This APA Online 2022 session focused on the future of the DSM, and how it can remain relevant to the field of psychiatry. The speakers discussed the importance of addressing social determinants of mental health, race, ethnicity, and nationality, and patient functioning, and the advantages of the broader Research Domain Criteria framework, in psychiatric diagnostic criteria.
Social determinants of mental health
‘Social determinants of mental health (SDoMH)’ was the theme for the 2022 APA Annual Meeting. Professor Roberto Lewis-Fernández (Columbia University, USA) described how the conditions in which people are born, grow, live, work, and age are the forces and systems that shape daily life. They impact on a person’s biology, subjective experience, risk behaviour, and coping mechanisms. They influence the onset and course of psychopathology and affect their access to and quality of healthcare.
Inequality is an underacknowledged source of mental illness
Inequality has been highlighted as an underacknowledged source of mental illness and distress. Data shows that the prevalence of mental illness is greater in more unequal societies, even amongst high income countries.1
Race, ethnicity and nationality
Dr Altha Stewart (University of Tennessee, USA) stressed the importance of addressing race, ethnicity, and nationality when making a psychiatric diagnosis. "Failure to do this may result in patient mistrust of services and institutions and limited engagement with healthcare. Discriminatory practices and racism can exacerbate psychiatric disorders and contribute to poor outcomes. It may result in misdiagnosis and differing treatment options and quality of care".
It is important to address race, ethnicity, and nationality when making a psychiatric diagnosis
The latest revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) was published in early 2022.2 The role of SDoMH has been expanded, especially in the disorder subsections on Prevalence, Environmental Risk and Prognostic Factors, and Culture-Related Diagnostic Issues, and Culture and Psychiatric Diagnosis chapter. In order to address race, ethnicity and nationality a Cross-Cutting Review Committee on Cultural Issues was established. The entire DSM text was also reviewed and revised by an Ethnoracial Equity and Inclusion Work Group, to ensure appropriate attention to risk factors, such as the experience of racism and discrimination, as well as to the use of non-stigmatizing language.
Research Domain Criteria
In 2008 the National Institute of Mental Health3 highlighted the emerging concern that the current diagnostic system was limiting translational research, as the disorder categories often represented heterogeneous syndromes rather than specific diseases. This led to the establishment of the Research Domain Criteria (RDoC) project,4 and Bruce Cuthbert (National Institute of Mental Health, USA) discussed how this is helping inform new conceptions of mental illness, which can be used for future revisions of the DSM.
Current diagnostic system is limiting translational research, as the disorder categories often represented heterogeneous syndromes rather than specific diseases
RDoC provide an alternative framework for studying psychopathology across the lifespan, involving domains based on normal functions, that can become dysfunctional in a range of diseases. It includes the impact of environmental factors and integrating measurement types (e.g., genetics, cognitive functioning, and symptoms).
Dr Cuthbert highlighted ways this approach can be applied when compiling future DSMs, including integration of subjective experience, functioning and biology (e.g., mind-body problems), and addressing clinical problems and mechanisms that cut across disorders.
Importance of functioning
Functioning is a key factor in patients with mental health symptoms seeking or being referred for healthcare
Diana Clarke (American Psychiatric Association) talked about the importance of functioning in future DSMs, as a key factor in patients with mental health symptoms seeking or being referred for healthcare. DSM-5 moved from the use of the Global Assessment of Functioning to the WHODAS 2.0,5 which separates assessment of symptoms from functioning. This helps in identifying and treating patients who might be considered high functioning but are still in mental distress.
Future of the DSM
It will be crucial to ensure the DSM encompasses and remains relevant to all patients
The speakers agreed that in the future harmonizing the DSM with RDoC, and adequately addressing SDoMH, race, ethnicity, and nationality, and patient functioning will be crucial, to ensure the DSM encompasses and remains relevant to all patients.
APA : American Psychiatric Association
DSM : Diagnostic and Statistical Manual of Mental Disorders
SDoMH : Social Determinants of Mental Health
USA : United States of America
RDoC : Research Domain Criteria
WHODAS : World Health Organization Disability Assessment Schedule
BE-NOTPR-0214, approval date : 10.2022