Mental health diagnosis overhaul

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For the past 60 years, there has been a harsh disconnect between the fields of brain research and brain treatment, and it is a disconnect that deeply impacts the quality, access, culture, and efficacy of mental health care today. While we have a plethora of new treatment options for mental illnesses, the primary issue that creates a bottleneck in treatment is in the diagnosis and treatment planning procedures.

The current mainstream of mental health diagnosis relies on the DSM-5: the Diagnostic and Statistical Manual of Mental Disorders edition 5. The DSM-5 creates definitions of mental illnesses that lump together people that have vastly different root causes, manifestations, and treatment responses together under a single category and often leaves people that don’t fit enough core criteria of a single definition but are not mentally healthy out in the cold. This system is predominantly based on the external symptoms and traits a physician or patient notice during a visit. This is called a taxonomic classification.

Unfortunately, this system is limited in its ability to actually describe what is going on beneath the surface, something that is crucial if we are to reach a point where we can have highly specific and effective treatments for mental illnesses, rather than putting patients into generic categories, prescribing treatments, and finding out if they work only by trial and error.

Compounded, these issues mean that receiving a diagnosis as defined by the DSM-5 does little to actually suggest a method of treatment for the issue other than an archaic system of trial-and-error that has long since been abandoned as the first line of defense in most other areas of medical science.

For example, a symptom of anxiety can represent an endocrine disorder, a psychotic process, a drug response, or a currently recognized anxiety disorder, and each of these has a different treatment protocol, not including the variety of treatment protocols for the psychologically-based anxiety disorders.

The result is that patients have to go through rounds of medical tests and screenings in a process of elimination that eventually dumps them in the category of anxiety disorder if no other explanation turns up. In this way, anxiety disorder turns into a catch-all for problems we don’t have medical tests for instead of a specific diagnosis with a clear treatment protocol like a patient would receive if they were diagnosed with pancreatic cancer or kidney disease.

What is necessary for the advancement of mental health care for the future is for the field of psychiatry to catch up to the advances in fields such as neuropsychology, molecular genetics, and neurobiochemistry. The present search for biomarkers, genetic predictors, or neuroimage markers for our existing system of mental illness categories is doomed to fail. These suffer at the same impasses as the rest of the DSM-5 diagnoses. With the overlap between different mental illness definitions and the extreme variety within each single definition, these DSM-5 categories are often not biologically discernible. What needs to change is how we classify mental illnesses.

We need a system that classifies along a multidimensional matrix that accounts for all the ways a mental health disorders can manifest, from the genomic and molecular level to the way they take shape in emotions and social interactions. This is exactly what the Research Domain Criteria Initiative (RDoC) by the National Institute of Health is attempting to do.

Instead of viewing mental illnesses as collections of symptoms for a diagnostic label for ease of communication, the RDoC looks at the brain as a system of multiple different, interrelated but discernibly neural circuits that can be evaluated not only on self-reported or physician observed symptoms, like in our current system, but also described through variance in specific neuroimaging patterns, behavioral-cognitive tasks, and biomarker tests. The best part is that we have a substantial amount of data already available about these biomarkers and neuroimaging patterns; researchers have simply been trying to interpret them in the current taxonomic structure that invalidated these smaller subpopulations.

Through this system, researchers hope to eventually reach a point where the health care provider does not simply issue a diagnosis of schizophrenia, but instead is able to locate which specific neurotransmitter and receptors are specifically malfunctioning and in which part of the brain, allowing them to issue a specifically tailored treatment for that patient’s condition. The RDoC will allow healthcare providers to see what is wrong in the patient’s brain, not simply how it manifests.

With this new matrix of different core elements, the primary diagnostic tool will be based on biomarkers, neuroimaging strategies, patient-reported data, cognitive-behavioral task, and observed behavior all taken into consideration. The differences along each of these domains will relate to a specifically discernibly neural circuit difference and treatment procedure.

What will be required to improve treatment efficacy is a complete overhaul of the current system of classifying, diagnosing, and describing mental illnesses themselves. Until this revision occurs, mental health care will continue to misdiagnose illnesses and operate a non-targeted, trial-by-error method of treatment protocols, which in turn will jeopardize time, resources, and the well-being of patients all across the board.