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PERSPECTIVE
If residents “never leave the ICU
. . . they’re never going to have
a comfort level to even imagine”
working in a community setting.
He added that tracking of students who are interested in different career pathways should begin
much earlier than it currently
does. “Somebody who wants a
rural setting needs to have experiences that prepare him for that
— not working in a big innercity clinic,” he said. “The training
experiences need more to match
the career pathway.” Both the duration and the content of medical
school and residency training
could be varied to reflect physicians’ career goals. The number
and type of accredited programs
for training physicians in various
specialties should also more closely match the country’s needs,
Thibault suggested.
The Macy Foundation is also
focusing on the development of
interprofessional education, funding grants at about 20 universi-
The Evolving Primary Care Physician
ties and health systems to pilot
programs for teaching medical
students, nursing students, and
other health professionals how to
work together in teams, beginning
early in their education. Currently, “we professionalize everybody
separately, and only when they’re
fully formed do we do the mixing,” Thibault said. Each profession has its own culture, so “it’s
not surprising that they don’t work
well” together.
He believes regular training
and experience working collaboratively with other professionals
should be incorporated throughout medical school and residency.
“You need to learn both to be a
leader and to be a member of a
team, because we’re all going to
play this whole gradient of roles,”
Thibault said. “I really do believe
that we’ll never have the health
care system we want and need
unless we pay a lot more attention to how we’re training people
to enter it.”
Disclosure forms provided by the author
are available with the full text of this article at NEJM.org.
Dr. Okie is a medical journalist and a clinical assistant professor of family medicine at
Georgetown University School of Medicine,
Washington, DC.
1. Conference summary, Atlanta 2011 —
Ensuring an effective physician workforce
for the United States: recommendations for
reforming graduate medical education to
meet the needs of the public. New York:
­Josiah Macy Jr. Foundation (http://
josiahmacyfoundation.org/docs/macy_pubs/
Macy_GME_Report,_Aug_2011.pdf).
2. Dower C, O’Neil E. Primary care health
workforce in the United States. Research synthesis report no. 22. Princeton, NJ: Robert
Wood Johnson Foundation, July 2011 (http://
www.rwjf.org/pr/product.jsp?id=72579).
3. Margolius D, Bodenheimer T. Transforming primary care: from past practice to the
practice of the future. Health Aff (Millwood)
2010;29:779-84.
4. Mechanic D, McAlpine DD, Rosenthal M.
Are patients’ office visits with physicians getting shorter? N Engl J Med 2001;344:198204.
5. Sung SH, Price M, Tallman K, et al. Ambulatory care visits: squeezing 22 minutes into
a 19-minute visit? Presented at the 10th Annual HMO Research Network Conference,
Dearborn, MI, May 3–5, 2004 (poster).
Copyright © 2012 Massachusetts Medical Society.
Mental Illness — Comprehensive Evaluation or Checklist?
Paul R. McHugh, M.D., and Phillip R. Slavney, M.D.
T
he debate over revising the
Diagnostic and Statistical Manual
of Mental Disorders (DSM) is of more
than intramural interest, for the
way in which the promised fifth
edition (DSM-5) resolves the debate will shape the nature and
scope of psychiatric services for
years to come. Now established
as the master reference work for
U.S. psychiatrists, the DSM initially emerged, like the companion volume for internists, the International Classification of Diseases,
with a public health interest in
the incidence and prevalence of
illnesses. But with its third edition
in 1980 (DSM-III), the DSM began
prescribing how clinicians should
identify psychiatric disorders.
The editors of the DSM-III justified this move by noting that
the likelihood of diagnostic agreement between any two psychiatrists about the same patient was
scarcely better than that achievable by chance. They attributed
much of the difficulty to sectarian
discord among proponents of psychodynamic, behavioral, and neurobiologic explanations of mental illness. And they concluded
that the diagnostic muddle could
be cleared up if psychiatrists put
aside disputes over causes and instead identified disorders by their
symptoms, signs, and clinical
course.
The DSM-III produced a revolution in psychiatry. The manual
identified every condition with
lists of diagnostic criteria; its editors presumed that causes, mechanisms, and rational treatments
of the conditions would emerge
through investigative efforts that,
supported by these reliable definitions, drew from the boundless
explanatory resources of the biopsychosocial body of knowledge.
