Field Trials in Routine Clinical Practice Settings Test Drive Manual’s Criteria
Arlington, VA (July 15, 2013) – Clinicians and patients view the newest psychiatric manual as easy to use and useful for clinical care, according to findings from field trials in routine clinical practice settings of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The results of the field testing were published online today in Psychiatric Services, a peer-reviewed journal of the American Psychiatric Association (APA).
“This is the first time DSM was field tested in routine clinical practice settings. It was important for us to test not just the reliability of the criteria, which we did in our large academic field trials, but also how well the DSM-5 criteria and approach worked for clinicians and patients,” said Darrel A. Regier, MD, MPH, Vice-Chair of the DSM-5 Task Force, and Director of the Division of Research at APA. “The positive feedback echoes our view that DSM-5 provides clinicians a stronger guidebook to help them deliver the best care possible to patients.”
DSM-5 field trials in routine clinical practice settings were conducted parallel to testing in large academic medical centers to examine how proposed changes fared in small group or solo practices. More than 600 mental health clinicians from various disciplines and 1,200 patients participated in the study to examine the clinical utility and feasibility of draft criteria and dimensional measures.
In adult care, 75 percent of clinicians responded that the DSM-5 approach for all disorders was better or much better than DSM-IV, reporting the most favorable ratings for PTSD, bipolar II disorder, substance use disorders, and somatic symptom disorder. Nearly half of clinicians (46 percent) rated the new manual’s approach as very or extremely easy to use.
Similarly, more than half (51 percent) of clinicians of pediatric patients said that DSM-5’s criteria and cross-cutting and severity measures were very or extremely easy to use. Nearly 85 percent of clinicians treating patients with ADHD rated DSM-5’s approach as better or much better than DSM-IV’s (71 percent, 13 percent). Pediatric clinicians also reported that the DSM-5 approach for all disorders was better or much better than DSM-IV (76 percent).
During the field trials, more than half of adult and pediatric patients, as well as parents of those children, said that they felt the self-assessment questionnaires introduced in DSM-5 would help their clinicians better understand their problems and symptoms. These self-assessments help patients report their own symptoms and can serve as a baseline for measurement-based care, a quality indicator that is already being incorporated in integrated care networks and electronic health record systems.
Clinicians who participated in the study reported similar impressions of DSM-5, rating the clinical utility of the criteria and measures as very or extremely useful. Nearly half of all clinician participants (48 percent) said the cross-cutting measures were very or extremely useful in diagnosing their patients. The new diagnostic criteria fared that high in regard to adult patients (49 percent) and pediatric patients (49 percent). These results were useful for understanding the feasibility and clinical utility of select disorders.
Clinicians taking part in the DSM-5 testing in routine clinical settings included psychiatrists, psychologists, licensed clinical social workers, advanced practice psychiatric nurses, licensed counselors, and licensed marriage and family therapists. After undergoing extensive training, each participating clinician was asked to report on at least one new or existing patient.
For the study visit, the patient or patient’s guardian completed the patient measures and a brief set of questions about his or her impression of the measures before meeting with the clinician. The results and interpretation of the patient-reported measures were transmitted to a database for clinician review before the patient evaluation. The clinician then conducted a diagnostic interview and completed one or more relevant DSM-5 diagnostic checklists and severity measures, any additional indicated measures, and the clinical utility questionnaire. All required clinician forms were completed in the online system, REDCap, a suite of Web-based tools designed to support data capture and dissemination. Staff of the APA’s Practice Research Network led the testing and collected data between October 2011 and March 2012.
The study did have several limitations that may have impacted the results, including that the participating clinicians were self-selected and highly motivated group rather than a representative sample. As such the findings reported here should not be generalized to all mental health clinicians and patients. Also, the diagnoses reported in these field trials do not represent treated prevalence rates and should not be generalized. Some diagnostic categories were not able to be evaluated and the findings for diagnostic categories with small numbers of patients should be interpreted with caution.
Complementary Field Trial Designs
The field trials in routine clinical practices represented one of two complementary study designs employed to better to understand how revised diagnostic criteria would perform prior to their adoption. The other design was implemented in large academic medical centers and focused on the reliability of criteria (e.g., are the same conclusions reached consistently when the criteria are used by different clinicians with the same patients?). Both designs used computer-assisted diagnostic checklists to aid clinical assessments, patient self-ratings of symptoms, and immediate data transfer through a secure website to a central server to ensure independence of assessments and data integrity.
Prior to completion of DSM-5 the results of both field trials were evaluated by the DSM-5 Task Force and APA Leadership and helped influence decisions and final review of the manual.
DSM-5 was published in May 2013. More information on changes to DSM-5 and how to purchase the manual and other products from the DSM-5 Collection can be found at www.psychiatry.org/dsm5.
The American Psychiatric Association is a national medical specialty society whose physician members specialize in the diagnosis, treatment, prevention and research of mental illnesses, including substance use disorders. Visit the APA at www.psychiatry.org.
Source: American Psychiatric Association News Releases, July 2013