As a follow up to the June 2022 Almanac article by Katherine Biles, we reviewed ways in which  the update to “The Diagnostic and Statistical Manual of Mental Health Disorders” is being used in continuing medical education (CME) programming.

Mental health disorders can often be among the most difficult disorders to identify and diagnose. In March 2022, the American Psychiatric Association released updated text revisions to “The Diagnostic and Statistical Manual of Mental Health Disorders,” the association’s authoritative diagnostic guide to mental health disorders, publishing its “Fifth Edition, Text Revision (DSM-5-TR™).”

It is critical that healthcare professionals and teams stay educated regarding the latest diagnostic changes, as treatment for a disorder might hinge on a nuance in the patient’s presentation. Many CME providers are actively working to educate healthcare providers on a continuous basis to keep professionals apprised of new standards.

Some continuing education options around the new “DSM-5” diagnostic codes and standards include:

• CME Institute’s “Addressing Unmet Needs in the Screening and Diagnosis of Bipolar Disorder” launching just in time for October, the National Depression and Mental Screening Month
• The American Academy of Family Physicians’ “So It Changed Again: Intro to ‘DSM-5-TR’”
• University of Nebraska Medical Center Behavioral Health Education Center webinar: “‘DSM-5-TR’ Updates: What Providers Need to Know”
• Indian Health Service TeleBehavioral Health Center of Excellence Webinar Series: “‘DSM-5-TR’ Updates: Revised Terminology and Diagnostic Criteria”

The last “DSM-5” update in 2013 included some significant updates for clinicians regarding diagnosing and treating bipolar disorder specifically. The latest update continues to refine how mental healthcare professionals can best diagnose and treat bipolar disorder.

Bipolar disorder presents a unique challenge for mental health professionals attempting to accurately diagnose a patient. The “DSM-III,” released in 1980, was the first edition of the mental health classification tool to use the term “bipolar disorder” and to allow more nuance in terms of diagnosing “episodes.”¹ Bipolar disorder can be a particularly difficult disorder to identify and treat. Certain treatments for depression are not as effective for patients with  underlying mania or hypomania, and those treatments can possibly exacerbate and escalate mental health symptoms for those patients.

The American Psychiatry Association states in its “Highlights of Changes from ‘DSM-IV-TR’ to ‘DSM-5’”:

“To enhance the accuracy of diagnosis and facilitate earlier detection in clinical settings, Criterion A for manic and hypomanic episodes now includes an emphasis on changes in activity and energy as well as mood. The ‘DSM-IV’ diagnosis of bipolar I disorder, mixed episode, requiring that the individual simultaneously meet full criteria for both mania and major depressive episode, has been removed. Instead, a new specifier, ‘with mixed features,’ has been added that can be applied to episodes of mania or hypomania when depressive features are present, and to episodes of depression in the context of major depressive disorder (MDD) or bipolar disorder when features of mania/hypomania are present.”²

Goldberg wrote in an email to the CME Institute this month that he believes there is a “critical need” for ongoing continuing medical education on the diagnostic criteria in the “DSM.” “In real-world clinical practice settings, busy clinicians may not always be familiar with the formal diagnostic criteria that define a major psychiatric disorder, and consequently may implement treatments that might only loosely conform to some patient presentations. Because evidence-based treatments hinge on reliable, accurate diagnoses, it is vital that practicing clinicians are up to date on making criteria-based diagnoses, understanding differential diagnoses, and recognizing concepts such as psychiatric comorbidities when a singular overarching diagnosis may be inadequate to account for a given clinical presentation.”

Larry Culpepper, MD, MPH, professor of family medicine at Boston University School of Medicine and editor-in-chief for The Primary Care Companion for CNS Disorders, shared with the CME Institute that, often, primary care practices employ a physician “champion” who is available to help the team of clinicians diagnose and manage patients with complex medical symptoms. “This is particularly the case for patients with psychiatric conditions,” he said, adding that irritability can also be associated with depressed patients with no mixed features.

“In well-documented unipolar depressed patients, 40% or more will have very prominent elements of anger, anger attack and irritability,” he explained. “Anger per se is not polarity-specific.” Therefore, a very irritable and even agitated depressed patient might not necessarily fit the mixed-features diagnosis and could, in fact, benefit from antidepressants as a treatment option.

“You have to be careful to differentiate the constellation of symptoms,” Goldberg said. Irritability, because it can be seen with both mania and depression, should not be considered a differentiating symptom, according to the “DSM.” A well-designed educational program can help clinicians identify the distinctions.

Other symptoms that could equally present for patients with both mania or hypomania, or depression or MDD, include distractibility, indecisiveness and even insomnia. This is a point that calls for continuing education as well.

“Insomnia from depression may be hard to tease apart from the loss of a need for sleep in mania; it’s a bit of a nuanced distinction,” Goldberg said.

Other diagnostic changes and updates made to the “DSM-5” in March 2022 and subsequent education from the activities mentioned above include:

Using the new diagnostic criteria for mixed features in the “DSM-5-TR” gives clinicians the ability to better diagnose and treat bipolar patients and mental health disorders. Clinicians can now better identify situations in which treating depression with an antidepressant could be potentially harmful and can then avoid treatment options, such as antidepressants, which could actively exacerbate the patient’s symptoms.

The currently available education on the updated guidelines is a major step in the right direction toward improving the mental health crisis in the United States. With continued focus on translating guidelines into practice, CME can make a difference in the lives of countless patients and their families.

^aLarry Culpepper, MD, MPH, is professor of family medicine at Boston University School of Medicine. 

^bJoe Goldberg, MD, is clinical professor of psychiatry at Icahn School of Medicine at Mount Sinai.

^cKatherine Biles, CHCP, is currently a contractor for EVR Consulting with Takeda Pharmaceuticals.

^dKurt Kleefeld is managing director, CME Institute.

References

1. Mason, Brittany L., Brown, Sherwood E., and Croarkin, Paul E. “Historical Underpinnings of Bipolar Disorder Diagnostic Criteria.” National Library of Medicine, July 15 2016. Accessed August 30, 2022. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5039514/
2. American Psychiatry Association. “Highlights of Changes from DSM-IV-TR to DSM-5.” Accessed August 30, 2022. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/DSM/APA_DSM_Changes_from_DSM-IV-TR_-to_DSM-5.pdf
3. Goldberg, Joseph F., MD. “Treatment Approaches to Mixed Features of Bipolar vs. Unipolar Depression.” Psychiatric Times, August 12, 2022. Accessed August 30, 2022. https://www.psychiatrictimes.com/view/treatment-approaches-to-mixed-features-of-bipolar-vs-unipolar-depression