DSM-5: APA Responds to American Counseling Association Concerns

On November 21, 2011, John Oldham, MD, president of the American Psychiatric Association (APA), wrote a response letter to Don W. Locke, EdD, president of the American Counseling Association, who had some concerns with proposed revisions for DSM-5.

Dr Locke's letter of November 8 was referenced in a recent blog post by Allen Frances, MD. Below is the full text of the letter from the APA. Click here for the original pdf. Psychiatric Times invites interested parties to submit your views for publication in the DSM-5 blog, or by writing in the comment box below.

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American Psychiatric Association
1000 Wilson Boulevard
Suite 1825
Arlington, VA 22209
Telephone 703.907.7300
Fax 703.907.1085
E-mail apa@psych.org
Internet www.psych.org

November 21,2011

Don W. Locke, EdD
President
American Counseling Association
5999 Stevenson Avenue
Alexandria, VA 22304

Dear Dr. Locke:

Thank you for outlining the American Counseling Association's (ACA) concerns with proposed revisions for the fifth edition of Diagnostic and Statistical Manual of Mental Disorders (DSM-5). We value the role of professional counselors in the delivery of mental health care, and we welcome the comments of mental health care providers on DSM. We share the goal of producing a DSM that is useful to all health professionals, researchers and patients so that the American Psychiatric Association (APA) can continue to play its longstanding role in advancing the understanding, diagnosis and treatment of mental disorders. A great deal of misinformation about DSM-5 has been circulating on the internet, so APA appreciates your direct inquiry and the opportunity to dispel myths generated from these sources. We address each of your concerns below.

Empirical Evidence and Independent Review. It is useful to review the most recent draft version of DSM-5 to truly understand the breadth of evidence collection and review that has taken place during its development. This process actually began in 1999 when APA and the National Institute of Mental Health (NIMH) sponsored a conference to begin creating a research agenda for the next DSM. Additional conferences sponsored by APA, NIMH, the World Health Organization (WHO) and the World Psychiatric Association took place in 2000, all of which resulted in the 2002 publication of A Research Agenda for DSM-V. Additional groups were commissioned in 2003 to further examine infant and young child, late-life and gender issues resulting in the 2007 publication of Age and Gender Considerations in Psychiatric Diagnosis: A Research Agendafor DSM-5.

APA, WHO, NIMH, and two other NIH agencies-the National Institute on Drug Abuse (NIDA) and National Institute on Alcohol Abuse and Alcoholism (NIAAA)-held 13 conferences between 2004 and 2008, involving nearly 400 participants representing 39 countries. Over half of the participants were non-U.S. residents. The work resulted in the creation of 10 monographs and hundreds of published journal articles regarding the current state of knowledge, gaps in research, and recommendations for additional research in many fields.

After the DSM-5 Task Force was formed in 2007, and based on the work described above, APA established 13 work groups, each with 8-15 members who are leading clinicians and researchers in the field, to address various areas for review. Since then, the 160 members of the DSM-5's 13 work groups have sought to review nearly two decades of research published since the introduction of DSM-IV. Work group members selected specific diagnoses on which to focus their individual reviews of the literature in support of or against each specific topic. APA granted work group members permission to publish all of their literature reviews and nearly all have been accepted for publication in peer-reviewed scientific journals. The 2009 guidelines you referenced were developed to ensure the standardization of presentations by all work group members as they prepared draft diagnostic criteria and rationales for Task Force review. These guidelines were subsequently adopted to facilitate reviews by the Scientific Review Committee (SRC).

ACA's call for an "independent, third party review" of the DSM process and evidence has already been answered in the establishment of these work groups and the close coordination APA has with other national and international scientific groups. The members of the work groups are not APA employees, they are not paid by APA and are not under contract with APA. Their participation is strictly voluntary, based upon their interest in advancing the field of psychiatry and better serving patients. They are free to leave the work group if at any time they are not satisfied that the process is unbiased or believe that the results are lacking in empirical evidence. Attachment A lists the institutions from which work group members are drawn. As you can see, they represent academic and mental health institutions throughout the world. No more than two members of anyone institution are represented on anyone work group in order to achieve diversity of opinion. It should be noted that although many of these participants are affiliated with universities, the vast majority of them also engage in clinical practice.

