Diagnostic and Statistical Manual-5: Position Paper of the Indian Psychiatric Society

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Byline: K. Jacob, R. Kallivayalil, A. Mallik, N. Gupta, J. Trivedi, B. Gangadhar, K. Praveenlal, V. Vahia, T. Sathyanarayana Rao

The development of the Diagnostic and Statistical Manual-5 (DSM-5) has been an exhaustive and elaborate exercise involving the review of DSM-IV categories, identifying new evidence and ideas, field testing, and revising issues in order that it is based on the best available evidence. This report of the Task Force of the Indian Psychiatric Society examines the current draft of the DSM-5 and discusses the implications from an Indian perspective. It highlights the issues related to the use of universal categories applied across diverse cultures. It reiterates the evidence for mental disorders commonly seen in India. It emphasizes the need for caution when clinical categories useful to specialists are employed in the contexts of primary care and in community settings. While the DSM-5 is essentially for the membership of the American Psychiatric Association, its impact will be felt far beyond the boundaries of psychiatry and that of the United States of America. However, its atheoretical approach, despite its pretensions, pushes a purely biomedical agenda to the exclusion of other approaches to mental health and illness. Nevertheless, the DSM-5 should serve a gate-keeping function, which intends to set minimum standards. It is work in progress and will continue to evolve with the generation of new evidence. For the DSM-5 to be relevant and useful across the cultures and countries, it needs to be broad-based and consider social and cultural contexts, issues, and phenomena. The convergence and compatibility with International Classification of Diseases-11 is a worthy goal. While the phenomenal effort of the DSM-5 revision is commendable, psychiatry should continue to strive for a more holistic understanding of mental health, illness, and disease.

Introduction

The President and the Executive Committee of the Indian Psychiatric Society (IPS) constituted a Task Force to study the draft of the American Psychiatric Association's (APA's) Diagnostic and Statistical Manual-5 (DSM-5) in May 2012. The mandate of the Task Force was to examine the DSM-5 and its implications, discuss issues, consult members of the IPS, and submit its report to the Executive Committee of the IPS by early June 2012. The shortage of time necessitated consultations by email.

A basic ground rule adopted for this exercise was that while individuals were free to express their opinions, such views needed to be substantiated by evidence. This report is a consensus of issues, which were raised and discussed. The report is divided into the following sections:

*DSM-5: A brief overview of the development process *Research from India on classification of mental illness *DSM-5: Universal categories for diverse cultures *DSM-5 and primary care *DSM-5 and use in community settings *Practical issues of relevance to India

Diagnostic and Statistical Manual-5 A Brief Overview of the Development Process

DSM-5 has been years in the making. The process included planning sessions, international research conferences, and a series of monographs. These conferences involved hundreds of scientists and clinicians. The DSM-5 Task Force and Work Groups included experts and advisors from various specialties and sub-specialties from many countries. The DSM-5 Task Force website, www.dsm5.org, provided details of the process, criteria, evidence and updates and allowed for comments and suggestions from the public. The development process included review of literature, secondary analysis of data, and field trials. Research evidence guided the process, which prioritized clinical utility. [sup][1]

The revision process set out four major principles: Clinical usefulness in routine specialist practice, based on evidence, continuity with past revisions, and the absence of a priori limits to change. …