Should Social Workers Use Diagnostic and Statistical Manual of Mental Disorders-5?

Among approximately 500,000 mental health professionals in the United States who use the Diagnostic and Statistical Manual of Mental Disorders (DSM), the 250,000 social workers (Center for Health Workforce Studies, 2006) comprise by far the largest group, followed by 120,000 mental health counselors (American Counseling Association, 2011), 93,000 psychologists (American Psychological Association, 2011), and 38,000 psychiatrists (American Psychiatric Association, 2011). For many social workers, DSM is a daily companion having a dramatic impact on how they assess patients, make a diagnosis, and plan treatment.

The American Psychiatric Association (APA) is the sole group that revises the DSM, despite the fact that psychiatrists account for only 7% of all mental health professionals and only 10% of all physicians who prescribe psychotropic medications. In the past, social workers and other mental health professionals have relied on APA and the DSM for guidance in the diagnosis process. And while previous DSMs have failed to achieve universal admiration, none has failed to achieve universal acceptance. Certainly, there have been numerous controversies about the overall reliability of the system; its seeming tilt toward a biological approach; the relative lack of participation of professional groups other than psychiatry; and the inclusion and/or definition of particular mental disorders. But no one questioned whether DSM should be used at all or suggested that there was an alternative way forward.

DSM-5 has changed this landscape by being so closed in its process, so unrealistically ambitious in its hopes, so flawed in its execution, and so dangerous in its product that many mental health professionals may choose not to use it. This article will describe the problems and controversies that surrounded the DSM-5 and how its use can be avoided by simply using the codes of the International Classification of Diseases (ICD), which are available for free on the Internet.

The work on DSM-5 has been secretive, geared less to protecting the public trust than to generating publishing profits for the APA. Participants were forced to sign confidentiality agreements, the scientific review was conducted behind closed doors, and APA rebuffed a petition endorsed by more than 50 professional organizations for an open and independent review of its suggestions. Everything has been done in a disorganized way: constant missing deadlines, inconsistent methods for conducting literature reviews, poor research design for the field trials, and finally the cancellation of the crucial quality control step because time was running out (Frances, 2012; Jones, 2012). This process has not inspired confidence.

DSM-5 is frightening in its overinclusiveness, with lowered diagnostic thresholds and the addition of new “subthreshold” disorders. The boundary between pathology and normal behavior is blurred in a way that is likely to result in increased prevalence rates of mental disorders and new false epidemics. Millions of normal people will be mislabeled as mentally ill and subjected to stigma and to unnecessary treatment and testing.

This exacerbates the existing medicalization of normal behavior. We are already in the midst of a national glut of excessive medication use causing harmful and unnecessary side effects and complications. Twenty percent of our population uses a psychotropic medicine and we have more deaths from overdose with prescription medication than from street drugs.

DSM-5 makes this worse by relabeling as mental disorder the sadness of grief, the temper tantrums of children, the normal forgetfulness of old age, the everyday distractibility of adult life, the worries of the medically ill, and the temptations of binge eating. It is also sloppily written in ways that will most certainly lead to diagnostic confusion.

What can social workers do if they don’t like the DSM-5 final product? The alternative is to bypass DSM-5 altogether and instead use the free and readily available diagnostic codes of the International Classification of Diseases (ICD-9-CM). Social workers probably don’t realize that they are not required to use the DSM and can instead use the ICD codes. In fact, they are doing so already, since all the DSM-5 codes are drawn from the ICD-9-CM coding system. The combination of DSM-5 being less safe and very expensive (US$200 for a hard copy) and ICD-9-CM being free and convenient will likely have many clinicians just going directly to the ICD-9-CM and ignoring DSM-5.

There is nothing official about DSM coding and it is not mandatory for clinicians unless specifically required by their institutional settings (First, 2010). In fact, the ICD is the only classification system approved by Health Insurance Portability and Accountability Act of 1996 (HIPAA; Department of Health and Human Services, 2009)—not the DSM classification. As such, ICD codes meet all insurer-mandated and HIPAA coding requirements. The reason why mental health professionals can use the DSM for diagnosis is because the DSM derives its code numbers from the ICD. Until October 2014, social workers do not have to learn a whole new classification system—the ICD-9-CM codes are available in DSM-IV or free online. And, when all health and mental health professionals switch to ICD-10-CM codes in October 2014, these codes will also be free online.

The DSM-5 proposals should have been subjected to a systematic, comprehensive, independent, and multidisciplinary external review done by experts in evidenced-based decision making who are completely independent of the DSM-5 process. The APA has lost credibility as the keeper of the DSM flame. New diagnoses in psychiatry can be more dangerous in their impact than new drugs. A better and more inclusive way of revising the system needs to be devised.