Howthe DSM IsUsedinClinicalPractice
MichaelB. AQ1 First,MD,* MatthewD. Erlich,MD,* DavidA. Adler,MD,* Shirley Leong,PhD,† LisaB. Dixon,MD,MPH,* DavidW. Oslin,MD,* Beth Goldman,MD,MPH,* Steve Koh,MD,MPH,MBA,* Bruce Levine,MD,* JeffreyL. Berlant,MD,PhD,*and SamuelG. Siris,MD*
METHODS
Abstract: Despitewidespreaduse,howcliniciansusethe DSM inpsychiatric practiceisnotwellunderstood.Recognizingpublicandprofessionalattitudestowardthe DSM areintegraltofuture DSM development,toaddresscommonly heldassumptionsuchasthatthe DSM isusedprimarilyforcoding,andtoassess itsclinicalutility.Aconveniencesampleof PsychiatricTimes readerswassurveyedtoassessthe DSM'suseinclinicalpractice.Atotalof394behavioralhealth carepractitionersfullycompletedtheonlinesurvey.Resultssuggestthatthe DSM,beyondadministrativeandbillinguse,isusedforcommunicationwith healthcareproviders,forteachingdiagnosestotrainees,and,importantly,asan educationaltooltoinformpatientsandcaregiversalike.
KeyWords: DiagnosticandStatisticalManualofMentalDisorders,nosology, clinicalutility,nototherwisespecified,unspecified,healthcareadministration, psychiatriceducation
(JNervMentDis 2019;00:00 00)
Littleinformationisavailableastohowcliniciansusethe DSM ineverydaypractice(Firstetal.,2004).Abetterunderstandingofitsclinicalapplicationisimportantfortwocrucialreasons(Firstetal.,2014). First,the DSM isintendedtoserveasauniversalauthorityfordiagnosis andtoaccuratelyandfaithfullycommunicatediagnosticinformation amongclinicians(aswellasresearchers).Consequently,howclinicians applythe DSM criteriaduringadiagnosticassessmentisofsignificant interest.Second,understandingcurrentusageiscriticaltotheplanning processoffutureupdatestothe DSM (First,2016)andtoassesstheimpactofproposedchangesto DSM criteriauponpracticepatterns.
Acommonlyheldassumptionregardingpsychiatricclassificationsystems,suchasthe DSM or ICD,isthattheyareusedbyclinicians primarilyforadministrativepurposesratherthanformakingclinicaldiagnoses.Forexample,a2015editorialin WorldPsychiatry (Maj,2015) positedthatEuropeanpsychiatristsoftenuse ICD criteriaadministratively,notclinically.Suchbeliefsarealsoreflectedinthelaypress (“Rarely,ifever,[do]Iconsultthehandbooktomakeadiagnosis.”) (Reidbord,2016).Moreover,highutilizationratesoftheresidualnot otherwisespecified(NOS)/otherspecified/unspecifiedcategoriesare assumedtobeamanifestationofthe DSM'sinabilitytoaccuratelydescribeamajorityofclinicalpresentations(Clarketal.,1995;Widiger andSamuel,2005).
Tobetterunderstandtheroleofthe DSM inpsychiatricpractice, anInternet-basedsurveywasconductedtoclarifyhowcliniciansuse the DSM toarriveatdiagnoses,toguidetreatment,toassessclinicalattitudestowardthe DSM,andtoelucidatetheprevalenceoftheuseof NOScategory(referredtoas “otherspecified” and “unspecified” in DSM-5).
