For more than 70 years, physicians seeking to diagnose mental-health conditions have turned to the ‘bible for psychiatry’ — The Diagnostic and Statistical Manual of Mental Disorders (DSM). Last updated in 2022, and published by the American Psychiatric Association (APA), the DSM sets out diagnostic criteria for a panoply of mental-health conditions, from autism spectrum disorder to substance-use and personality disorders.
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For almost as long, the manual has been hotly critiqued. In January, the APA announced a future road map to address some of the criticisms. For example, the APA plans to start including data on the biological, environmental and cultural causes of mental-health conditions — long-discussed gaps in the manual. It also emphasizes the importance of consulting people with lived experience.
These changes aim to refine clinicians’ abilities to diagnose individuals. But in my view, this is just tinkering with a flawed approach. Improved lives are more important than diagnoses. Experts in psychiatry need to focus on the care that people need — not the label assigned to them.
In the Netherlands, roughly 25% of the population has been diagnosed with a mental-health disorder (M. ten Have et al. World Psychiatry 22, 275–285; 2023). But diagnoses don’t tell us what drives the feelings behind these conditions, or how to abate those that are problematic. Indicators of deteriorating mental health — such as persistent sadness and suicidal ideation — align with social inequality, educational pressure and other stressors. Treating poor mental health as solely a medical issue, rather than one with a social component, decreases the impetus to tackle the root problem.
Mental distress is poorly captured by symptom lists and labels. People who are diagnosed with anxiety, addiction or psychosis might all describe feelings of entrapment or hopelessness. Two people diagnosed with the same disorder will have different vulnerabilities to, say, stigma or self-harm, different resources available to them and different care needs. It is these needs that clinicians should focus on.
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If the basic logic of the DSM is flawed, it should be abandoned. Instead, psychiatrists should move towards a system that looks at an individual’s mental experiences in context, alongside their unique developmental vulnerabilities and strengths, as the main source for analysing and responding to their distress. Diagnosis would no longer name a disorder but map what kinds of support, relationships and learning processes are most likely to help a person regain agency, coherence and a sense of future.
Take a person who presents with paranoia, hearing voices, social withdrawal, sleep disruption and cannabis use. At present, they might be diagnosed with schizophrenia and directed towards medication and — if available — individual psychotherapy. Using a model that is based on care needs, that person might be offered help with substance regulation, support in rebuilding trusting relationships and access to a peer-support group.
