NIMH withdraws support for DSM

[Ninja]

Dr. Thomas Insel, current director of the National Institute of Mental Health (NIMH), posted a public statement on the institution's withdrawal of support for the DSM.

NIMH will be re-orienting its research away from DSM categories. Going forward, we will be supporting research projects that look across current categories – or sub-divide current categories – to begin to develop a better system.

As to why...

While DSM has been described as a “Bible” for the field, it is, at best, a dictionary, creating a set of labels and defining each. The strength of each of the editions of DSM has been “reliability” – each edition has ensured that clinicians use the same terms in the same ways. The weakness is its lack of validity. 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. 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. Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment.

Patients with mental disorders deserve better.

[jarek56]

Fascinating. What will this mean for the future of medicine for the mind, I wonder? I know very little of the intricacies of medicine, so I really can't comment on this too much.

[Ninja]

This shift away from the DSM is most immediately going to affect research - how grant parameters are set, how methodologies for answering certain questions are framed, and how these questions are asked. Today, anyone who wants to ask empirical questions about human thoughts, feelings, and behavior in terms of mental health are indirectly required to frame them in the context of DSM diagnostic criteria, which are heavily biased, non-scientific, and intensely debated to be corrupted by industrialized practices (e.g., the direct, immediate, and pervasive influence of drug companies).

The DSM was always intended to be a clinical tool; a sort of handbook professionals could refer to quickly if a client displayed a very specific set of symptoms they were not yet familiar with. The DSM is a manualization of special clients clinicians have encountered, what symptoms they displayed, and how they treated them. Tragically, and at the expense of those affected by any and all kinds of mental health issues (i.e., every single person ever), this somehow got twisted into a dogmatic if-then rulebook of best practice when it is and always has been a general guideline of strategies found effective in past cases.

In the immediate future, the shift Insel is talking about doesn't have any actual implications for clinical practice. Everyone will still be (mis)using the DSM to (mis)diagnose and (mis)treat clients' symptoms, but only until research practices, now liberated from the confines of reifying the DSM, find better ways of identifying, assessing, treating, and preventing concerns of mental health.

From the article: "RDoC, for now, is a research framework, not a clinical tool. This is a decade-long project that is just beginning. 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. But patients and families should welcome this change as a first step towards "precision medicine,” the movement that has transformed cancer diagnosis and treatment. RDoC is nothing less than a plan to transform clinical practice by bringing a new generation of research to inform how we diagnose and treat mental disorders. As two eminent psychiatric geneticists recently concluded, “At the end of the 19th century, it was logical to use a simple diagnostic approach that offered reasonable prognostic validity. At the beginning of the 21st century, we must set our sights higher.”

[WookieLast]

Hm. I've always been under the impression that mental health is always treated second rate in both diagnoses, treatment and aftercare atleast when compared with physical health. That and the stigma attached with it. Improving the accuracy of diagnosis is always a good thing, but the cut in funding at a time where funding is already tight against something that at times feels like its 'second class' isn't so encouraging.

I'm mainly speaking from the UK's NHS services (which are now becoming privatized, *groan*)

[Ninja]

The abysmal (or inadequate, at least) state of mental health in the United States is indeed conflated with issues of stigma. President Obama and Vice President Biden just recently held the National Conference on Mental Health talking specifically about this issue.

In general, Americans are horribly dismissive of mental health concerns. It's either an "excuse" or "not my problem," but most commonly a scapegoat. Ernst Mayr hit on the difference between proximate and ultimate causes in much of his philosophy that still stands as the foundation for most sciences today; however, psychology and biology remain mired in failures to make such differentiations.

Proximate cause: Why did this person do this? --> They have mental illness --> Mental illness caused their behavior. All people with mental illness must be monitored.
Ultimate cause: Why does this person have mental illness? --> Effective detection and treatment were not made immediately available to them. --> Make effective detection and treatment more widely available.

Right now, most institutions who provide services for mental health only do so passively. I am not familiar with the political history of mental health in the public in the UK, but here in the US, the federal government ceased providing centralized mental health in the 1950's and eventually totally phased out in 1970's. Leaning on "community health" initiatives, a lot of service providers set up to and still currently arrange for ineffective treatment methods for the sole purpose of receiving billable health insurance.

It's difficult to blame any one provider for coasting on such principles, however, because many of their methods are shamefully efficient from certain perspectives. It's still considered "best practice" to sit people diagnosed with mental illness in groups to talk about their feelings over all other methods. The failures of clinicians are largely the failures of researchers to find better methods. This is where withdrawal of support for the DSM comes into play.

