Sunday, September 23, 2012

What replaces DSM5? Whither RDoC?

"However, in antedating contemporary neuroscience research the current diagnostic system is not informed by recent breakthroughs in genetics; and molecular, cellular, and systems neuroscience. Indeed it would have been surprising if the clusters of complex behaviors identified clinically were to map on a one-to-one basis onto specific genes or neurobiological systems." NIMH 2011.

With the thorough politicization of the DSM5 and the dichotomous debates in the media it is surprising that nobody talked about what is in the works to replace it at the largest government funded think tank - The National Institute of Mental Health (NIMH). The proposed solutions in the media were generally to do nothing or to let a wide variety of professionals have input into criteria that have essentially been static for the past 30 years.  There was very little comment about how the DSM5 is not a very good framework for incorporating recent scientific discoveries from brain imaging, molecular biology and genomics in addition to the typical subjective descriptions of each disorder.  That is where NIMH's Research Domain Criteria (RDoC) come in.

Looking at the "Draft Research Domain Criteria Matrix" - it is hard to envision a standard 60 (or usually 30) minute clinical interview as a starting point for diagnosis or treatment.   For example, with an initial episode of psychosis, there will probably be a lot more work done trying to identify cognitive endophenotypes or other transitional phenotypes within the current subjectively derived domains.  A very conservative estimate suggests that this alone will take take least one hour of testing.  There will probably need to be a lot of time and effort expended on determining when a person is testable.  An RDoC diagnosis will be both time and resource intensive.  It won't be a template or a checklist.

I am sure that the antipsychiatry/myth of mental illness crowd and some of the thinly veiled variants of this philosophy will be disappointed.  After all,  this is a diagnostic approach that directly assails one of the most typical arguments from them: "There is no "test" for mental illness."  When the RDoC comes to fruition there will not just be one test.  There will be many tests.

Like most things psychiatric, the biggest threat to the realization of a more comprehensive diagnostic system for our most complex illnesses is not the obvious detractors.  It is the current political culture that applies junk science to the management of the health care system.  It remains an incredible fact that political ideology and not medical science dictates medical treatment in this country.  The current political consensus is that psychiatric care (like medical care) can be managed for both cost and quality by companies who can profit by rationing care.  The care they ration the most is for the treatment of mental illnesses and addictions.

Will an Accountable Care Organization (ACO) in the future spend what it necessary to thoroughly evaluate an initial episode of psychosis if it takes as many or more resources than Cardiology  currently uses to assess heart disease?  The answer to that lies in whether the stigma against mental illness and addictions in health care and governing organizations can be overcome.  Despite all of the lip service - it is that stigma that supports the current system of care that is predominately brief hospitalizations orchestrated by case managers and 15 minute "medication management" approaches to the treatment of mental illness.

You can't implement an RDoC in that environment.

George Dawson, MD, DFAPA

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