Overview
ThePsychopathologyCommitteeoftheGroupfortheAdvancementofPsychiatry(GAP)developedanInternet-basedsurveyvia SurveyMonkeyaspartofa PsychiatricTimes articleaboutthe DSM anditsclinicalutility(Kweskin,2015). PsychiatricTimes isa monthlyperiodicaldistributedbymailandavailableonlinetonearly 40,000mentalhealthprofessionals.Inaddition, PsychiatricTimes includedthelinkinseveralofitse-mailnewsletterssenttoregistered usersonthe PsychiatricTimes Website.ThesurveywasopentoparticipationfromFebruary1,2015,throughApril15,2015.Thesurvey tookbetween10and15minutestocomplete.Thesurveywasexempt frominstitutionalreviewboardreviewasindividuallyidentifiableinformationwasnotcollected.Subjectsdidnotreceivereimbursement forcompletingthissurvey.Theonlyrequirementsforparticipation inthisconveniencesampleincludedbeing18yearsofageorolder, English-languageproficiency,andhavingdirectclinicalcontactwith patientsforatleast4hoursaweek.
SurveyInstrument
ThesurveywasdevelopedusingamodifiedDelphiprocessby anexpertcommitteecomprisedofmembersofthePsychopathology CommitteeofGAPbasedonthemostrecentliteratureaboutthe DSM (Firstetal.,2014).Usageofthesurveywasassessedwithfive questiondomains.Thefirsttwoquestionsassessedtheusageofthe DSM ineverydaypracticebothwhenmakinginitialdiagnosesand inthecontextofongoingcareacrossthefollowingfivescenarios: useofthe DSM foradministrative/billingpurposes;useof DSM criteriatodetermineifthediagnosticcriteriaaremet;reviewingdiagnosticcriteriafrommemorytodeterminediagnosis;reviewingrelevantsectionsofthe DSM text(e.g.,differentialdiagnosis);and assessinghow DSM criteriaareusedwiththepatientand/orfamily andcaregivers.Foreachscenario,participantswereaskedtoquantify thefrequencyofusageusingafive-pointLikertscale(“never,” “rarely,”“sometimes,”“often,” and “always”).
Thethirdquestionaskedrespondentstoassesshowusefulthey foundthe DSM criteriaanddiagnosticframeworktobebasedontheir experiencewiththe DSM inpracticeoverthepastyear,forthefollowingdomains:treatmentselection,educatingthepatientand/orfamily aboutthepsychiatricdiagnosis,determiningprognosis,meetingadministrativerequirements,communicatingwithcolleagues,andteaching traineesorstudents.Foreachoftheabovedomains,respondentswere askedtorateitsdegreeofusefulnessonadifferentfive-pointLikert scale(“notatall,”“slightly”“moderately,”“very,” and “extremely”).
*Psychopathology AQ2 CommitteeoftheGroupfortheAdvancementofPsychiatry; †MIRECC,CorporalMichaelJ.CrescenzVeteranAffairsMedicalCenter, Philadelphia,Pennsylvania.
Send AQ3 reprintrequeststoMichaelB.First,MD,PsychopathologyCommitteeofthe GroupforAdvancementofPsychiatry.E mail:mbf2@columbia.edu.
Copyright©2019WoltersKluwerHealth,Inc.Allrightsreserved.
ISSN:0022-3018/19/0000 0000 DOI:10.1097/NMD.0000000000000953
TheremainingtwosurveyquestionsfocusedonusageofNOS categoriesduringthepastyear,startingwithaqueryabouthowoften respondentsusetheNOSdiagnosiswhentheyrecordapsychiatricdiagnosis.(TheNOSdesignationisusedinthisarticletorefertoboth theNOScategoriesin DSM-IV-TR andotherspecifieddisorderand unspecifieddisordercategoriesin DSM-5.)Ifrespondentsreported anyNOSusageduringthepastyear,theywerepresentedwithsixpossiblereasonsforusingtheNOSdiagnosisandwereasked,foreach
reason,toratethefrequencywithwhichtheyusedtheNOScategory onthesamefive-pointscaleusedtoratethefrequencyofusageofthe DSM components.
Thesurveyconcludedwithquestionsaboutthesurveyparticipants,includingdemographics,mentalhealthspecialty,practicesetting, versionofthe DSM (DSM-IV-TRvs DSM-5)therespondentcommonly usedatthetimeofthesurvey,percenttimespentdoingvariousprofessionalactivities(e.g.,clinical,administrative,research,etc.),andthe numberofhoursperweekofdirectclinicalcontact.
