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Psychiatry’s New Guide Falls Short, Experts Say - NYTimes.com Psychiatry’s Guide Is Out of Touch With
Science, Experts Say
By and Just weeks before the long-awaited publication of a new edition of the so-called bible of
mental disorders, the federal government’s most prominent psychiatric expert has said the
book suffers from a scientific “lack of validity.”
The expert, Dr. Thomas R. Insel, director of the National Institute of Mental Health, said inan interview Monday that his goal was to reshape the direction of psychiatric research tofocus on biology, and neuroscience so that scientists can define disorders by theircauses, rather than their symptoms.
While the Diagnostic and Statistical Manual of Mental Disorders, or D.S.M., is the best toolnow available for clinicians treating patients and should not be tossed out, he said, it doesnot reflect the complexity of many disorders, and its way of categorizing mental illnessesshould not guide research.
“As long as the research community takes the D.S.M. to be a bible, we’ll never makeprogress,” Dr. Insel said, adding, “People think that everything has to match D.S.M.
criteria, but you know what? Biology never read that book.” The revision, known as the D.S.M.-5 and the first since 1994, has stirred unprecedentedquestioning from the public, patient groups and, most fundamentally, senior figures inpsychiatry who have challenged not only decisions about specific diagnoses but thescientific basis of the entire enterprise. Basic research into the biology of mental disordersand treatment has stalled, they say, confounded by the labyrinth of the brain.
Decades of spending on neuroscience have taught scientists mostly what they do not know,undermining some of their most elemental assumptions. Genetic glitches that appear toincrease the risk of in one person may predispose others to -likesymptoms, or . The mechanisms of the field’s most commonly used drugs— like, and antipsychosis medications like Zyprexa — have revealednothing about the causes of those disorders. And major drugmakers have scaled backpsychiatric drug development, having virtually no new biological “targets” to shoot for.
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Dr. Insel is one of a growing number of scientists who think that the field needs an en new paradigm for understanding mental disorders, though neither he nor anyone els knows exactly what it will look like.
www.nytimes.com/2013/05/07/health/psychiatrys-new-guide-falls-short-experts-say.html?_r=0&adxnnl=1&pagewanted=print&adxnnlx=1368036744-1msPk… Psychiatry’s New Guide Falls Short, Experts Say - NYTimes.com Even the chairman omaking revisions to the D.S.M., Dr. David J. Kupfer, aprofessor of psychiatry at the University of Pittsburgh, said the new manual was faced withdoing the best it could with the scientific evidence available.
“The problem that we’ve had in dealing with the data that we’ve had over the five to 10years since we began the revision process of D.S.M.-5 is a failure of our neuroscience andbiology to give us the level of diagnostic criteria, a level of sensitivity and specificity thatwe would be able to introduce into the diagnostic manual,” Dr. Kupfer said.
The creators of the D.S.M. in the 1960s and ’70s “were real heroes at the time,” said Dr.
Steven E. Hyman, a psychiatrist and neuroscientist at the Broad Institute and a formerdirector at the National Institute of Mental Health. “They chose a model in which allpsychiatric illnesses were represented as categories discontinuous with ‘normal.’ But this istotally wrong in a way they couldn’t have imagined. So in fact what they produced was anabsolute scientific nightmare. Many people who get one diagnosis get five diagnoses, butthey don’t have five diseases — they have one underlying condition.” Dr. Hyman, Dr. Insel and other experts said they hoped that the science of psychiatrywould follow the direction ofresearch, which is moving from classifying tumors bywhere they occur in the body to characterizing them by their genetic and molecularsignatures.
About two years ago, to spur a move in that direction, Dr. Insel started a federal projectcalled Research Domain Criteria, or RDoC, which he highlighted Dr. Insel said in the blog that the National Institute of Mental Health would be“reorienting its research away from D.S.M. categories” because “patients with mental Dr. Insel said in the interview that his motivation was not to disparage the D.S.M. as aclinical tool, but to encourage researchers and especially outside reviewers who screenproposals for financing from his agency to disregard its categories and investigate thebiological underpinnings of disorders instead. He said he had heard from scientists whoseproposals to study processes common to schizophrenia andwererejected by grant reviewers because they cut across D.S.M. disease categories.
“They didn’t get it,” Dr. Insel said of the reviewers. “What we’re trying to do with RDoC issay actually this is a fresh way to think about it.” He added that he hoped researcherswould also participate in projects funded through the Obama administration’s new braininitiative.
Dr. Michael First, a psychiatry professor at Columbia who edited the last edition of themanual, said, “RDoC is clearly the way of the future,” although it would take years to get www.nytimes.com/2013/05/07/health/psychiatrys-new-guide-falls-short-experts-say.html?_r=0&adxnnl=1&pagewanted=print&adxnnlx=1368036744-1msPk… Psychiatry’s New Guide Falls Short, Experts Say - NYTimes.com results that could apply to patients. In the meantime, he said, “RDoC can’t do what theD.S.M. does. The D.S.M. is what clinicians use. Patients will always come into offices withsymptoms.” For at least a decade, Dr. First and others said, patients will continue to be diagnosed withD.S.M. categories as a guide, and insurance companies will reimburse with such diagnosesin mind.
Dr. Jeffrey Lieberman, the chairman of the psychiatry department at Columbia andpresident-elect of the which publishes the D.S.M., saidthat the new edition’s refinements were “based on research in the last 20 years that willimprove the utility of this guide for practitioners, and improve, however incrementally, thecare patients receive.” He added: “The last thing we want to do is be defensive or apologetic about the state of ourfield. But at the same time, we’re not satisfied with it either. There’s nothing we’d likebetter than to have more scientific progress.” www.nytimes.com/2013/05/07/health/psychiatrys-new-guide-falls-short-experts-say.html?_r=0&adxnnl=1&pagewanted=print&adxnnlx=1368036744-1msPk…

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