mental illness — comprehensive evaluation or checklist?

n engl j med 366;20 nejm.org may 17, 2012

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Mental Illness — Comprehensive Evaluation or Checklist?Paul R. McHugh, M.D., and Phillip R. Slavney, M.D.

The Evolving Primary Care Physician

The debate over revising the Diagnostic and Statistical Manual

of Mental Disorders (DSM) is of more than intramural interest, for the way in which the promised fifth edition (DSM-5) resolves the de-bate will shape the nature and scope of psychiatric services for years to come. Now established as the master reference work for U.S. psychiatrists, the DSM ini-tially emerged, like the compan-ion volume for internists, the In-ternational Classification of Diseases, with a public health interest in the incidence and prevalence of illnesses. But with its third edition

in 1980 (DSM-III), the DSM began prescribing how clinicians should identify psychiatric disorders.

The editors of the DSM-III jus-tified this move by noting that the likelihood of diagnostic agree-ment between any two psychia-trists about the same patient was scarcely better than that achiev-able by chance. They attributed much of the difficulty to sectarian discord among proponents of psy-chodynamic, behavioral, and neu-robiologic explanations of men-tal illness. And they concluded that the diagnostic muddle could be cleared up if psychiatrists put

aside disputes over causes and in-stead identified disorders by their symptoms, signs, and clinical course.

The DSM-III produced a revolu-tion in psychiatry. The manual identified every condition with lists of diagnostic criteria; its edi-tors presumed that causes, mech-anisms, and rational treatments of the conditions would emerge through investigative efforts that, supported by these reliable defi-nitions, drew from the boundless explanatory resources of the bio-psychosocial body of knowledge.

Revolutions solve some prob-

If residents “never leave the ICU . . . they’re never going to have a comfort level to even imagine” working in a community setting.

He added that tracking of stu-dents who are interested in differ-ent career pathways should begin much earlier than it currently does. “Somebody who wants a rural setting needs to have expe-riences that prepare him for that — not working in a big inner-city clinic,” he said. “The training experiences need more to match the career pathway.” Both the du-ration and the content of medical school and residency training could be varied to reflect physi-cians’ career goals. The number and type of accredited programs for training physicians in various specialties should also more close-ly match the country’s needs, Thibault suggested.

The Macy Foundation is also focusing on the development of interprofessional education, fund-ing grants at about 20 universi-

ties and health systems to pilot programs for teaching medical students, nursing students, and other health professionals how to work together in teams, beginning early in their education. Current-ly, “we professionalize everybody separately, and only when they’re fully formed do we do the mix-ing,” Thibault said. Each profes-sion has its own culture, so “it’s not surprising that they don’t work well” together.

He believes regular training and experience working collabor-atively with other professionals should be incorporated through-out medical school and residency. “You need to learn both to be a leader and to be a member of a team, because we’re all going to play this whole gradient of roles,” Thibault said. “I really do believe that we’ll never have the health care system we want and need unless we pay a lot more atten-tion to how we’re training people to enter it.”

Disclosure forms provided by the author are available with the full text of this arti-cle at NEJM.org.

Dr. Okie is a medical journalist and a clini-cal assistant professor of family medicine at Georgetown University School of Medicine, Washington, DC.

1. Conference summary, Atlanta 2011 — Ensuring an effective physician workforce for the United States: recommendations for reforming graduate medical education to meet the needs of the public. New York: Josiah Macy Jr. Foundation (http:// josiahmacyfoundation.org/docs/macy_pubs/Macy_GME_Report,_Aug_2011.pdf).2. Dower C, O’Neil E. Primary care health workforce in the United States. Research syn-thesis report no. 22. Princeton, NJ: Robert Wood Johnson Foundation, July 2011 (http://www.rwjf.org/pr/product.jsp?id=72579).3. Margolius D, Bodenheimer T. Transform-ing primary care: from past practice to the practice of the future. Health Aff (Millwood) 2010;29:779-84.4. Mechanic D, McAlpine DD, Rosenthal M. Are patients’ office visits with physicians get-ting shorter? N Engl J Med 2001;344:198-204.5. Sung SH, Price M, Tallman K, et al. Ambu-latory care visits: squeezing 22 minutes into a 19-minute visit? Presented at the 10th An-nual HMO Research Network Conference, Dearborn, MI, May 3–5, 2004 (poster).Copyright © 2012 Massachusetts Medical Society.