Analyses
Generalizedestimatingequations(GEE)modelswereusedto assesstheoddsofmore DSM usageandtheoddsofmorepositiveattitudewithacumulativelogitlinkfunction.Outcomeswerecollapsed intothreecategories:usage(never/rarely,sometimes,often/always) andattitudeabouttheusefulness(notatall/slightly,moderately, very/extremely).For DSM usagescenario,abinaryvariableindicating initialevaluationandtheirinteractionwereincludedinthemodel.For attitudesaboutusefulness,onlyusagescenariowasincludedasapredictor.Demographicvariablesandtheirinteractionswithscenario wereaddedintothemodels.Thesignificanceofinteractionterms wasevaluatedbasedon p-valuesfromtype3Waldscores.
Toinvestigatetherelationshipbetween DSM usageandattitudes aboutitsusefulness,Pearsoncorrelationcoefficientswerecalculated usingthesurvey'soriginalfive-pointLikertscale.
TheoddsofmoreNOSusagewerealsomodeledusingGEE modelswithacumulativelogitlinkfunction.NOSusagewascollapsed intothreecategories:never/rarely,sometimes,andoften/always.NOS useintheprioryear,scenario,andtheirinteractionwereincludedin themodel.Thesignificanceofinteractiontermswasevaluatedbased on p-valuesfromtype3Waldscores.
RESULTS
DescriptionoftheSample
Atotalof907individualsparticipatedinthesurvey,394participantscompletedallsurveyquestionsabout DSM componentusage,
attitudesaboututility,andNOSusageandfullycompletedthedemographicssection.Excludedfromtheresultswere23participantsasthey listedtheirprofessionaslawyeror “other” and74participantswhoreportedfewerthan4hoursperweekofdirectpatientcontact.
Inthissample,254respondents(65%)wereage50orolderand 235(60%)weremale.Twenty-three(6%)reportedlessthan1yearsince completingtraining,63(16%)were1to5years,57(15%)were6to 10years,164(42%)were11to30years,and87(22%)were31to 50yearssinceresidency.Twohundredsix(52%)reported30hours/week ormoreperofdirectclinicalcontact(354[90%]reportedspecializing inadultcareand126[32%]specializingbutnotexclusivelytreating children/adolescents).Withrespecttospecialization,78(20%)reported treatingaddictions,54(14%)forensics,69(18%)community/public sectortreatment,and53(14%)consultation-liaisonpsychiatry.Regardingpracticesetting,218(55%)reportedprimarilyoutpatientprivate practice,135(34%)publicsector,96(24%)academicsettings(either inpatientoroutpatient),and54(14%)nonacademichospital-basedinpatientoroutpatientpractices.
DSM Usage
Table1presentsthefrequenciesofusageforvarious DSM usage scenarios,bothduringtheinitialevaluationandduringongoingtreatment.Usingthe DSM diagnosticcodesforadministrativeorbillingpurposeswasthemostfrequentusagescenarioduringtheinitialevaluation with64%reportingusingthemoftenoralways.Anoverwhelming numberofrespondentsreportedreferringtothe DSM criteriaduring theinitialdiagnosticevaluationtodeterminewhetherthediagnostic criteriaaremet(with55%oftenoralwaysreviewingthecriteriafrom memoryand39%oftenoralwaysreferringtothewritten DSM criteria). Asmallnumberreportedthattheyneverorrarelyreviewthediagnostic criteriaeitherfrommemory(16%)orinwrittenform(29%).Thirty percentreportedtheyoftenoralwaysreviewedrelevanttextsections ofthe DSM duringtheinitialevaluation.Reviewing DSM criteriawith thepatientand/orthepatient'sfamilyduringtheinitialevaluationwas theleastfrequentusagescenario,with20%reportingoftenoralways and51%reportingneverorrarely.
