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Time's up for psychiatry's bible

Since this article was first posted, the American Psychiatric Association has announced that the publication of DSM-V will be delayed until May 2013. "Extending the timeline will allow more time for public review, field trials and revisions," says APA president Alan Schatzberg.

BOOKS are by and large riding out the online revolution that is devastating the sales of many newspapers, magazines and other printed works. But this week we report on a volume that has outlived its usefulness. The American Psychiatric Association (APA) is in the midst of rewriting the mammoth tome called the Diagnostic and Statistical Manual of Mental Disorders, or DSM, which provides checklists of symptoms that psychiatrists and other doctors use to diagnose what form of mental illness a patient has - and fights are breaking out all over.

The final wording of the new manual will have worldwide significance. DSM is considered the bible of psychiatry, and if the APA broadens the diagnostic criteria for conditions such as schizophrenia and depression, millions more people could be placed on powerful drugs, some of which have serious side effects. Similarly, newly defined mental illnesses that deem certain individuals a danger to society could be used to justify locking these people up for life.

Newly defined mental illnesses could be used to justify locking up certain people for life

Given such high stakes, we should all be worried by the controversy (see "Psychiatrists at war over broadening mental illness definition"). Proponents of some of the changes are being accused of running ahead of the science, and there are warnings that the APA is risking "disastrous unintended consequences" if it goes ahead with plans to publish DSM-V, as the new manual will be known, in 2012.

It doesn't have to be this way. With the advent of the internet, there is no longer any compelling need to rewrite the diagnostic criteria for the whole of psychiatry in one go. Yes, diagnoses should be revised as new scientific findings come in. But for this, specialists can be assembled when necessary to address specific areas that have become outmoded. Their suggestions can be posted on the web for comment. More research can be commissioned, if necessary. And when consensus is reached, new diagnostic criteria can be posted online.

Similarly, standing panels could periodically review issues that cut across the whole of psychiatry - such as the inevitable shift away from checklists of symptoms towards a system based on measurements of the underlying biological and psychological determinants of mental health.

The APA's leaders suggest that DSM-V will become a "living document" that will be amended as necessary. It's a shame they didn't simply move the current DSM into this mode. That would have hurt the APA's coffers, as a book that becomes a required reference is a big earner; DSM sales since 2000 exceed $40 million. But it's hard to see who else stands to gain from the current exercise - and if the critics' dire predictions come to pass, patients will be the biggest losers.

Issue 2738 of New Scientist magazine
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