The New England Journal of Medicine Downloaded from nejm.org at LINKOPING UNIVERSITY on August 19, 2013. For personal use only. No other uses without permission.

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lems — but usually raise others that are unintended and unexpect-ed. The DSM revolution was no exception. The diagnostic approach based on clinical appearances, one akin to using a naturalist’s field guide, proved to be a tactical success in that it stilled sectarian conflict, but a strategic failure in that it offered no way of making sense of mental disorders — that is, no better answer to the ques-tion “What are they?” than a mul-titude of examples.

Undeniably, the DSM-III brought some gains to psychiatric prac-tice, including consistency of diag-nosis, uniformity in therapeutic regimens, and confidence in clin-ical research based on the reli-able inclusionary and exclusion-ary criteria that DSM diagnoses can provide to investigators. Many psychiatrists who recollect the discord within psychiatry before the DSM-III find these gains suf-ficient. In their view, the subse-quent revised editions corrected the flaws that remained.

Yet the publication of a fifth revision of the DSM — now promised in 2013 — has been re-peatedly postponed, mainly be-cause fundamental problems tied to the approach of the DSM-III proved hard to solve. A most se-rious problem, common to field guides, is the difficulty of sepa-rating entities that are similar in appearance.

For example, psychiatrists us-ing the DSM diagnosis “major depression” tend to mingle be-reaved patients with both those afflicted by classic melancholia and those demoralized by circum-stances.1 The mixing of similar-appearing patients who have con-ditions that are distinct in nature probably explains why use of this diagnostic category expanded

over time and suggests why the effectiveness of antidepressant medications given to people with a diagnosis of major depression has, of late, been questioned.2 This tendency to blur natural dis-tinctions may explain why other DSM diagnoses — such as post-traumatic stress disorder (PTSD) and attention deficit disorder — have been overused, if not abused.

Many issues of concern derive from another change in practice that the DSM-III inadvertently en-couraged. Its emphasis on mani-festations persuaded psychiatrists to replace the thorough “bottom-up” method of diagnosis, which was based on a detailed life his-tory, painstaking examination of mental status, and corroboration from third-party informants, with the cursory “top-down” method that relied on symptom checklists.

Checklist diagnoses cost less in time and money but fail woe-fully to correspond with diagno-ses derived from comprehensive assessments.3 They deprive psy-chiatrists of the sense that they know their patients thoroughly. Moreover, a diagnostic category based on checklists can be pro-moted by industries or persons seeking to profit from marketing its recognition; indeed, pharma-ceutical companies have notori-ously promoted several DSM diag-noses in the categories of anxiety and depression.

Together these problems ex-pose a critical issue of design in the DSM. By forgoing thought about causation in identifying psychiatric disorders, the manual promotes a rote-driven, essential-ly rule-of-thumb approach to the diagnosis and treatment of pa-tients — and there is no obvious way of escaping the practice.

Identifying a disorder by its symptoms does not translate into understanding it. Clinicians need some heuristic concept of its na-ture, grasped in terms of cause or mechanism, to render it intel-ligible and to justify their actions in practice and research.

The editors of the DSM-5 indi-cate that the new edition will provide new categories of disor-ders, alter some criterion sets, and emphasize matters of sever-ity.4 But it will not divide psychi-atric disorders into causally intel-ligible groups. Disregard for this issue — after 30 years’ experience with an appearance-driven policy — makes these proposed chang-es for the DSM-5 seem small. The big question — “What are these disorders?” — will remain unaddressed.

Much turns on causation. For practical psychiatrists, a cause is not some issue for philosophers to ponder but rather anything that makes a difference in the evok-ing or sustaining of a disorder. Causes may be single or multi-ple, necessary or sufficient, etio-pathic or mechanistic; they are as diverse in human psychologi-cal life as the wide-ranging bio-psychosocial model implies. But they must be specified to render the manifestations of psychiatric illness intelligible and their treatments rational.

Although defining causes as “anything that makes a difference” can serve, the causes of psychiat-ric disorders derive from four in-terrelated but separable families: brain diseases, personality dimen-sions, motivated behaviors, and life encounters. And although for most patients a cause from one of these families is the most sa-lient, causal influences from sev-eral often contribute to a given

Mental Illness — Comprehensive Evaluation or Checklist?




