Saturday, July 21, 2012

DSM-5: More Dynamic?



Over on KevinMD, Dr. David Kupfer has an article up called DSM-5 Will Capture the Dynamic Nature of Mental Illness.  Huh? 


Let me start by saying that Dr. Kupfer has been an influential person in my course to becoming a psychiatrist.  In the 1980's, he ran a program called The Mellon Fellowship in Psychiatry for Undergraduates, where he paid undergraduates to spend 8 weeks in Pittsburgh doing research and observing clinical settings at Western Psychiatric Institute and Clinic.  I was a Mellon fellow.  I hit medical school knowing I wanted to be a psychiatrist and with a notable head start on the other shrinks-to-be.

But I don't see how the DSM-5 captures the dynamic nature of mental illness.  From what I can tell, it's like the DSM-5: checklists of symptoms that either box you into a category or exclude you from it.  The DSM is a very useful tool for researchers --- it lets them be sure that when they test a medication on a group of people with "depression," that those people have a similar condition.  Clinically, it's not that useful.  I'm sorry, you're suffering terribly but you only have 4 symptoms and you need 5, so you don't have an illness and so I'm not prescribing a medication for you, not coding it on your statement so you can get reimbursed, and you'll need to leave now.   Oh, that's not how psychiatry works.

Psychiatric disorders are dynamic in nature.  People get better and you never hear from them again.  Or years later, they call and say "I saw you way back when, I stopped taking medicine because I felt better, I've been well for years, but now I'm having trouble and I'd like to come see you again."  Sometimes they have a recurrence of the old problem, sometimes they're having a rough patch that has nothing to do with their past issue.  Some people have chronic illnesses and stay chronically symptomatic, others don't.   We know surprisingly little about the course of mental illness.  And when you start to talk about developmental illnesses, we really know very little.  I can't tell you how many teenagers I've known, or known about, who've been horribly distressed or disturbed, who clearly meet criteria for major mental illnesses -- often life-threatening-- who benefited from treatment (medications and psychotherapy), but who seem to age themselves out of their problems.  Was it an episode/s that will recur in years to come? Or was it just a bad teenage phase?  Of course these kids need treatment, but if we're making diagnoses dynamic, we need to acknowledge that we don't know if these kids have lifetime illnesses or transient phase of life issues. 


I'm not so hopeful that DSM-5 is going to prove to be a clinically useful tool.  Your thoughts?