T1
TABLE2. ClinicianPerceptionsoftheUsefulnessofthe DSM (n =394)
“BasedonYourExperienceUsingthe DSM WithPatientsOverthePastYear, HowUsefulIsthe DSM CriteriaandDiagnosticFrameworkFor:”
NotatAll Useful Slightlyor ModeratelyUseful Veryor ExtremelyUseful
Selectingatreatment180(46%)125(32%)89(23%) Educatingthepatientand/orfamilyabouthisorherdiagnosis144(37%)149(38%)101(26%)
Determiningprognosis199(51%)124(32%)71(18%) Meetingadministrativerequirements(e.g.,determiningthediagnostic codeandnameofdiagnosisforanencounter/billingform) 86(22%)79(20%)229(58%)
Communicatingaclinicaldiagnosiswithacolleagueorotherhealth careprofessional 75(19%)103(26%)216(55%)
Teachingtraineesorstudentsaboutdiagnosisandpsychopathology83(21%)109(28%)202(51%)
Whencomparing DSM useintheinitialdiagnosticphasetoongoingtreatment,differencesinusagepatternswerestatisticallysignificantandgreaterforinitialdiagnosiscomparedwithongoingtreatment forallfiveusagescenarios(chi-square=22.22, df =4, p =0.0002).
AttitudesAboutUsefulnessofthe DSM
T2 Table2presentsrespondentsattitudestowardtheusefulnessofthe DSM forvariouspurposes.Oddsofmorepositiveattitudeswasdifferent betweenthevarioust ypes(chi-square=322.43, df =5, p <0.0001). Amajorityofcliniciansratedthe DSM asusefulformeetingadministrativerequirements(78%),communicatingaclinicaldiagnosis withanotherhealthcareprofessional(81%),teachingtraineesabout
psychopathology(51%),selectingatreatment(54%),andeducatingthe patientorfamilyaboutdiagnosis(64%),withonlyslightlylessthan half,findingitusefulfordeterminingprognosis, “veryorextremely” usefulformeetingadministrativerequirements(58%),communicating aclinicaldiagnosiswithanotherhealthcareprofessional(55%),and teachingtraineesaboutpsychopathology(51%).
RelationshipBetween DSM UsageandAttitudes AboutUsefulness
T3 Table3showsthecorrelationbetweenthedifferent DSM usage scenariosduringtheinitialevaluationandcorrespondingattitudes
TABLE3. CorrelationsBetween DSM UsageDuringtheInitialEvaluationandAttitudesAbouttheUsefulnessofthe DSM
“
Selectinga Treatment
BasedonYourExperienceUsingthe DSM WithPatientsOverthePastYear, HowUsefulIsthe DSM CriteriaandDiagnosticFrameworkfor:”
Educatingthe Patientand/or FamilyAbout HisorHer Diagnosis Determining Prognosis
Meeting Administrative Requirements
Communicatinga ClinicalDiagnosis WithaColleagueor OtherHealthCare Professional
“Regardingyour usageofthe DSM ineveryday practice,based onyourexperience withpatients overthepast year,howoften doyou:”
Usethe DSM diagnosticcodes foradministrative/ billingpurposes
Refertothewritten DSM criteria(online, hardcopy,checklist) todetermineifthe diagnosticcriteria aremet
Reviewdiagnostic criteriafrommemory todetermineif diagnosticcriteria aremet
Reviewrelevant sectionsofthe DSM textforthedisorder
TeachingTrainees orStudentsAbout Diagnosisand Psychopathology
0.2340.2020.1710.6370.2100.170
0.4270.4220.4190.2620.4790.377
0.4420.4250.3680.2620.4330.434
0.4010.4080.3720.1330.4050.356
0.3240.5550.2660.2040.3260.239
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3
TABLE4. Usageof DSM NOSCategories
NeverorRarelySometimesOftenorAlways
