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Mental Health Pathfinders: The Future of the DSM · The Medical Mind

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  Welcome to this episode of Mental Health Pathfinders.
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  I'm your host, Erin Connors.
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  Today we'll take a closer look at the future of the DSM, the Diagnostic and Statistical Manual of Mental Disorders.
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  It's the foundational framework for mental health diagnosis in this country and around the world.
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  When revisions or updates happen, there is great interest in what's next.
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  And right now, a roadmap for the future is taking shape, and here to talk about it today is Dr.
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  Maria Eckendo.
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  Chair of the Future DSM Strategic Committee and Vice Chairs Dr.
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  Jonathan Albert and Dr.
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  Nitin Gotay.
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  Thank you all for being here today.
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  Really appreciate it.
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  Thank you.
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  My pleasure.
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  Alpern, I'm going to start with you if that's okay.
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  You the last major revision to the DSM came in 2013 and the DSM-5, with the DSM-5 TR, the text revision came in 2022.
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  Now we're thinking about things in a little bit of a different way.
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  Tell us about the roadmap for the future and where it's leading the strategic committee.
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  Thank you so much, Aaron.
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  So the future DSM strategic committee is very much focused on how has science continued to evolve?
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  has our field continued to evolve?
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  And what are the ways that we can continue to help DSM evolve?
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  And uh one of the um areas that we've been focusing a lot on is thinking both
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  as science evolves and also thinking about what have been some of the critiques and so what are some of the limitations uh of the current DSM and how can we address them in the
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  future DSM.
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  So one of our goals is to think about DSM-defined diagnoses, which by definition are categories, are distinct categories, and how to put them in a larger context, not only
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  looking at symptoms and duration and severity,
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  but looking at the larger context such as socioeconomic and cultural and social determinants factors, uh thinking about lifespan and developmental factors, thinking about
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  biomarkers and biological factors, uh thinking of ways to incorporate measures of functioning and quality of life.
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  And finally, although we will likely continue to have categorical diagnoses,
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  thinking about ways that we could begin to bring in dimensional thinking to a greater extent.
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  DSM-5 began to do that with cross-cutting measures and we hope to build on that as well, continuing to bring in dimensions which may inform research and treatment development.
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  Just to clarify a little bit, there is still a committee working on the DSM-5 TR and revisions for that.
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  That may be a little bit confusing for some people.
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  Dr.
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  Gotay, can you talk a little bit about that?
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  Sure.
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  So the DSM is an ongoing work, which means that the field is allowed in real time to bring to DSM's attention any changes that might be necessary, any new proposals, any changes to
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  the existing diagnostic criteria and so on.
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  And there is an ongoing committee that was created right after the DSM-5 was released.
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  which is an independent committee of experts, and they evaluate such proposals that come to the DSM inbox, so to say.
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  And they evaluate them for the scientific merit, they evaluate for the validity of the data and all the other aspects of that to rigorously test to make sure that if those
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  proposals merit incorporation into the DSM and if things need to be changed.
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  And that is an ongoing work which cannot be stopped.
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  as we work towards the future iteration of the DSM, the field still is requesting many changes and we have to continue to evaluate those works.
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  And that is the committee, the DSM 5 TR committee, which is the latest version of the DSM, which continues to do that on an ongoing basis.
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  Yeah, and Dr.
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  Akendo, let's dig in a little deeper on some things that Dr.
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  Alpert talked about earlier.
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  Some areas of focus will look at the patient as a whole.
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  Where they live, how they're functioning day to day, their quality of life.
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  These are all important factors in the well-being of patients.
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  So one of the things that we are very interested in doing is addressing the issues that bring patients to care.
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  Their ability to function and the quality of their life is perhaps one of the top concerns that patients have when they develop a psychiatric condition.
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  And yet, there hasn't really been a formal way of looking at quality of life.
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  Functioning had been assessed in the DSM-3 and the DSM-1.
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  and although it was not intended for the DSM-5 to not focus on function, by virtue of the way that the book was structured, it ended up being de-emphasized.
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  And we want to make sure that both of those items, which are so important to being able to understand the impact of the psychiatric condition on the person's life, that those are
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  evaluated when the patient presents for care.
