Critics question DSM-5 methodology, transparency

Nurse practitioners, physicians disagree on primary care roles
Nurse practitioners, physicians disagree on primary care roles

The release of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) this past May was met with criticism within the mental health profession.

Modifications in diagnostic criteria for autism, bipolar disorder, attention-deficit hyperactivity disorder, and other conditions have been questioned by experts. Many suspect that the manual has been influenced by the pharmaceutical industry, which figures to benefit from an increase in drug prescriptions for people with the aforementioned conditions.

Among the crowd of detractors are two authors of previous versions of the manual. Robert L. Spitzer, MD, head of the task force for DSM-3, expressed outrage over the fact that the creators of DSM-5 signed a non-disclosure agreement, allowing them to operate confidentially.

“When I first heard about this agreement, I just went bonkers. Transparency is necessary if the document is to have credibility,” said Spitzer.

Allen Frances, MD, chair of the DSM-4 task force, was also skeptical, pointing to the increasingly mild and ambiguous signs for disorders like ADD and ADHD proposed by DSM-5 that could add to the widespread over-diagnosis of these conditions.

“The DSM-5 should buck the trend and its inclinations – it should be ending false epidemics, not starting them,” said Frances, who also called the work a “most unhappy combination of soaring ambition and weak methodology.”

In an effort to quantify the concern over DSM-5, the Massachusetts General Hospital Psychiatry Academy partnered with myCME to conduct a survey of medical professionals' opinions on the matter. The survey was emailed to clinicians in December 2012 and January 2013, and received 144 responses.

Responses were split into physicians (36.8%) and nonphysicians (63.2%). Almost all nonphysicians (94.6%) were nurse practitioners or physician assistants. More than 75% of responders had more than 10 years of practice experience, and 91.6% were in the field of psychiatry.

Nonphysicians appeared to be more interested in the release of DSM-5 than physicians: 88% of the former expressed at least moderate anticipation about the new manual, compared with 70.6% of the latter. Meanwhile, 11.3% of physicians were indifferent to the release, and 15.1% said they would only pay attention once it impacted their practice, compared with 4.4% and 6.6%, respectively, for nonphysicians.

In general, clinicians expressed anxiety about understanding the changes made to diagnostic criteria. A large majority (84%) were at least “somewhat concerned” that implementing the revisions would be complicated, with more than half (50.7%) reporting high levels of concern.

Moreover, only 14.6% of participants felt “very confident” that they would be able to put the changes into practice. Nonphysicians were more optimistic about the prospects of DSM-5, as 67% reported at least moderate confidence in incorporating the changes, compared with 47.2% for physicians.

When clinicians were asked to specify what exactly concerned them about DSM-5, the most common answers were the time required and available to understand the new manual, access to education on the new guidelines, and insurance- and reimbursement-related issues.

Therapeutic areas of DSM-5 that troubled clinicians most were bipolar disorder (59.0%), autism spectrum disorders (47.9%), depression (47.2%), substance abuse disorders (45.8%), and post-traumatic stress disorder (41.0%).

With regard to educating themselves, 87.8% of participants said they would seek to obtain education either right away or soon after the release of DSM-5, while almost half (49.3%) planned on primarily using the internet to learn about the revised manual.

While there are certainly some clinicians who are not fretting about DSM-5, the general trends of the survey seem to indicate high levels of doubt surrounding the manual and reflect the overall anxious mood related to the changes.
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