The work group members include multiple types of mental health practitioners. Approximately one third of the work group members hold PhDs and 30 percent are international professionals. Ninety-seven members of the work groups are psychiatrists, 47 members are psychologists, 2 are pediatric neurologists, 3 are statisticians/epidemiologists and there is one representative each from pediatrics, social work, psychiatric nursing, speech and hearing specialists, and consumer groups. In addition, there are more than 300 outside advisors - each selected because of a specific and well-recognized expertise in a particular field. These individuals represent an independent group of volunteer medical and mental health professionals who are also leaders in their respective fields and who have every conceivable incentive to ensure that the work they produce is soundly based in science and supported by empirical evidence.

Every proposed change in DSM-5 is guided by a review of scientific literature, analyses of relevant data sets and full discussion by the work group members. In an unprecedented move, the APA has opened the DSM-5 development process to the public to further ensure that the widest range of opinion and information could be sought and all clinical and "real world" implications of the diagnostic criteria could be considered. The drafts that APA has put out for review by the public are posted to elicit comments from others in the field and from patients and family members who may be impacted by changes. APA has received through its website alone more than 10,000 comments-each of which has been considered and evaluated by the work groups.

Dimensional and Cross-Cutting Assessments. These assessments were introduced in order to diagnose psychiatric disorders in a more detailed way and to recognize the frequent co-morbidities in persons who suffer from mental illness. Level 1 crosscutting assessments are based on the model of the brief two-question screener for depression, adopted by the U.S. Task Force for Preventive Services, to assess the presence of significant symptoms in 12 different psychological domains-a total of 23 questions that permit a rapid review of mental systems. If positive symptoms are present, level 2 cross-cutting measures are modeled on the NIH-developed Patient Reported Outcome Measurement Information System (PROMIS) that has been extensively tested. Where PROMIS measures were not available, we used the most widely tested comparable measures to cover other domains such as the NIDA developed ASSIST scale. Severity measures for individual diagnoses include well-documented and publicly available measures such as the PHQ-9 for Major Depression, PHQ-8 for somatic symptoms, the Swanson SNAP scale for Attention, the Stringaris scale from NIMH for irritability, the Altman scale for bipolar disorder, and others that were developed specifically by the DSM-5 work group experts that are built on past instruments and are being tested in the field trials.

All of these scales are being subjected in field trials to test-retest reliability assessments, patient evaluations of their utility, and clinician assessments of their feasibility and utility in identifying symptomatic areas such as substance abuse or suicidal risk, which might otherwise be overlooked. External validators will include correlates with diagnoses as well as other measures of impairment and disability. Regarding the cross-cutting disability measure, the WHO Disability Assessment Scale (WHO-DAS) is one of the most widely tested disability measures in the world-developed by NIH and WHO with over a decade of testing.

Field Trials/Validity of Diagnoses. With regard to the critique of our field trials, we were pleased to see that you referenced Dr. Helena Kraemer, who serves on the DSM-5 Task Force. Dr. Kraemer helped design the field trials and authored the referenced paper as part of the DSM-5 conference series on the integration of dimensional and categorical diagnosis. As Dr. Kraemer notes in the referenced paper, a field trial is not the forum in which validity can be fully assessed, and as in every field of medicine, diagnostic criteria reflect the best scientific understanding at the time, but they continue to develop and evolve as more scientific research comes to light.

