Research Planning for Future Psychiatric Classifications Darrel A. Regier, M.D., M.P.H.

1. Research Planning for Future Psychiatric Classifications Darrel A. Regier, M.D., M.P.H. Executive Director, American Psychiatric Institute For Research and Education; and Director, Division of Research, American Psychiatric Association; Vice-chair, DSM-V Task Force The 99th Meeting of the National Advisory Council on Drug Abuse Wednesday, May 14, 2008

2. Overview • Darrel A. Regier, M.D., M.P.H.; Review of conference series output and research implications • David J. Kupfer, M.D.; Update status of task force activities • Charles O’Brien, M.D., Ph.D.; Update on work group activities

3. Perceived Shortcomings in DSM-IV • High rates of comorbidity • High use of –NOS category • Treatment non-specificity • Inability to find a laboratory markers/ tests • DSM is starting to hinder research progress

4. New Developments • Pressures to improve “validity” • Move toward an “Etiologically Based” Classification • Are there data in these areas that can be helpful in developing/changing/refining diagnoses? • cognitive or behavioralscience • family studies and molecular genetics • neuroscience Requires a Paradigm Shift Neo-Kraepelinian to ??

5. Strategies for Improving DSM • Incorporate research into the revision and evolution of the classification • Move beyond a process of clinical consensus and build diagnoses on a foundation of empirical findings from scientific disciplines • Seek multidisciplinary, international scientific participation in the task of planning the DSM-V revision

6. Planning for DSM-V • 1999-2002 – three initial work conferences and six “white papers” • Identification of “gaps”

8. 2003 • APIRE obtains $1.1M NIH conference grant for DSM/ICD dx research planning • 13 Conferences over 5 years • APIRE commissions 3 additional White Papers: • Infant/Young Child, Sex/Gender, Geriatric Mental Health

9. Aims of Research Review Work Groups and Conferences • To promote international collaboration among members of the scientific community in order to increase the likelihood of developing a future unified DSM/ICD • To stimulate the empirical research necessary to allow informed decision making regarding crucial diagnostic deficiencies identified in the current nosology

11. Conference Output • Initial publication of papers in relevant peer-reviewed journals, e.g., Journal of Personality Disorders, Addiction, Journal of Geriatric Psychiatry and Neurology, Psychosomatic Medicine, Schizophrenia Bulletin, International Journal of Methods in Psychiatric Research • American Psychiatric Publishing Inc. (APPI) publishing monograph proceedings of all conferences • Special sessions at international forums

12. Conference Output • 13 Conferences (2004-07) • 5 internationally-held • 4 monographs published • Diagnostic Issues in Substance Use Disorders • Diagnostic Issues in Dementia • Dimensional Models of Personality Disorders • Dimensional Approaches in Diagnostic Classification • 4 monographs in press • 4 monographs in preparation • 83 journal articles published

13. Sept. 2006, Vol 101, Supp 1.

14. Diagnostic Issues in Substance Use Disorders Rockville, MD February 16, 2005

15. Substance Use Disorders Conference Representatives SUD conference representative at each conference, except Autism and Pervasive Developmental Disorders Examination of impact of co-occurrence of SUDs with each specific diagnostic topic Emphasized importance of SUD in conceptualizing diagnoses and etiologies

16. Substance Use Disorders Conference Representatives

17. Research Implications • Dimensional vs. categorical classification • Facilitating etiology research • Retaining face validity • Implications for genotyping • Issues of nomenclature • Non-substance use addictions, or behavioral compulsions • “addiction” versus “dependence”

19. On the Road to DSM-V and ICD-11 David J. Kupfer, M.D. University of Pittsburgh Medical Center Western Psychiatric Institute and Clinic The 99th Meeting of the National Advisory Council on Drug Abuse Wednesday, May 14, 2008

20. Revision Principles • The highest priority in modifying DSM-V should be optimizing clinical utility • Recommendations should be guided by research evidence • Continuity with previous editions should be maintained • Unlike in DSM-IV, there will be no a priori constraints on the degree of change between DSM-IV and DSM-V

21. Revision Principles 2 • Development – across the life span • Dimensional concepts – measurement of distress, disability and severity • Incorporation of new knowledge – risk factors, prodromes, prevention • Living document

22. Toward DSM-V and ICD-11 The object is: “to facilitate the highest possible extent of uniformity and harmonization between ICD-11 mental and behavioral disorders and DSM-V disorders and their definitions”

23. Initial List of Tasks and Activities Harmonize the timeline of both revision processes Considering severity as a separate dimension Considering disability/impairment/functioning as a separate dimension Review and identification of broad/super-ordinate categories of diagnosis

24. DSM-V Task Force Workgroup chairs Health professionals from stakeholder groups Workgroups Members work in specific diagnostic areas Advisors for workgroups http://www.dsm5.org

25. Overall DSM-V Task Force • Broadly based Task Force (TF) to oversee Workgroup chairs and committees for every diagnostic area • TF and Workgroups will assess the readiness of individual disorders to incorporate biological measures and dimensional approaches • TF will work closely to utilize the recommenda-tions derived from the 13 research conferences • TF will coordinate closely its efforts with the WHO / ICD developments • Study Groups

26. Cross-Cutting Study Groups • Diagnostic Spectra • Life Span Developmental Approach Study Group • Gender and Cross-Cultural Study Group • Psychiatric/General Medical Interface Study Group

27. Possible Validators for Diagnostic Groupings • Neural substrates • Familiality • Genetic risk factors • Specific environmental risk factors • Biomarkers

28. Possible Validators for Diagnostic Groupings • Temperamental antecedents • Symptom similarity • Abnormality of cognitive or emotional processing • Course of illness • High rates of comorbidity • Treatment response

29. DSM-V Timeline 2003-2008 APA/WHO/NIH Research Conferences 1999-2002 Research Agenda For DSM-V 2007- 2011 DSM-V Workgroups 2012 DSM-V 2007 Infant, Gender, Geriatric 2004 Prelude Page Launched 2014 ICD-11

31. DSM-V Substance Use Disorders Current Status Charles P. O’Brien, M.D., Ph.D. University of Pennsylvania Philadelphia VA Medical Center The 99th Meeting of the National Advisory Council on Drug Abuse Wednesday, May 14, 2008

32. SUD Work Group C. O’Brien, Chair T. Crowley, Co-chair M. Auriacombe D. Hasin G. Borges W. Ling K. Bucholz S. Manson A. Budney T. McLellan W. Compton* H. Moss* B. Grant N. Petry M. Schuckit Plus large cast of advisers * DSM-V Task Force Member Liaisons to SUD Work Group

33. Deliberative Process Work group divided into small sub-committees Frequent teleconferences Present findings to large work group at meetings and conference calls Review DSM IV Where can it be improved? What are the opportunities to move beyond behavioral criteria and use biomarkers?

34. Issues currently under active discussion and research Non-substance addictions Gambling Computer games, etc. List of candidates still under discussion Chair: N. Petry Collaborating with Impulse control disorders group

35. Issues Cannabis withdrawal Chair: Alan Budney Dimensions v. Categories, experimental criteria applied to large databases, need for “abuse” category Chair: Howard Moss Bio-markers Chair: Deborah Hasin Terminology Dependence v. Addiction Should criteria be substance specific? Whole work group is addressing these issues

36. Possible field trials Co-morbidity in treatment programs SUD and OCD SUD and Compulsive Gambling Reanalysis of large databases NESARC Cross cultural data Bio-markers Brain imaging comparisons, e.g. gambling and SUD