Psychiatry’s Guide Is Out of Touch With Science, Experts Say
By PAM BELLUCK and BENEDICT CAREY
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 in an interview Monday that his goal was to reshape
the direction of psychiatric research to focus on biology, genetics and neuroscience so that scientists can define disorders by their causes, rather than their symptoms.
While the Diagnostic and Statistical Manual of Mental Disorders, or
D.S.M., is the best tool now available for clinicians treating patients
and should not be tossed out, he said, it does not reflect the
complexity of many disorders, and its way of categorizing mental
illnesses should not guide research.
“As long as the research community takes the D.S.M. to be a bible, we’ll
never make progress,” 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, is the first major reissue since
1994. It has stirred unprecedented questioning from the public, patient
groups and, most fundamentally, senior figures in psychiatry who have
challenged not only decisions about specific diagnoses but the
scientific basis of the entire enterprise. Basic research into the
biology of mental disorders and 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 to increase the risk of schizophrenia in one person may predispose others to autism-like symptoms, or bipolar disorder. The mechanisms of the field’s most commonly used drugs — antidepressants like Prozac,
and antipsychosis medications like Zyprexa — have revealed nothing
about the causes of those disorders. And major drugmakers have scaled
back psychiatric drug development, having virtually no new biological
“targets” to shoot for.
Dr. Insel is one of a growing number of scientists who think that the
field needs an entirely new paradigm for understanding mental disorders,
though neither he nor anyone else knows exactly what it will look like.
Even the chairman of the task force
making revisions to the D.S.M., Dr. David J. Kupfer, a professor of
psychiatry at the University of Pittsburgh, said the new manual was
faced with doing 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 10 years since we began the revision process of D.S.M.-5 is
a failure of our neuroscience and biology to give us the level of
diagnostic criteria, a level of sensitivity and specificity that we
would be able to introduce into the diagnostic manual,” Dr. Kupfer said.
About two years ago, to spur a move in that direction, Dr. Insel started a federal project called Research Domain Criteria, or RDoC, which he highlighted in a blog post last week. 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 disorders deserve better.” His commentary has created ripples throughout the mental health community.
For at least a decade, Dr. First and others said, patients will continue
to be diagnosed with D.S.M. categories as a guide, and insurance
companies will reimburse with such diagnoses in mind.
Dr. Jeffrey Lieberman, the chairman of the psychiatry department at Columbia and president-elect of the American Psychiatric Association,
which publishes the D.S.M., said that the new edition’s refinements
were “based on research in the last 20 years that will improve the
utility of this guide for practitioners, and improve, however
incrementally, the care patients receive.”
He added: “The last thing we want to do is be defensive or apologetic
about the state of our field. But at the same time, we’re not satisfied
with it either. There’s nothing we’d like better than to have more
scientific progress.”
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