More Frequent DSM Updates Recommended
There should be a new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) each year. The present DSM has diagnostic criteria last updated in the early 1990s, with text last updated in the late 1990s. The clinician turning today to the DSM-IV-TR does not know whether the conceptualization of the criteria over the past dozen years has changed and does not know the currency of the text. Examples of the need for diagnostic criteria classification are in the areas of childhood bipolar disorder and adult attention-deficit/hyperactivity disorder, where DSM-IV-TR is unenlightening. In addition, disorders have emerged and grown, such as fetal alcohol syndrome, on which the DSM-IV-TR is silent.
Some say that the costs of such an endeavor would be astronomical and that to develop each new criterion set would be a million-dollar project. That is not true. APA can and should do what other medical specialties do: have the experts state where the field is today—not require the development of new science.
Some say that publishing a new DSM each year would be seen as a revenue-driven initiative. That is not true. Each year the specific changes could be placed on the APA Web site for those not wanting to buy the book.
APA does not plan to complete a substantial revision of the DSM until about 2012. We should not assume that the growth of knowledge in psychiatry is so minimal that we are justified in waiting until then.
The possibility of developing a process for more frequent updates of the DSM has been discussed with APA's Committee on Psychiatric Diagnosis and Assessment and the Board of Trustees on several occasions over the past two to three years. Models for such updates are the AMA's CPT procedure codes, APA's practice guidelines, and the National Center for Health Statistics' ICD-9-CM annual updates of diagnostic codes. These organizations and agencies have established a permanent infrastructure to support regular reviews of emerging medical procedures, the clinical trials and other research bases to support treatment modifications, and proposals from the scientific community for changes in diagnostic names or code numbers. However, modifications of explicit diagnostic criteria in the DSM-III, DSM-III-R, DSM-IV, and DSM-IV-TR have not been made between revisions because of the absence of a credible, established scientific review structure and because of a concern that each change could have significant impacts on national and international research studies, which include the clinical trials that lend support for treatment guidelines.
The Division of Research is currently reviewing the research base for modifying diagnostic concepts and criteria in DSM-V with a $1.2 million grant from the National Institutes of Health. At the same time, we are examining alternatives both for modifying the text more frequently to reflect new associated features and for considering changes in the criteria for individual disorders when substantial scientific evidence supports such changes. ▪
