The American Psychiatric Association held its annual meeting in San Francisco this week to discuss current trends and advancements in the field. One of the hallmarks of the conference was an update of the organization's manual for diagnosis and treatment, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), often referred to as "the bible of psychiatry." This handbook has served for years as the definitive guide to both diagnosis and treatment, allowing psychiatrists an easy mode to search for symptoms and assign corresponding medications, a sort of trial and error that has become standard practice for the modern psychiatrist. It is the great textbook of the art of psychiatry.
Symptom-based diagnosis was for decades the only method known to physicians in all fields of medicine. Doctors, without corresponding laboratory data to confirm suspicions about root causes of illness, would analyze symptoms such as fatigue, muscle pain, or fever and assign drugs accordingly. But as technology has advanced, so too have our methods of diagnosis. From blood tests to genomics to full-body scans, doctors now have the ability to search for and treat many root causes of disease. Trial and error, for the modern physician, is outdated, costly, even dangerous. Our advancing ability to measure pathophysiology has saved millions of dollars and millions of lives.
Psychiatry, however, remains stuck in the past. Dr. Thomas Insel, director of the National Institute of Mental Health, recently took the bold step of dumping the DSM-5 for its lack of scientific validity. Insel said, "Indeed, symptom-based diagnosis, once common in other areas of medicine, has been largely replaced in the past half century as we have understood that symptoms alone rarely indicate the best choice of treatment." He continues, "The diagnostic system has to be based on the emerging research data, not on the current symptom-based categories." So why haven't our methods changed?
The answer is that it's both difficult and expensive to study the brain. As of yet, not nearly enough data exists to design a new "gold standard" of diagnosis based on cognitive performance or biological markers. Furthermore, as many in the field accept the DSM as an effective enough method of diagnosis, many of those performing new research are looking for immediate, rather than long-term solutions to this problem. For decades, researchers have been rejecting results because they do not fit current DSM categories and standards, wasting millions of dollars and countless hours of work. With government studies showing that as few as 12.7 percent of those suffering from mental health disorders receive even minimally effective drug treatment, however, the stakes are too high to continue to accept the status quo.
This challenge has driven many entrepreneurs and private companies to build better systems to guide treatment and give those suffering with mental health issues the same quality of care enjoyed by patients in almost all other fields. Capitalizing on developments in the field of electroencephalography (EEG), companies like CNS (Central Nervous System) Response have developed databases of brain response that can be used to more effectively assign medication and predict adverse effects. Though the fundamental technology has existed for more than 80 years, with 75 peer-reviewed studies confirming its utility in prescribing, only recently have these results been applied at the point of care. Under Dr. Insel's direction, the NIMH has turned its research focus away from DSM categories and toward neurophysiological markers of response made possible by advances in computing power, neuroimaging, and crowdsourcing of physician outcomes. It's time the rest of the field catch up.
As every other medical field has been driven by high tech and dynamic science, psychiatry has spent decades refining the art of trial and error. With more patients every year suffering from mental health disorders, it's time to take the lessons we've learned in the rest of medicine. We need to not only join Dr. Insel in asserting that "patients with mental disorders deserve better," but we need to start using the technologies we have today to bring better treatment to those suffering from mental illness.
So many of the stories we read every day -- school shooters, ex-professional athletes with depression, military suicides -- transit through multiple treatments with medications... and fail.
We have scientifically valid instruments -- today -- which can help physicians dramatically reduce trial and error. It's time to use them.
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