Inthepastyear,howoftendoyouusetheNOScategory(n =394)113(29%)161(41%)120(30%)
Basedonyourexperiencesusingthe DSM withpatientsoverthepastyear, inthosecircumstanceswhereyouusetheNOScategory,pleaseindicate howofteneachofthefollowingreasonsforusingNOSapply:
Toindicatethatthepatient'spresentationdoesnotconformtoanyofthe specificcategories(n =370)
33(9%)122(33%)215(58%)
Toindicatethereisinsufficientinformationtomakeamorespecific diagnosis(n =370) 54(15%)127(33%)189(52%)
Topreventmorespecificdiagnosticinformationfrombeingenteredinto thepatient'srecordforprivacyreasonsortoavoidstigma(n =370)
Toindicatethatthecriteriaaremetformorethanonediagnosisina groupingratherthanlistingcomorbiddiagnoses(e.g.,usingAnxietyNOS insteadoflistingmultipleanxietydisorders)(n =370)
Toindicatethatitcannotbedeterminedwhetherthesymptomsareduetoaprimary condition(e.g.,schizophrenia)oraresecondarytoasubstance(e.g., substance-inducedpsychosis)oramedicalcondition(e.g.,braintumor)(n =370)
Becausemakingamorespecific DSM-IV diagnosis,likemajordepressivedisorder (asopposedtodepressivedisorderNOS)isnotusefulforpatientcare(n =370)
aboutthe DSM'sclinicalutilityinpractice.Strongcorrelations(Cohen, 1988)werefoundbetweenattitudesabouttheusefulnessofthe DSM foradministrativerequirements,suchasusingthe DSM foradministrativeorbillingpurposes(r =0.637, p <0.0001),andattitudesabouthow the DSM'sutilityforeducatingthepatientand/orfamilyaboutdiagnoses,anditsusageforreviewing DSM criteriawiththepatientandfamily (r =0.555, p <0.0001).Inaddition,moderatecorrelationswerefound forusingthe DSM (memory,written,andrelevanttextsections)for treatmentselection,prognosis,patient,family,andstudenteducation, aswellasameansofcommunicatingwithothers.
RelationshipBetween DSM Usage/Attitudesand DemographicInformation
Therewasnodifferencewithrespecttoclinicalexperience whenusingthe DSM foradministrativeorbillingpurposes(oddsratio [OR],0.97;95%confidenceinterval[CI],0.90 1.04).Therewasa significantinteractionbetweenthevariousotherusagescenariosand therespondents'age(chi-square=13.2, df =4, p =0.01)andthenumberofyearssincecompletingtraining(chi-square=16.0, df =4, p =0.003,datanotshown).Every5yearsofexperiencebeyondtrainingindicatedloweroddsoffindingthe DSM usefulby10%to19%for allotherscenarios.Clinicianswhoare50yearsorolderwereless likelytorefertothe DSM criteriafrommemoryascomparedwith thoselessthan50years(OR,0.66;95%CI,0.46 0.94).Therewas nodifferenceinagegroupswhenassessing DSM usageforanyother scenario.Moreexperiencedclinicianswerelesslikelytorefertoorreviewthe DSM.Forevery5yearsposttraining,theoddsofusingthe DSM decreasedbyafactorof7%to13%,eithertoassesswhether criteriaweremetortoreviewthe DSM criteriawithpatientand/ortheir family.Ageandyearssincetrainingwererelatedtoattitudesaboutthe DSM'sutility.Respondentsaged50yearsorolderwerelesslikelyto findthe DSM usefulforcommunicatingaclinicaldiagnosiswithacolleagueorotherhealthcareprofessional(OR,0.51;95%CI,0.34 0.78). Moreover,respondents50yearsorolderwerelesslikelytousethe DSM forteachingtraineesorstudentsaboutdiagnosisandpsychopathology(OR,0.61;95%CI,0.41 0.91).
