The head of the U.S. federal mental-health institute has issued a blow to the American Psychiatric Association just weeks before the scheduled release of its newly revised diagnostic manual, stating that the psychiatric "bible" lacks validity and that "patients with mental disorders deserve better."
In a blog post published last week, Thomas Insel, director of the National Institute of Mental Health, said the highly anticipated fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) shares the same shortcomings as earlier versions of the guide – its diagnoses are based on experts' agreement on sets of symptoms rather than on any measurable criteria, such as genetics, brain imaging and cognitive data.
"Unlike 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," Insel wrote. "In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever," he said, adding that "symptoms alone rarely indicate the best choice of treatment."
The fact that Insel has publicly expressed such views so close to the DSM-5's release at the May 18-22 APA annual meeting has been regarded as not only a rebuke of the APA, but also a call for a new way of approaching psychiatric diagnoses.
"It's huge," says U.S. psychotherapist Gary Greenberg, author of The Book of Woe: The DSM and The Unmaking of Psychiatry. "This is the government's psychiatrist-in-chief. … He's using the bully pulpit to try to, I think, draw attention to the fact that the DSM is a failure."
In his blog, Insel went on to say the National Institute of Mental Health is aiming to create an alternative system of classifying mental disorders and, to do so, had launched a Research Domain Criteria (RDoC) project to collect research data, such as genetics, brain imaging and cognitive science. Thus, he said, the institute would be "reorienting its research away from DSM categories" and would seek new and better treatments for patients.
"He's basically signalling that the NIMH is going to not necessarily get out of the DSM business, but they're opening a new business right next to it," Greenberg explains.
Greenberg says that while he believes that this change in the institute's research direction will generate a huge amount of science on mental health, he is skeptical that researchers will be able to boil down the extraordinarily complex workings of the brain into sound and specific diagnostic criteria.
In response to Insel, the APA issued a statement on Saturday by David Kupfer, chair of the DSM-5 task force, noting that it has been waiting for decades for reliable biological and genetic markers on which to base precise diagnoses. "We are still waiting," Kupfer said.
In the meantime, the DSM is the "strongest system currently available for classifying disorders," he said.
"Efforts like the National Institute of Mental Health's Research Domain Criteria (RDoC) are vital to the continued progress of our collective understanding of mental disorders," Kupfer said. "But they cannot serve us in the here and now, and they cannot supplant DSM-5."