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  And Dr.
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  Alpert, we hear the word biomarkers used in medicine, but that's been lacking in psychiatric diagnosis.
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  Is this something that the committee is keeping in mind as the science changes?
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  Obviously, this will be evolving over time.
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  That's an area we're very excited about.
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  know, since DSM 3 in the 1980s, um DSM has really been a theoretical.
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  It's been agnostic with respect to underlying mechanisms.
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  oh And it's really been a tabulation of symptoms, symptom checklists and oh duration severity of symptoms or what determines whether someone has a diagnosis.
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  um As science progresses and we learn more about the underpinnings,
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  of psychiatric disorders, some of which inevitably involve biology and some involve many other factors of experience coming together with biology.
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  But as we learn more about biology, uh we feel confident that over time there will be validated biomarkers and those biomarkers may be helpful in terms of making a diagnosis.
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  or determining what treatment will be most helpful for a given person who has or doesn't have that biomarker, or even making a prognosis about what is the likelihood of a positive
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  outcome or what is the likelihood of relapse for a given patient.
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  And there are multiple other uses of biomarkers as well.
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  We know in other fields like oncology, biomarkers are used to a very great extent.
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  uh Right now, with the exception of Alzheimer's disease,
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  There are really no validated biomarkers for psychiatric uh conditions, but we're really at a time at an inflection point where science is continuing to progress at a more rapid
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  rate.
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  And so the future DSM strategic committee and in particular the biomarkers and biological factors subcommittee uh of the overall committee are focusing a lot on what are the most
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  promising areas
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  of neurobiology that uh might inform our understanding and our ability to treat uh psychiatric disorders?
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  And can we create a meaningful placeholder uh that will be able to incorporate as new information comes forward, be able to incorporate that information?
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  It's really, really interesting.
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  And Dr.
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  Goktae, one question that always comes up, and I know you hear it, we hear it all the time too, what will the new manual be called?
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  Will it be DSM-6?
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  I understand there's actually a proposal to change at least part of the name.
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  Thank you, and that's an interesting question.
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  Yes, so there is a proposal to change part of the name from the diagnostic and statistical manual to diagnostic and scientific manual.
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  We think at the future DSM Strategic Committee thinks that it is more appropriate now to change from statistical to scientific.
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  DSM has always been based on science, so we don't want to give...
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  the impression that science is something new for the DSM.
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  But what is different is that there is not much statistics in the DSM.
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  So we think it is a good time to emphasize that the scientific basis of the DSM, probably when DSM-1 was created, one of the intentions was to document the prevalence and incidence
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  statistically of the various conditions.
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  So at that time it was probably appropriate, but now it makes sense to make it more in line with what the DSM is, which is it's the scientific man.
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  And this is a living manual, right?
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  yeah, sure, sure.
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  if I could just hop in and add to Dr.
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  Gokhtey's comments, the reality is that if in fact we are going to recognize the important role of biology and the important role of the environment and their interaction in the
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  genesis of psychiatric disorders, it really makes sense to emphasize science in its title.
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  Absolutely.
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  And this will be a living manual.
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  So this will be something, you talk a little bit more about that too?
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  Sure.
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  this was this is not necessarily a new concept.
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  DSM 5 had sort of thought about making it into a living manual, but somehow the concept at that time did not get the traction that it was intended to have.
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  So what has happened over the last several decades of the DSM is that the next every iteration of the version of the DSM has
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  time lapse between the versions of 10 years or 12 years and so on.
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  So they sort of have this static appearance and the science keeps on advancing at a very rapid pace.
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  So our goal is to make the DSM into a living document so that we will create some sort of a digital first version of the DSM.
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  And as long as...
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  we vet very carefully and rigorously the scientific advancements.
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  Our intention is to disseminate those advancements to the field as early as possible, as close to in real time as possible without causing undue disruption.
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  So we'll have to carefully establish the timelines and not too many updates and what is the right frequency of the updates and so on.
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  But nobody should have to wait between the versions 10 or 12 year period to get updated about what are the latest in state of the art scientific advancements in the field.
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  So that's the concept of the living document.
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  There have been many critics of the DSM over the history of the manual and this committee really wants to listen to these critics and hear what they have to say.