Definition of Mental Disorder. The definition of mental disorder that is used in DSM-IV is undergoing a thorough review by the DSM-5 Task Force. There have been two revised definitions proposed: one, as you mention, by Stein et al. published in Psychological Medicine, the other proposed by the DSM-5's Study Group on Impairment and Disability Assessment. Neither definition has been accepted by the Task Force at this time. There is no intent on the part of the Task Force to overstate the psychobiological advances in mental disorders; all other paradigms are being considered as well. Through the review process, APA assimilated input from around the world and across disciplines and is reformulating its recommendations for the definition of a mental disorder. Many other proposals have been revised after consideration of public comments as well. We continue to work towards a definition of mental disorder that is evidence-based and acceptable to the mental health community at large. We will look forward to your comments on the revised definition when it is posted in the third round of revisions expected to come out in the spring-when we plan to open another public comment period on our website.

Transparency. The APA asked those involved in the DSM-5 process to sign a member acceptance form. The form contains a confidentiality provision that has been the subject of much misunderstanding and which APA has addressed in detail in the past. This form is not intended to restrict the free discussion of ideas on the issues involved in revising DSM and developing new diagnostic criteria. In fact, DSM-5 Task Force and work group members have presented and participated in open discussions at hundreds of psychiatric and other major medical meetings around the world. Work group members have requested and received permission whenever requested to publish on the proposed changes in DSM-5 without regard to their point of view. (A list of those meetings and publications is available for review on the DSM-5 website.)

Indeed, we encourage members to have open discussions with knowledgeable colleagues just as APA has encouraged comments from those interested in mental health on its website. It is only through broad and diverse opinions that we can, as scientists and clinicians, come to a consensus on how to interpret the data that are available. Further, by widely discussing these issues, APA hopes to stimulate funding for further research into areas that are not sufficiently developed to date to be included in the main body of DSM. Thus, our publication and review process has been beneficial in defining various mental disorders and also in defining and developing interest in additional areas in the field of mental health that require further study.

The confidentiality portion of the member acceptance form is not intended to promote secrecy. Instead, APA sought confidentiality to facilitate the verbal process of deliberation. Most, if not all scientific institutions of which APA is aware, including NIH, the Institute of Medicine, WHO, and all scientific journal preparations and reviews share results of research and explanations for their conclusions, but do not fully open the deliberative process itself for comment. This is crucial in order to ensure the free-exchange of ideas. While the work groups are  following this established model in our own deliberations, we also made an important decision to make our proposed revisions to the diagnostic criteria, while still in draft form, available for public review both nationally and internationally.

The Scientific Review Committee. The SRC was appointed by the Board of Trustees of APA which is charged with the ultimate approval of the final DSM-5 recommendations. The SRC's charge is to evaluate the strength of the evidence in support of proposed revisions, based on a specific template of validators. This separate peer-review process will provide important guidance to the Board. While the ongoing feedback from the SRC to work groups on specific disorders will not be made available during the DSM-5 development process (as is the case for the deliberations of NIH study sections), summaries of the committee's final decisions will be incorporated into DSM-5 "source books." The SRC's contributions will be reflected in the final criteria of DSM-5. Another committee, the Clinical and Public Health (CPH) Committee, has recently been appointed by the Board to consider clinical utility and public health issues that are not being reviewed by the SRC.

In addition, the APA has worked with the World Health Organization on an ongoing basis to develop harmonization between disorders included in both DSM-5 and ICD-11. Public comment has twice been solicited on proposed diagnostic criteria, and a third public comment period is planned for 2012. Work group members review each comment submitted through the DSM-5 website and consider revisions to criteria based on this input from other health professionals, consumer advocates, patients and families, and other members of the public.

The APA believes that the extensive process of development for DSM-5 will result in a scientifically and clinically useful new edition of the diagnostic manual, and we are indebted to the hundreds of experts who have contributed to its content. We are grateful, as well, for the valuable input from concerned individuals and organizations, and we appreciate the opportunity to respond to the concerns of the American Counseling Association.

Sincerely,

John Oldham, MD
President

Attachment [see attached pdf]