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Mental Health

Counter-argument: Changes to DSM-V bring needed improvements

On May 14, Dr. Keith Ablow, a Fox News contributor and practicing psychiatrist, posted comments on the Fox News website about the American Psychiatric Association and its current revision of the Diagnostic Statistical Manual. 

The DSM was created in 1952 to provide a complete and reliable source of diagnostic categories and descriptions of mental disorders. Its formation was guided by two fundamental principles; that the diagnostic categories and criteria that define mental disorders, are supported by substantial scientific evidence, and that they are consistent with public health needs. The DSM is periodically revised to update diagnoses and their defining criteria as new knowledge is generated. The last revision to the DSM was in 1994.

In his article, Ablow made comments about the APA and DSM-V, which I believe are inaccurate and unsubstantiated by scientific evidence. Moreover, they are misleading to the public and potentially harmful in that by undermining the credibility of the psychiatric profession and its scientific underpinnings. They may even deter people in need from seeking treatment.

For this reason, I offer the following comments in response. I believe that I am qualified to do so as Professor and Chair of Psychiatry at Columbia University College of Physicians and Surgeons and the President Elect of the APA.

It is one thing to have a distressing and disabling psychiatric condition that affects one’s perception, cognition and emotions, and impairs quality of life, relationships and well-being.  But it is quite another level of tragedy when that condition goes undiagnosed, or when one is unable to get access to treatment because of stigma and shame or a lack of insurance coverage.  Relief from symptoms and recovery may be postponed or may never happen.  The consequences are not just inconvenience – as with any serious non-psychiatric medical condition, they are real, life-altering and potentially life-threatening.

For decades, the APA has worked diligently to provide definition in the environment of mental health through the development of the Diagnostic and Statistical Manual of Mental Disorders.  Since DSM-III, each edition has provided evidence-based guidance in manual form for use by clinicians and researchers to diagnose and classify mental disorders so that patients in need can be effectively evaluated and gain access to treatments.

Since DSM-IV was released in 1994, there has been a wealth of new research and knowledge about the nature and frequency of mental disorders, how the brain functions and its neurobiology, and the lifelong influences of genes and environment on a person’s health and behavior.  Accordingly, the newest edition – DSM-V – will reflect that new body of knowledge.  And people who now suffer from a range of conditions will be the beneficiaries as they become increasingly likely to get an accurate diagnosis and access to treatment for it.

Many of the changes that are being proposed for this new edition were done to better characterize symptoms and behaviors of groups of people who are currently seeking clinical help but are less well-defined under the guidelines of the current DSM-IV edition.  The hope is that by more accurately defining disorders, diagnosis and clinical care will be improved and new research will be facilitated to help improve our understanding.  

The APA recognizes the importance not only of the document, but of the process for creating it and takes this responsibility with the utmost seriousness and as a sacred trust. Contrary to Ablow’s comments, the process for revision is not arbitrary and not politicized.  

For this revision, the APA recruited more than 160 of the top researchers and clinicians from around the world to be members of the DSM-V Task Force, Work Groups and Study Groups.  

These experts in neuroscience, biology, genetics, statistics, epidemiology, social and behavioral sciences, and public health were rigorously vetted for any conflict of interest using guidelines derived from other academic professional organizations and from the federal government itself and have worked assiduously for over five years to scour the scientific literature and determine whether any changes to existing DSM-4 diagnoses and additions were warranted.  They participated on a strictly voluntary basis and come from several medical and health care disciplines including psychiatry, psychology, pediatrics, nursing and social work.

The definition of mental illnesses may at times be a matter of debate – and they should be.  But the importance of mental illness and the need to recognize and diagnose it cannot be understated.  Without them, diagnostic approaches could vary widely.  The treatment of conditions would be uneven.  Payment for services would be difficult, to say the least.

For too long in human history, persons with mental illness were feared, persecuted or ignored. Stigma of mental illness in our society was pervasive. 

However, through biomedical research and enhancement of public awareness we have made great strides in the U.S. to establish a strong scientific basis for our understanding of human behavior and brain disorders that affect mental functions and bring them out of the shadows so that people can recognize symptoms and seek treatment. 

That is why the APA has gone to great lengths, and taken great care, from every angle, to produce a document that incorporates new knowledge to develop the latest guidelines that will benefit practitioners and patients alike.

Dr. Jeffrey Lieberman is the chairman of Department of Psychiatry at Columbia University College of Physicians and Surgeons, and director at the New York State Psychiatric Institute.

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