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Grief, Depression, and the DSM-5Richard A. Friedman, M.D.

Mental Illness — Comprehensive Evaluation or Checklist?

Nearly 2.5 million Americans die each year, leaving behind

an even larger group of grief-stricken people.1 Such a univer-sal human experience as grief is recognized by the lay public and medical professionals alike as an entirely normal and expect-ed emotional response to loss. Cli-

nicians and researchers have long known that, for the vast majority of people, grief typically runs its course within 2 to 6 months and requires no treatment.

In a common clinical scenario, a patient who has just lost a loved one presents to a physician with mild depressive symptoms,

such as sadness, tearfulness, and insomnia. Under the guidelines of the American Psychiatric Asso-ciation’s Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV), a practitioner would reasonably view these de-pressive symptoms as grief-related and not diagnose clinical depres-

Some Examples of DSM Diagnoses Clustered by Causal “Perspectives.”

Brain diseases

Delirium

Schizophrenia

Panic disorder

Personality dimensions

Mental retardation

Obsessive–compulsive personality

Borderline personality

Motivated behaviors

Anorexia nervosa

Conversion disorder

Alcohol dependence

Life encounters

Bereavement

Adjustment disorder

Post-traumatic stress disorder

patient’s clinical picture. This latter fact led us, in describing the causal families and their dis-tinctive ways of affecting mental life, to name them “perspectives” and by that metaphor to empha-size how understanding a case from one causal viewpoint might blind the diagnostician to contri-butions from others.5 PTSD, for example, is a state of mind pro-voked by traumatic life encoun-ters. But for most patients, issues of behavior and temperament con-tribute to precipitating and sus-taining the condition and must

be identified in treatment. Only the painstaking assessment of patients, which was standard be-fore the publication of the DSM-III, can bring the relevant causal factors to light. Symptom check-lists will never suffice — and, of course, were never intended to.

What to recommend now? No replacement of the criterion-driven diagnoses of the DSM would be acceptable; clinicians are too ac-customed to them, and investiga-tors cannot forgo the usefulness of the DSM’s inclusionary and exclusionary diagnostic criteria when defining a condition or a group to be studied. In the new edition, however, entities could easily be rearranged so that those tied causally to diseases, person-ality dimensions, behaviors, or en-counters were identified as such and clustered separately (see table).

Grouping disorders by putative causation would promote fruitful thought and, consequently, prog-ress. Clinicians who were aware of the causal proposals and their several practical, heuristic impli-cations would be encouraged to proceed more analytically in their assessments, treatments, and in-vestigations of patients, while still using the DSM diagnoses for their records.

Psychiatrists would start mov-ing toward the day when they ad-dress psychiatric disorders in the same way that internists address physical disorders, explaining the clinical manifestations as prod-ucts of nature to be comprehend-ed not simply by their outward show but by the causal processes and generative mechanisms known to provoke them. Only then will psychiatry come of age as a med-ical discipline and a field guide cease to be its master work.

Disclosure forms provided by the authors are available with the full text of this article at NEJM.org.

From the Department of Psychiatry and Be-havioral Sciences, Johns Hopkins University School of Medicine, Baltimore.

1. Parker G. Beyond major depression. Psy-chol Med 2005;35:467-74.2. Fournier JC, DeRubeis RJ, Hollon SD, et al. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA 2010;303:47-53.3. Anthony JC, Folstein M, Romanoski AJ, et al. Comparison of the lay Diagnostic In-terview Schedule and a standardized psy-chiatric diagnosis: experience in eastern Baltimore. Arch Gen Psychiatry 1985;42:667-75.4. Kupfer DJ, Kuhl EA, Narrow WE, Regier DA. On the road to DSM-V. In: Gordon D, ed. Cerebrum 2010: emerging ideas in brain sci-ence. New York: Dana Press, 2010:81-93.5. McHugh PR, Slavney PR. The perspec-tives of psychiatry. 2nd ed. Baltimore: Johns Hopkins University Press, 1998.Copyright © 2012 Massachusetts Medical Society.



mental illness — comprehensive evaluation or checklist?

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