Patient Centric Health & DSM-5


In this blog we frequently discuss questions around Patient Centric health, connected medical devices, medical devices in the home, medication adherence, validated instruments and etc.  But we’ve never really tackled the question of Mental Health and how to approach it from a patient centric point of view.  A statement released on April 29th by Thomas Insel, Director of the National Institutes of Mental Health (NIMH), prompts me to discuss the notion of Patient Centric Mental Health.  His statement comes on the eve of – and is prompted by – a new Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and speaks to the approach that this current DSM – and all previous ones – have taken in diagnosing mental health.

In the area of medicine, the system has largely evolved from a symptomatic approach to a data-driven approach.  Consider the patient that presents with a stomach ache, a symptom of a problem and measurable by the patient on a scale from 1 to 10, but still largely subjective.  What’s needed is more objective data and so a few qualifying / diagnosing questions are given to give data to the diagnosis:

  • Where is the pain?  Lower Right Quadrant of the Abdomen. 
  • Is the area painful to the touch? Yes.
  • etc

While these questions provide somewhat more objective data, they are still subjective enough not to base a diagnosis on completely.  In an ER the patient would be given a battery of more objective tests such as:

  • blood work
  • a CT scan of the abdomen
  • etc

In combination, these tests provide subjective, measured data that are used to support a diagnosis (in this case perhaps, appendicitis).

While traditional psychiatry uses some objective data like blood work to rule out physical problems that should be attended to by a primary care physician (PCP), such as hypothyroidism, psychiatrists (PDocs) don’t have the tools at their disposal that a PCP would have in measuring blood work, radiological measurements, physical manifestations and etc.  Without those tools, mental health diagnoses are based on “clinical observation and patient’s phenomenological symptom reports”.  The question the NIMH is asking is: are there stronger, data-driven methods in which to diagnose and treat mental illness?

What then should be the criteria for diagnosing mental health issues?  Consider how many of currently diagnosed mental illnesses tend to run in families.  Are there biomarkers that address those genetically pre-disposed illnesses?  Or should work being done with MRI’s used to detect specific mental illnesses be included in the DSM?  Should these be used for diagnosing mental illness as much as they are used for diagnosing a ligament tear (for instance)?

To that end, NMIH has launched a Research Domain Criteria (RDoC) that will “Develop, for research purposes, new ways of classifying mental disorders based on dimensions of observable behave and neurobiological measures”.

An interesting approach: combine both the observable (and somewhat subjective) with the measureable (completely objective).

And with the launch of the RDoC, the NMIH hopes to drive more objective tests into the mental health system, and in doing so drive objective treatments and therapies driven by data.

What does this have to do with Patient Centric Mental Health? 

Data driven diagnosis leading to data driven treatments, measurable inputs, measureable outcomes, all of which can enhanced by patient centric tools. Consider some of the areas we’ve discussed around Patient Centrism in previous blog posts.  The fact that patients don’t take meds (patient adherence) or don’t fill out patient diaries, etc – those are issues that can be addressed by a patient centric approach.

There are more, of course.  More areas where patient involvement in diagnosis and treatment using objective, data driven tools, can help drive therapy that will result in better outcomes.

This is a great area to explore, which we’ll do in the next blog post.

What I ask of you (gentle reader) is tell me: what do you think?  How would you see patient centrism, and patient centric tools, being applied to the area of mental health?  Comments as always are appreciated!

Comments (1)

  1. Gary Newton says:

    Oh what a question, indeed.  And lest we risk incompleteness, we may want to even consider both a western AND eastern philosophy in addressing this, accounting for both "centric" and "centered."  Centric in that the approach revolves around the individual.  Centered in that, from an eastern perspective, true healing of the "mental" generates from deeper within – from the spiritual center, if you will, with the physical neurology and other bio markers being distal to, and dependent upon, that.  

    So does "going there" create even more subjectivity?  Probably, at least at first glance.  We'd likely have to get down into, if not beyond, the sub-sub-sub atomic level to get anywhere nearly anything even approaching objectivity.  And while there are folks working at that level (what with boson particles and all that), correlating that supermicro-level work with relatively macro brain and biomarker work?  Well…..  No time soon I suspect.  

    Meanwhile, we'll probably continue working from the outside in, which is helpful as long as we are mindful that the technology is not yet allowing us to measure the true source (center) in addition to the symptom's bio evidence.  So, is an objective based on a subjective really objective?  Hmmmmm…  Hey, I never claimed I could answer this.  At least we're making some progress advancing the use of technology in the healing domain.  You raise a question that was unthinkable just a few short years ago, and it's a great one.  

    As we compute our way down the mental health trail, going ever-deeper from the outer to the inner, the questions will get both harder, stranger, and, mark my words, contrary to DSM5 or 6 or 7.  Like in other industries (eg. music, book publishing, news), technological advances will blow away established models and force us to rethink what we were so convinced was "real."  And it's going to be fun to watch how technology plays this out in the mental health world.  Great article, Les.  Much food for thought, indeed.