Revolutions solve some prob-
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PERSPE C T I V E
Mental Illness — Comprehensive Evaluation or Checklist?
lems — but usually raise others
that are unintended and unexpected. The DSM revolution was no
exception. The diagnostic approach
based on clinical appearances, one
akin to using a naturalist’s field
guide, proved to be a tactical
success in that it stilled sectarian
conflict, but a strategic failure in
that it offered no way of making
sense of mental disorders — that
is, no better answer to the question “What are they?” than a multitude of examples.
Undeniably, the DSM-III brought
some gains to psychiatric practice, including consistency of diagnosis, uniformity in therapeutic
regimens, and confidence in clinical research based on the reliable inclusionary and exclusionary criteria that DSM diagnoses
can provide to investigators. Many
psychiatrists who recollect the
discord within psychiatry before
the DSM-III find these gains sufficient. In their view, the subsequent revised editions corrected
the flaws that remained.
Yet the publication of a fifth
revision of the DSM — now
promised in 2013 — has been repeatedly postponed, mainly because fundamental problems tied
to the approach of the DSM-III
proved hard to solve. A most serious problem, common to field
guides, is the difficulty of separating entities that are similar in
appearance.
For example, psychiatrists using the DSM diagnosis “major
depression” tend to mingle bereaved patients with both those
afflicted by classic melancholia
and those demoralized by circumstances.1 The mixing of similarappearing patients who have conditions that are distinct in nature
probably explains why use of this
diagnostic category expanded
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over time and suggests why the
effectiveness of antidepressant
medications given to people with
a diagnosis of major depression
has, of late, been questioned.2
This tendency to blur natural distinctions may explain why other
DSM diagnoses — such as posttraumatic stress disorder (PTSD)
and attention deficit disorder
— have been overused, if not
abused.
Many issues of concern derive
from another change in practice
that the DSM-III inadvertently encouraged. Its emphasis on manifestations persuaded psychiatrists
to replace the thorough “bottomup” method of diagnosis, which
was based on a detailed life history, painstaking examination of
mental status, and corroboration
from third-party informants, with
the cursory “top-down” method
that relied on symptom checklists.
Checklist diagnoses cost less
in time and money but fail woefully to correspond with diagnoses derived from comprehensive
assessments.3 They deprive psychiatrists of the sense that they
know their patients thoroughly.
Moreover, a diagnostic category
based on checklists can be promoted by industries or persons
seeking to profit from marketing
its recognition; indeed, pharmaceutical companies have notoriously promoted several DSM diagnoses in the categories of anxiety
and depression.
Together these problems expose a critical issue of design in
the DSM. By forgoing thought
about causation in identifying
psychiatric disorders, the manual
promotes a rote-driven, essential­
ly rule-of-thumb approach to the
diagnosis and treatment of patients — and there is no obvious
way of escaping the practice.
Identifying a disorder by its
symptoms does not translate into
understanding it. Clinicians need
some heuristic concept of its nature, grasped in terms of cause
or mechanism, to render it intelligible and to justify their actions
in practice and research.
The editors of the DSM-5 indicate that the new edition will
provide new categories of disorders, alter some criterion sets,
and emphasize matters of severity.4 But it will not divide psychiatric disorders into causally intelligible groups. Disregard for this
issue — after 30 years’ experience
with an appearance-driven policy
— makes these proposed changes for the DSM-5 seem small.
The big question — “What are
these disorders?” — will remain
unaddressed.
Much turns on causation. For
practical psychiatrists, a cause is
not some issue for philosophers
to ponder but rather anything that
makes a difference in the evoking or sustaining of a disorder.
Causes may be single or multiple, necessary or sufficient, etiopathic or mechanistic; they are
as diverse in human psychological life as the wide-ranging biopsychosocial model implies. But
they must be specified to render
the manifestations of psychiatric
illness intelligible and their
treatments rational.
Although defining causes as
“anything that makes a difference”
can serve, the causes of psychiatric disorders derive from four interrelated but separable families:
brain diseases, personality dimensions, motivated behaviors, and
life encounters. And although for
most patients a cause from one
of these families is the most salient, causal influences from several often contribute to a given
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PERSPECTIVE
Some Examples of DSM Diagnoses
Clustered by Causal “Perspectives.”
