In a potentially seismic move, the National Institute of Mental Health – the world’s biggest mental health research funder, has announced only two weeks before the launch of the DSM-5 diagnostic manual that it will be “re-orienting its research away from DSM categories”.
In the announcement, NIMH Director Thomas Insel says the DSM lacks validity and that “patients with mental disorders deserve better”.
This is something that will make very uncomfortable reading for the American Psychiatric Association as they trumpet what they claim is the ‘future of psychiatric diagnosis’ only two weeks before it hits the shelves.
As a result the NIMH will now be preferentially funding research that does not stick to DSM categories:
Going forward, we will be supporting research projects that look across current categories – or sub-divide current categories – to begin to develop a better system. What does this mean for applicants? Clinical trials might study all patients in a mood clinic rather than those meeting strict major depressive disorder criteria. Studies of biomarkers for “depression” might begin by looking across many disorders with anhedonia or emotional appraisal bias or psychomotor retardation to understand the circuitry underlying these symptoms. What does this mean for patients? We are committed to new and better treatments, but we feel this will only happen by developing a more precise diagnostic system.
As an alternative approach, Insel suggests the Research Domain Criteria (RDoC) project, which aims to uncover what it sees as the ‘component parts’ of psychological dysregulation by understanding difficulties in terms of cognitive, neural and genetic differences.
For example, difficulties with regulating the arousal system might be equally as involved in generating anxiety in PTSD as generating manic states in bipolar disorder.
Of course, this ‘component part’ approach is already a large part of mental health research but the RDoC project aims to combine this into a system that allows these to be mapped out and integrated.
It’s worth saying that this won’t be changing how psychiatrists treat their patients any time soon. DSM-style disorders will still be the order of the day, not least because a great deal of the evidence for the effectiveness of medication is based on giving people standard diagnoses.
It is also true to say that RDoC is currently little more than a plan at the moment – a bit like the Mars mission: you can see how it would be feasible but actually getting there seems a long way off. In fact, until now, the RDoC project has largely been considered to be an experimental project in thinking up alternative approaches.
The project was partly thought to be radical because it has many similarities to the approach taken by scientific critics of mainstream psychiatry who have argued for a symptom-based approach to understanding mental health difficulties that has often been rejected by the ‘diagnoses represent distinct diseases’ camp.
The NIMH has often been one of the most staunch supporters of the latter view, so the fact that it has put the RDoC front and centre is not only a slap in the face for the American Psychiatric Association and the DSM, it also heralds a massive change in how we might think of mental disorders in decades to come.
Link to NIMH announcement ‘Transforming Diagnosis’.