Things will indeed become even more competitive and difficult as the parameters for research funding change. I agree with the director in believing this concern is only temporary and necessary for greater potential for change in the future.

Scientists only spend about 1% of their time doing science. The rest of that time is figuring out how to sell it. It's a twisted, broken system, but it's the reality everyone has to work with. Nothing ever gets done unless there's someone willing to pay for it at the end. They'll figure it out. Or someone who can figure it out will do it instead.

[jarek56]

I'm sorry I didn't respond to your reply sooner, especially since I was one of the first to post in this thread.

Thank you for the highly informative and very...interesting information and explanations. I truly appreciate your response, since I am actively pursuing an education in psychology, particularly in the field of providing treatment for those with mental disorders/disease. Now that you mention all this, I really can't help but agree with you. Thank you for your highly informative posts. Here's to hoping that something comes of it.

Sadly, no one's going to bother making new science where there is no demand for it. At least, not many people. And that isn't necessarily bad, but leads to tragic results sometimes. Especially in healthcare, it seems.

[Ninja]

Fields remain stagnant as long as the greatest bang-for-the-buck can be gotten by just coasting on preexisting methods. The trick is doing research that finds something that is not only more effective, but also more efficient.

Think of how it happened with lightbulbs. We ran on incandescent bulbs since the 1800's because they put out the amount of light we needed at a cost we were willing to pay for its production, use, and maintenance. Over time, as the adoption of electricity expanded, what was previously seen as minimal impact for lighting soon came to compete with everything else that required electricity to run. The inefficiencies of scale became increasingly apparent. Compact fluorescent bulbs had been around almost as long as incandescent bulbs. We'd known for quite some time that compact fluorescent bulbs burned brighter for longer using less energy and producing less heat, but the procedures necessary to produce them were costly and required materials which were difficult to obtain - upwards of 5-8 times more costly than incandescent bulbs. However, once people started framing this cost difference in long-term reference, people started talking and thinking about it differently. Yes, compact fluorescent bulbs cost more to produce, but they last 10 times as long - by switching to compact fluorescent bulbs in your home, you end up saving hundreds of dollars that you would have spent on replacing incandescent bulbs more frequently and offsetting the heat they produce. Federal mandates to phase out incandescent bulbs in favor of compact fluorescent bulbs started in 2007 here in the US. Things are great, right? Well, kind of. We're much better off now with compact fluorescent bulbs than we were with incandescent bulbs. After all, compact fluorescent bulbs burn brighter for longer while costing less. Those are all good things, right? "Better" doesn't mean "good," and "better" is hardly equivalent with "best." There's this new technology increasing in popularity called light-emitting diodes that's even more energy efficient than compact fluorescent bulbs that doesn't require any of the hazardous materials to produce them. Are light-emitting diodes the best lighting source? We need to be able to tell if they're better, first.

Modern mental health treatment is at its most efficient state, given the methodological and technological standards with which it is provided. It's outdated, inefficient, and ineffective when compared to many other novel treatment methods out there; however, none of these alternative methods have proven efficient (or even replicable) on a scale convincing enough to initiate adoption. To make things even more difficult, no one agrees on what measures are important to focus on for indicating change in mental health. Do we measure subjective reports of feelings from clients? Do we ask the clinicians to report their own subjective ratings of client progress? Do we assess performance of clients across some battery of tests? For all those questions: how and why?

I think one of the best and worst things we can look at is cost efficiency for mental health treatment. How much money it costs to provide treatment is ultimately what's going to grab the attention of people with the power to make changes, but this overlooks so many important and critical variables of the individual seeking mental health treatment. It's like how medical doctors just tell their patients to get more exercise when they don't detect anything wrong. The assumption is that if the doctor gives that order and the patient never returns for the issue, the exercise worked and the patient's symptoms have subsided. No. Maybe the patient sought treatment elsewhere because the doctor couldn't tell them anything useful. Maybe the patient stopped seeking help at all and has decided to just live with the symptoms. Maybe this thing, and this other thing, etc. But none of that matters because the patient never reported having the issue again, right?

Right?

So, if you're someone interested in joining the discussion, whether it be informally like on forums here or hands-on in research or clinical services, the good news is that there's a lot to talk about and even more to do. The bad news is that it's currently a race to the bottom, and it's getting worse and worse as mental health is increasingly cited as the scapegoat of nearly all modern social problems.