Brain diseases
Delirium
Schizophrenia
Panic disorder
Personality dimensions
Mental retardation
Obsessive–compulsive personality
Borderline personality
Motivated behaviors
Anorexia nervosa
Conversion disorder
Alcohol dependence
Life encounters
Bereavement
Adjustment disorder
Post-traumatic stress disorder
patient’s clinical picture. This
latter fact led us, in describing
the causal families and their distinctive ways of affecting mental
life, to name them “perspectives”
and by that metaphor to emphasize how understanding a case
from one causal viewpoint might
blind the diagnostician to contributions from others.5 PTSD, for
example, is a state of mind provoked by traumatic life encounters. But for most patients, issues
of behavior and temperament contribute to precipitating and sustaining the condition and must
Mental Illness — Comprehensive Evaluation or Checklist?
be identified in treatment. Only
the painstaking assessment of
patients, which was standard before the publication of the DSMIII, can bring the relevant causal
factors to light. Symptom checklists will never suffice — and, of
course, were never intended to.
What to recommend now? No
replacement of the criterion-driven
diagnoses of the DSM would be
acceptable; clinicians are too accustomed to them, and investigators cannot forgo the usefulness
of the DSM’s inclusionary and
exclusionary diagnostic criteria
when defining a condition or a
group to be studied. In the new
edition, however, entities could
easily be rearranged so that those
tied causally to diseases, personality dimensions, behaviors, or encounters were identified as such
and clustered separately (see table).
Grouping disorders by putative
causation would promote fruitful
thought and, consequently, progress. Clinicians who were aware
of the causal proposals and their
several practical, heuristic implications would be encouraged to
proceed more analytically in their
assessments, treatments, and investigations of patients, while
still using the DSM diagnoses for
their records.
Psychiatrists would start moving toward the day when they address psychiatric disorders in the
same way that internists address
physical disorders, explaining the
clinical manifestations as products of nature to be comprehended not simply by their outward
show but by the causal processes
and generative mechanisms known
to provoke them. Only then will
psychiatry come of age as a medical discipline and a field guide
cease to be its master work.
Disclosure forms provided by the authors
are available with the full text of this article
at NEJM.org.
From the Department of Psychiatry and Behavioral Sciences, Johns Hopkins University
School of Medicine, Baltimore.
1. Parker G. Beyond major depression. Psychol Med 2005;35:467-74.
2. Fournier JC, DeRubeis RJ, Hollon SD, et al.
Antidepressant drug effects and depression
severity: a patient-level meta-analysis. JAMA
2010;303:47-53.
3. Anthony JC, Folstein M, Romanoski AJ,
et al. Comparison of the lay Diagnostic Interview Schedule and a standardized psychiatric diagnosis: experience in eastern
Baltimore. Arch Gen Psychiatry 1985;42:66775.
4. Kupfer DJ, Kuhl EA, Narrow WE, Regier
DA. On the road to DSM-V. In: Gordon D, ed.
Cerebrum 2010: emerging ideas in brain science. New York: Dana Press, 2010:81-93.
5. McHugh PR, Slavney PR. The perspectives of psychiatry. 2nd ed. Baltimore: Johns
Hopkins University Press, 1998.
Copyright © 2012 Massachusetts Medical Society.
Grief, Depression, and the DSM-5
Richard A. Friedman, M.D.
N
early 2.5 million Americans
die each year, leaving behind
an even larger group of griefstricken people.1 Such a universal human experience as grief
is recognized by the lay public
and medical professionals alike
as an entirely normal and expected emotional response to loss. Cli-
nicians and researchers have long
known that, for the vast majority
of people, grief typically runs its
course within 2 to 6 months and
requires no treatment.
In a common clinical scenario,
a patient who has just lost a
loved one presents to a physician
with mild depressive symptoms,
such as sadness, tearfulness, and
insomnia. Under the guidelines
of the American Psychiatric Association’s Diagnostic and Statistical
Manual of Mental Disorders, 4th
edition (DSM-IV), a practitioner
would reasonably view these depressive symptoms as grief-related
and not diagnose clinical depres-
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