UsageofNOSCategories
ThefrequencyofNOScategoryuseintheprioryearaswellas thefrequencyofNOSusageforspecificreasonsforthoserespondents whoreportedusingNOSisshownin T4 Table4.Therewasafairlyeven
227(61%)94(26%)49(13%)
188(50%)106(29%)76(21%)
133(36%)141(38%)96(26%)
247(67%)57(15%)66(18%)
splitamongthosewhoreportedthattheyoftenoralways(30%),sometimes(41%),andneverorrarely(29%)usedtheNOScategory.The threemostcommonreasonsforusingtheNOScategorywerenotmeetingcriteriaforaspecificcategory(91%),insufficientinformationto makeamorespecificdiagnosis(67%),andinabilitytodiscernwhether thediagnosiswasprimary,substance-induced,orduetoageneralmedicalcondition(64%).Theseresultsareconsistentwithguidelinesincludedinthe DSM-IV-TR “UseoftheManual” sectiondescribing appropriatecircumstancesfortheuseoftheNOScategory(American PsychiatricAssociation,2000,p4),” whichonlyincludesthesethree reasons.Theothersurveyedreasons(i.e.,usingNOStoavoidentering aspecificdiagnosisinthepatient'smedicalrecord,usingNOStoindicatethatcriteriaaremetformorethanonediagnosisinadiagnostic class,andhavinganNOSdiagnosisbecauseitisnotclinicallyuseful tomakeamorespecific DSM diagnosis)arenotconsideredtobevalid reasonsforusingtheNOScategoryandwerealsolesscommonlyendorsedasreasonsforusingNOSinthesurveyresults.
DISCUSSION
Thesurveyresultsconfirmedsomecommonlyheldexpectations about DSM usage.Themostfrequentlyusedcomponentofthe DSM in clinicalpracticeisitsdiagnosticcodes,whichmightbeexpectedgiven therequirementtousesuchcodesforadministrativeand/orbillingpurposes.Second,amajorityofcliniciansreviewthe DSM criteriaeither frommemoryinwrittenformtodeterminewhetherdiagnosticcriteria aremetduringtheinitialassessment.Thesurveyalsoconfirmedconventionalwisdomthat DSM componentsaremostlikelytobeusedduringtheinitialevaluation.Thelowerfrequencyofuseduringongoing treatmentmaybeduetothefactthatoncetheinitialdiagnosisismade, cliniciansarelikelytomaintainthesamediagnosisinsubsequentclinicalencounters.Third,thesurveysupportsthe DSM'susefulnessfor teachingtraineesorstudentsaboutdiagnosisandpsychopathology. Althoughonlyaminorityofcliniciansuseittoeducatepatientsand theirfamiliesabouttheirpsychiatricdiagnoses(Duckworth,2015), whentheydo,theyconsiderittobeuseful.
Clinicians'attitudesabouttheusefulnessofthe DSM largely mirroridentifiedstrengthsandweaknessesofthe DSM intheliterature(First,2010).Recognizedstrengthsofthe DSM includeadministrativeutilityandfacilitationofclinician-to-cliniciancommunication regardingpatients'psychopathology(Hyman,2007;Krueger,1999). Identifiedweaknessesofthe DSM intheliteratureincludethe
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diagnosticheterogeneityofindividualswiththesame DSM diagnosis andthelackofalignmentbetween DSM diagnosesandapplicable treatments,eachofwhichcompromisethe DSM'sutilityfortreatment selectionanddeterminingprognosis(Clarketal.,1995;Regieretal., 2009;WidigerandSamuel,2005).Accordingly,thesurveyrespondentsfoundthe DSM muchlessusefulfortreatmentselectionand determiningprognoses.
Despitealimitedsamplesize,agedidhaveanimpactonusage. Youngerandlessexperiencedcliniciansweremorelikelytousethe DSM criteriaascomparedwitholder,moreexperiencedclinicians.It isunclearhowaccumulatedclinicalexperienceimpactsclinicalperceptionsanduseofthediagnosticmanual.
