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One Third of Psychiatrists Not Using DSM-5
Medscape Psychiatry & Medical News
August 19, 2014

It's been just over a year since the American Psychiatric Association released the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), and new research shows that although the majority of psychiatrists are using the manual, a significant proportion has not put it into practice.

Results of a survey conducted by Medscape Medical News of more than 6000 healthcare practitioners, including psychiatrists and other clinicians involved in mental health diagnosis and care, show that overall, 3454 (55%) report that they do not use the DSM-5. Of these nonusers, 21% report that they are not using the manual because it is not relevant to their practice.

Among the remaining 2828 survey completers, most were mental health specialists ― 28% psychiatrists and 22% psychologists. Others included family practitioners (13%), pediatricians (10%), internists (9%), nurses (9%), neurologists (4%), and others (5%).

Among survey completers, psychiatrists (59%) and psychologists (60%) were most likely to have incorporated the new manual into their practice. These groups were followed by pediatricians (50%), neurologists (44%), primary care physicians (44%), and nurses (21%).

"Our survey suggests that plenty of clinicians encountering mental health patients are, for a variety of reasons, not using DSM-5. However, the majority of those who have adopted the manual seem relatively satisfied," authors Bret S. Stetka, MD, and Nassir Ghaemi, MD, MPH, write.

Controversial Release
Despite a great deal of heated debate in the years and months leading up to its release, most respondents report their decision to use, or not to use, the new manual was not influenced by the controversy.

As stated previously, of nonadopters who started the survey, implying an interest in the DSM-5, 21% cited a lack of relevance to their practice and dropped out.

Of the remaining nonadopter respondents, 22% cited a lack of familiarity with the updated manual, and 21% reported not using it because it is not necessary for billing and note that the International Classification of Diseases (ICD) is sufficient. This appears especially true among non?mental health specialists, such as family practitioners, who tend to see patients who have psychiatric conditions for which the DSM criteria have not changed considerably.

Five percent of clinicians who have opted not to use the DSM-5 believe that the manual's symptom checklists are lacking in clinical or scientific validity. This skepticism was especially evident among psychologists, many of whom cited economic incentives and a great deal of political jockeying by various interest groups as hindering the manual's credibility.

Three percent of respondents believe that not enough has changed from DSM-IV to justify switching.

Hot Button Issues
In addition to questions about adoption of DSM-5, participants were asked about several DSM updates and additions of new diagnoses, including the controversial move to a single autism spectrum disorder (ASD) category that does not differentiate among the multiple pervasive developmental disorder diagnoses in DSM-IV (eg, autistic disorder, Asperger's disorder).

Leading up to DSM-5's release, detractors worried that the new classification would result in many patients formerly diagnosed with an ASD falling outside of diagnostic criteria and becoming ineligible for certain support and treatment resources.

However, the survey results reveal that 66% of respondents encountering ASD patients report that the new criteria have not changed the percentage of their patients qualifying for the ASD diagnosis, or that not enough time has passed to tell.

However, 34% report both reductions ? most small, but some significant ? and increases in the number of their patients meeting the new criteria. Many survey participants believe the new criteria will allow more accurate diagnosis and better represent the continuum of neurodevelopmental disorders.

In addition to ASD, the survey also polled participants about the controversial removal of the bereavement exclusion as part of a diagnosis of major depressive disorder. Survey respondents were also asked about the new diagnosis of disruptive mood dysregulation disorder and the proposed major overhaul of diagnostic criteria for personality disorders and the mixed mood specifier for various bipolar disorder types, as well as new diagnostic criteria for substance use disorders.

"More and more clinicians will no doubt begin using the manual as it is increasingly adopted by employers and electronic health record systems. Hopefully, future DSM-5 revisions will further improve clinical accuracy and utility, while addressing shortcomings revealed by increasing experience with the manual," the survey authors conclude.
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