How Evolving Psychiatric Definitions Set the Tone for Care


Amid significant psychotherapy innovation and consideration to broader aspects of mental illness definition, Jonathan Alpert, MD, PhD, emphasizes the need for improved clinical trial standards.

What leads the other: the diagnosis or the therapy? In the case of psychiatry, major developments in both is leading to an inflection point when innovative clinical research and emerging disease definitions are simultaneously influencing each other.

In the second segment of an interview with HCPLive on the heels of an American Psychiatric Association (APA) 2022 Annual Meeting roundtable to discuss possible revisions and additions to the the fifth-edition Diagnostic and Statistic Manual of Mental Disorders (DSM-5), Jonathan Alpert, MD, PhD, chair of the department of psychiatry and behavioral sciences at Montefiore Health Systems and Albert Einstein School of Medicine, discussed what he called an exciting time of change in his field.

“(We have this) convergence of an increasing array of evidence-based psychotherapies that are really based on specific features like prolonged grief—or other features that have been noticed as part of the human experience but previously did not have a diagnosis associated with them,” Alpert said.

At the same time, neurobiological research is helping inform mental disorder and addiction pathophysiology that which remains in a “rudimentary stage,” Alpert said.

“But some of the work in looking at broad dimensions like attention or motivation are advancing that kind of work—looking at molecular targets that may not be specific to schizophrenia or depression, but may cut across multiple diagnoses and may suggest new treatment agents that work on these molecular targets,” he explained.

The end result may be new therapeutic agents that target “aspects of diagnosis,” despite not being formally labelled an antidepressant or antipsychotic.

“There’s so much heterogeneity in psychiatry—people come in all shapes and sizes, and being able to come up with treatments and ultimately, predictors for who does best with which of those combinations of treatments (is the goal),” Alpert said.

On the subject of current psychiatric clinical trial standards, Alpert believed the field is still lagging behind the innovations in disease definition and care strategies, noting trials are often designed around existing DSM categories and not dimensions of behavior.

“It’s been over the past decade a continued journey to try and develop meaningful clinical trials that take into account some dimensional measures, but also respect the fact that they’re presenting within specific categories,” he said.

At the same time, psychiatrists are seeking more meaningful clinical trial outcome measures for both their sake and that of the patient—the latter of whom is much more fixed on improving measures of daily life rather than arbitrary scales of disease severity. “It’s still a journey to try and join those 2 worlds,” Alpert said.

Lastly, Alpert considered the idea that mental health is “ultimate comorbidity” in medicine, and whether that contributes to the burden of refining the multitude of sought-after outcomes in psychiatry’s clinical research.

“Almost always, a major determinant of outcomes is psychiatric comorbidity,” he said. “At the end of the day, those are the things that count for people—their quality of life, and even their length of life, is affected very much by whether they have a mental disorder or a substance abuse problem.”

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