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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- n engl j med 366;20 nejm.org may 17, 2012 The New England Journal of Medicine Downloaded from nejm.org on May 7, 2017. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved. 1853 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 1854 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 n engl j med 366;20 nejm.org may 17, 2012 The New England Journal of Medicine Downloaded from nejm.org on May 7, 2017. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved. 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- n engl j med 366;20 nejm.org may 17, 2012 The New England Journal of Medicine Downloaded from nejm.org on May 7, 2017. For personal use only. No other uses without permission. Copyright © 2012 Massachusetts Medical Society. All rights reserved. 1855