Notsurprisingly,thereisarelationshipbetweentheclinician'sattitudesabouttheusefulnessofthe DSM forvariouspurposesandthe frequencyofuseofvariouscomponentsofthe DSM.Therewasa strongcorrelationbetweenclinicians'feelingthatthe DSM isuseful formeetingadministrativerequirementsandusageofthe DSM foradministrativeandbillingpurposes.Therewasastrongcorrelationbetweenfindingthe DSM usefulforeducatingpatientsandfamiliesand reviewingthe DSM criteriawiththepatientorfamily.Finally,therewere moderatecorrelationsbetweenattitudesabouttheusefulnessofthe DSM forvariousclinicalpurposes(treatmentselection,determiningprognosis, communicatingwithotherclinicians)andeducationalpurposes(educatingpatientsandfamiliesaboutdiagnosisandteachingtrainees)andusagescenariosinvolvingthediagnosticcontentofthe DSM (reviewing diagnosiscriteriafrommemoryorinwrittenformtodetermineifdiagnosticcriteriaaremet,reviewingrelevantsectionsofthe DSM text).
Recognizingthatthe DSM maynotprovideaspecificdiagnosis foreveryclinicalpresentation,eachsubsequent DSM editionandrevisionincludesresidualcategoriestoaddressclinicalpresentations, whichdonotconformtoanyofthediagnosticdefinitions.Forexample, DSM-IV-TR includedaNOScategoryforeachdiagnosticclass, whereas DSM-5 includedtworesidualcategories(“otherspecified” and “unspecified”).Along-standingcriticismofthe DSM system, especiallyamongthosethatfavoradimensionalapproachtopsychiatricdiagnosis,isthatreportedhighratesoftheNOScategories (Rajakannanetal.,2016)indicatethatthe DSM failstocoveramajorityofclinicalpresentations(Clarketal.,1995;WidigerandSamuel, 2005).SurveyresultsdemonstratingthatcliniciansoftenusetheNOS diagnosisforreasonsotherthanthepatient'spresentationnotfitting intoanydiscernible DSM categories(i.e.,havinginsufficientinformationtomakeamorespecificdiagnosis)indicatethatitismisleading tocharacterizehighreportedratesofNOSasdefactoevidenceofthe inadequacyofthe DSM categoricalapproach.
Thereareseverallimitations.Solicitingparticipantsfromaconveniencesampleraisesgeneralizabilityconcerns.Problemsofgeneralizabilityareinherenttoallsurveys,eventhosethatrandomlyselect participants,becausetraditionallylowresponseratesasoccurredinthis samplemeanthatthosewhoagreetoparticipatearethosemostinterestedinthetopiccoveredbythesurvey.Asthelinktothesurveywas embeddedinanarticleabouthowcliniciansusethe DSM,thosethat participatedmayhavehadaninterestinthe DSM andpsychiatricdiagnosis,andthus,surveyparticipantsmayhavebeenmoreinclinedtouse the DSM ratherthantheaverageclinician.Inaddition,someofthesurveyquestions,particularlythoseaboutusage,mayhavebeensubjectto asocialdesirabilitybias,ascliniciansmighthavewantedtopresent theirdiagnosticpracticeinthebestpossiblelight.
CONCLUSIONS
Theresultsofthisstudychallengethenotionsthatthe DSM isalmostexclusivelyusedforlookingupdiagnosticcodesforbillingpurposesandchartingrequirements.Mostclinicianrespondentsreported
reviewingthediagnosticcriteriaineitherwrittenformorfrommemory todetermineifdiagnosticcriteriaaremetduringtheinitialevaluation. Moreover,the DSM wasoftenusedasaneducationaltooltotrainthe nextgenerationofmentalhealthpractitioners.Lesspositiveattitudes wereapparentwhenusingthe DSM fortreatmentselectionanddeterminationofprognosis,suggestingthatthevalueofthe DSM forthesetwo pillarsofclinicalutilityisproblematic.Feedbacksuchasfromthissurveymaycontributetofutureimprovementstothe DSM torenderit moreusefulforthecoreaspectsofclinicalmanagement.
DISCLOSURE
Dr.FirstreceivesroyaltiesfromAPPIpress.Dr.Adlerisco-owner ofHealthandProductivitySciences.
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