by William Van Ornum, Ph.D. on
The evolution of the Diagnostic and Statistical Manual (DSM I, II, III, IV, IV-TR) and upcoming DSM V is an interesting one. The first manual was a short volume with a small number of diagnoses. The diagnosis itself was often not as important as the detailed clinical description written about the patient, often written from the psychodynamic point of view. This continued through the DSM II.
Beginning with the DSM III there was greater emphasis on “measurable and behavioral” symptoms. Concurrently, the insurance industry began greater monitoring of mental-health care, particularly regarding long-term therapy, psychiatric hospitalization, and long-term residential alcohol/substance-abuse treatment.
Proponents of this evolution noted that research into mental health could become more scientific since diagnoses would be more measurable. Critics said that the individual nature of mental illness would no longer be captured. A kind of compromise occurred in the DSM III, where five “axes” instead of simply a diagnosis were included. Information on these also included the presence of personality, developmental, or learning disorders; medical diagnoses; an estimate of stress or trauma experienced within the past year; and an estimate of overall functioning.
The two editions of DSM IV continued the trend toward behavioral specification. The DSM V will move toward greater specificity by incorporating the “spectrum concept.” This holds that psychiatric conditions exist, not in an either/or manner, but along a continuum, one that can be measured numerically. The concept of depression as a spectrum holds potential for the inclusion of more children and teens as experiencing this condition, and making them eligible for insurance reimbursement.
An article in the July 2011 issue of Counseling Today (a publication of The American Counseling Association) explains how this will affect the diagnosis and treatment of childhood and adolescent depression. One of the effects of this change may be to render more children falling under the diagnosis of depression.
Gary Gintner, associate professor of counselor education and program leader at Louisiana State University, states: “The DSM-5 will introduce the idea of looking at disorders such as depression on a spectrum, with certain severity levels used as cut points to identify maladaptive symptoms and functioning, much [as] we associate blood pressure of 140 over 90 as higher risk. Depression, too, will have a dimensional rating that notes severity.”
At any time, about two percent of children younger than age twelve have depressive disorders, said Gintner. That number can go up to 4-to-8 percent for those in the 12-to-18 age range. Adolescent girls display twice the risk for depression as boys. Gintner stated the rate of depression has increased every decade since the 1940s. He has trained counselors in the use of the DSM and is considered an expert in planned revisions of the DSM V.
It will be interesting to see how all of this plays out. Here we have an expert pointing out the need to diagnose more youngsters as having clinical depression. On the other hand, there are those who note the possible over-diagnosis of mental-health problems, including depression, in our young people, as well as the concomitant use of medication. This is a topic worth very serious consideration.