How Mental Illness Definitions Are Still Being Uncovered and Refined

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Strategic Alliance Partnership | <b>Montefiore</b>

Montefiore psychiatry chair Jonathan Alpert, MD, PhD, discusses suggested updates to the DSM-5—with consideration to social determinants and patient-reported functioning.

A roundtable at the American Psychiatric Association (APA) 2022 Annual Meeting in New Orleans this weekend convened to review the Diagnostic and Statistic Manual of Mental Disorders, which is currently in its fifth edition with a text revision from this past year (DSM-5-TR).

The review of the standard for mental conditions came at what one committee member called a “very interesting inflection point” for the future of psychiatric definitions—a time when ideas around contextual factors of health are being considered more directly in diagnoses and care.

In an interview with HCPLive during APA 2022, roundtable member Jonathan Alpert, MD, PhD, chair of the department of psychiatry and behavioral sciences at Montefiore Health Systems and Albert Einstein School of Medicine, discussed the growing embrace of both social determinants of mental health in reviewing the DSM—as well as “broad dimensions of behavior” including attention or motivation that are present in most psychiatric conditions.

“The idea is, how do you integrate those 2 worlds: the world that looks at things in terms of specific diagnoses…and the world that looks at broad dimensions which might have their own neurobiologic underpinnings and social factors that contribute to them,” Alpert said.

Alpert additionally discussed the roundtable’s discussion around addressing measurements of psychiatric function—moving from a previously-shelved clinician-based score that introduced bias to clinical scales of function, to model similar to the World Health Organization Disability Assessment Scale (WHODAS) 2.0.

“The very nice thing about the WHODAS scale is that it’s been studied across more than 30 countries, it’s translated into multiple languages, it’s a self-assessment form that patients can fill out on their own,” Alpert said. “Their clinicians can fill it out, their guardians can fill it out…and it asks about different domains of function.”

Alpert praised the scale’s flexibility—asking patient perspective on various factors and lifestyle behaviors that constitute function—and use of “concrete questions.”

“In many ways, it breaks down the traditional barriers between mental functioning and the rest of function, because they’re really all interconnected, when you think about it,” Alpert said.

On the matter of seeking new definitions for future DSM editions, Alpert said there’s many areas that psychiatrists are still “trying to get a better grasp on.” He cited the text revision’s addition of prolonged grief disorder to differentiate major depression from bereavement-borne mental issues—as well as still-lacking refinements in eating disorders—as evidence of missing work in psychiatric diagnoses.

“An attempt continues to be made—and this will continue for years—to try to notice what are the clinical scenarios and conditions that people are recognized to have that somehow haven’t had a home in DSM,” Alpert said.