The soon-to-be-released update of the Diagnostic and Statistical Manual of Mental Disorders doesn't adequately take into account the social influences on psychiatric illness and diagnosis, researchers said.
"The DSM-5 revisions are taking place at a time when there is increasing public scrutiny of the accuracy and integrity of psychiatric diagnoses and growing awareness of the role that social and economic influences can play, both in the incidence of disease and in its diagnosis," argued a 12-member research group led by Helena Hansen, MD, PhD, of New York University in New York City, online in Health Affairs.
"These factors go beyond the reach of biological science and psychiatry and are not adequately accounted for in the understanding of disease currently promoted by the DSM and its revision process."
DSM-5 and its predecessors have been developed by the American Psychiatric Association (APA). The new edition is scheduled to be formally released next month at the APA's annual meeting, culminating a process that began 5 years after the previous version, DSM-IV, came out in 1994.
Hansen and colleagues, most of whom are social science and public health researchers, suggested that the APA's recent focus on individual biological determinants of mental illness is both too narrow and too preliminary to adequately inform the clinical diagnostic process.
"Mental health leaders -- including those revising the DSM -- should go a step further and understand how social and institutional processes shape both the epidemiological distribution of disorders in the population and the way that disorders are identified and labeled."
For example, they noted that people may aggressively seek certain diagnoses for themselves or family members to secure benefits such as Social Security payments or access to medications.
By the same token, Hansen and colleagues contended, pharmaceutical companies often publicize particular diagnoses to sell drugs to treat them, which affects the reported prevalence of such disorders. The researchers cited restless leg syndrome as an example.
Although Hansen and colleagues cited no specific evidence that the APA's DSM-5 Task Force had not considered such factors, they called for an "independent research review body" to oversee future updates to the manual. The APA has promised that review and reconsideration of DSM-5's diagnostic criteria and taxonomy would be a continuous process.
The independent review body would "monitor population-level data on variations in psychiatric diagnosis and coordinate research on the institutional, social, and cultural causes of those variations," Hansen's group wrote. Its mission should also include recommending new research directions as well specific changes to DSM-5, and to mediate scientific controversies over "diagnostic patterns and their causes."
As further justification for the review body, Hansen and colleagues noted that previous editions of the DSM have been "a substantial source of income for the APA," potentially clouding the organization's judgment.
"It thus would be important for the review body to be governed by, and to have its members appointed by, processes independent of the association," the group contended. "This would insulate the review body from pressure to consider the sales potential of the DSM in various mental health provider markets when making future revisions."
Primary source: Health Affairs
Hansen H, et al "Independent Review Of Social And Population Variation In Mental Health Could Improve Diagnosis In DSM Revisions" Health Affairs 2013; doi: 10.1377/hlthaff.2011.0596.
John Gever, Senior Editor, has covered biomedicine and medical technology for 30 years. He holds a B.S. from the University of Michigan and an M.S. from Boston University. Now based in Pittsburgh, he is the daily assignment editor for MedPage Today as well as general factotum on the reporting side. Go Pirates/Penguins/Steelers!