 5) was released on May 22, 2013. Orders abound, as do books, blogs, and sites promising to explain the latest changes in the diagnostic criteria. Media have focused on changes, deletions, and additions to the taxonomy. Critics and supplicants alike have turned to the internet for information about the “Bible” of psychiatry. Psychiatrists, hospitals, and others have prepared for new codes; insurance companies are adjusting accordingly. The world seems prepped for the DSM 5.
In the midst, however, of all the hoopla and on the eve of the release of the DSM 5, the Director of the National Institute on Mental Health (NIMH), the largest mental health organization in American, made astoundingly negative assertions about psychiatry’s “holy book.”
Dr. Thomas Insel noted in a blog entry published April 29, 2013, that the initial goal of the DSM – that of diagnosis based on scientific evidence – has become more of an ideal than reality. The blog further announces NIMH’s abandonment of the DSM project altogether and the launching of its own diagnostic tool, the “Research Domain Criteria (RDoC).” NIMH will no longer fund research based on the DSM taxonomy of “mental illness.”
Many NIMH researchers, already stressed by budget cuts and tough competition for research funding, will not welcome this change. Some will see RDoC as an academic exercise divorced from clinical practice. Others suggest that mental health patients and their families should welcome this change as a first step towards “precision medicine,” the movement that has transformed cancer diagnosis and treatment. To be sure, RDoC is an effort to transform clinical practice by bringing a new generation of research to bear on how we diagnose and treat mental disorders.
In the meantime, two mental health giants—NIMH and the American Psychiatric Association– continue to disagree over the appropriate way to diagnose patients with mental or emotional "disorders" and how to determine which medication or evidence-based practice should be utilized for their treatment. As the Titans duke it out, non-medical mental health providers can only run for cover and contemplate the outcome.
The DSM has traditionally been used by insurance carriers to approve the type and length of treatment required by a person, couple, or family to resolve a given presenting problem based on...what, exactly? The DSM, as pointed out on the DSM website and the aforementioned blog, has been developed by a consensus of subjective opinion, not statistical evidence based in clinical research. The psychiatric profession has for decades turned a blind eye to the lack of science behind the DSM taxonomy until now.
The new system proposed by NIMH will base diagnosis on “biological markers” for various disorders. However, there are as yet no diagnostic tests that definitively connect any mental or emotional “disorder” with a measurable neurochemical condition. If such markers exist, the NIMH admits that the research involved to discover them will require a decade of work.
Where, then, does that leave mental health professionals and those that consume their services? While many non-medical mental health providers who are not steeped in “medial model envy” may breathe a sigh of relief that the psychiatric/ psychological community is finally critiquing itself with some measure of objectivity and is finally asserting the truth about the DSM taxonomy, the system that may take its place—the RDoC—could be worse than it’s predecessor. The thinking behind the RDoC continues to be rooted in the same “blind faith” that brought us the DSM; that reducing the emotions and psychology of human beings to the molecular level can and will lead to healing practice. After fifty years of asserting this notion with diminishing result in the general population, when will we conclude that the failure of the DSM is in the rubric that produced it? Instead, the vision now being cast by NIMH reflects an even narrower commitment to “precision medicine.”
In the long run, where is this “molecular dogmatism” in the mental health field leading us? If the current trend continues, it will push us toward the creation of a system of care that is increasingly profitable for the psychiatric profession, increasingly irrelevant–and harmful–to the mental and emotional health of individuals seeking care, and marginalizing to those non-medical mental health providers—mostly LPCs and LMFTs– that advocate for them.