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  We think that the best way to improve a product like the DSM is to really evaluate very carefully what the critiques have been.
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  And there have been some really important critiques.
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  So for example, uh there are concerns that the DSM categories don't really carve nature at its joints, so to speak.
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  That in some ways, there's aspects of the categories that are somewhat arbitrary.
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  One of the things that we did to try to address that, mean, certainly we're gonna have to have categorical diagnoses because medicine is by definition at this juncture categorical,
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  right?
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  The doctor does an evaluation, they determine whether the person has a disorder or not, a categorical decision, yes, no, and based on that determines what the treatment is gonna
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  be.
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  So categories are gonna be important, but what we've done is integrated
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  transdiagnostic aspects that clinicians can identify.
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  And what we're hoping is that with these transdiagnostic symptoms that can be identified as being important to the clinical picture and the possibility of biological factors
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  identifying subcategories that research on these two aspects will help us better delineate
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  where the boundaries between the diagnoses are.
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  Another thing that has been uh criticized, of course, is its a theoretical stance, as well as the checklist of symptoms.
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  And we think that with uh the integration of environmental factors such as culture, socioeconomic, et cetera,
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  and with the integration of neuroscientific types of evidence, that that will expand the view that clinicians take of their patients when they're trying to determine what the
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  diagnosis is.
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  And Dr.
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  Alpert, lived experience is still an important factor here.
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  You need to hear these voices, the voices of those living with mental illness as you move forward.
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  It's absolutely essential.
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  the expression, nothing about us without us is so important to all of us on the future DSM strategic committee in taking very seriously the insights and unique perspectives of
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  people who uh have lived experience, which are many, people.
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  know the prevalence.
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  of psychiatric disorders and uh no family goes untouched.
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  We're talking about a very large number of people who have really important insights to share.
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  uh And we're planning on involving people with lived experience already have had communications and discussions with people with lived experience and will be involving in
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  a more formal way going forward to make sure the ways we think about, for example, measuring quality of life or function.
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  uh
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  are meaningful to people with lived experience, the way we're putting together uh what we feel is a more integrated and holistic view of a diagnostic formulation that includes
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  culture and that includes social determinants of health, how that resonates with people with lived experience and what suggestions they have uh for a kind of formulation that
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  would both be pragmatically useful, but also connect with the experiences of real
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  real people and family members and caregivers of people with lived experience.
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  And so we're very eager to be sure that the future DSM captures not only the best that we could bring to it, but also the best contributions from people with lived experience.
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  There's so much to know.
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  want to open this up to all of you.
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  Is there anything else that our listeners should know or how they can learn more?
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  So one of the things that I think is an additional critical factor is the inclusion of caretakers, right?
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  Because a lot of times the individuals who are assisting those with lived experience have a very important perspective that may differ from that of the patient and differ from that
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  of the clinician.
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  And we want to make sure to include those voices as well as we think about.
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  developing the future.
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  DSM.
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  I completely agree and I would also add that what we are also uh doing is create several focus groups of people with lived experience, caregivers, and hear them out in a
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  systematic, standardized, quantifiable way uh and do scientific analysis of the data that we'll get so that we can incorporate those things in a very structured and scientific
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  manner.
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  And in terms of getting more information about what we're all working on and for us to get feedback from the field at the annual APA meeting, in May we will be having several
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  sessions, four or more sessions specifically related to the future DSM.
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  uh There will be a place on the APA website uh going forward that will be a place where people will be able to get updates.
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  There already is a lot of material about DSM.
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  on the website that's focused a little bit more on the existing DSM, but in terms of activities from the future strategic committee and um news about uh views about future
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  DSM, there'll be a place on the website.
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  And we continue to expand the groups that we're reaching out to to be able to share what we're doing.
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  We want the process to be as open and as amenable to feedback.
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  um as possible.
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  So we hope people will look out for those um activities both at the annual APA meeting um and in other organizations that they may be part of and on the APA website going forward.
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  such important work that this committee is doing.
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  really appreciate all three of you taking the time to speak with us today.
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  Thanks for being here.
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  And to our listeners, you can find more episodes like this on a range of mental health topics on APA's Medical Mind Channel, available on all major podcasting platforms.