Mental health ‘bible’ overhauled

The new model, DSM-5, could have wide-ranging implications for employers in areas such as disability management, health plans and arbitration.

Created by the American Psychiatric Association (APA), the manual is used by employers, arbitrators, insurers, workers compensation authorities and mental health professionals, according to Earl Phillips, partner in the labour and employment group at McCarthy Tétrault in Vancouver.

"The DSM has been treated as the authoritative source for diagnosis of mental illness," he said. "There really is nothing else like it."

The manual is used for everything from categorizing disorders to looking at medication, planning treatment and making decisions about disability and functioning levels, said Ann Malain, vice-president of client services at Homewood Human Solutions in Toronto.

The latest version was tested in Canada and the United States and comes closer to the model used by the World Health Organization (WHO) in its International Classification of Diseases, she said — but there is always controversy.

"Any kind of change like that can affect diagnosis, it can affect access to health or mental health programs, it can affect civil rights in the States, human rights in Canada, it can determine potentially what you can prescribe for and what you can’t," she said.

"It certainly can affect, if there’s jurisprudence related to the old categories and it’s not easily translated to the new, then it can affect that. It can affect even an academic’s research, what gets funded going forward and what doesn’t."

There are several areas that could be a real problem for employers, according to Greg Heywood, a lawyer at Roper Greyell in Vancouver.

For example, there is a new chapter on disruptive, impulse control and conduct disorders featuring oppositional defiant disorder, intermittent explosive disorder and conduct disorder.

These include symptoms such as an angry or irritable mood, argumentative or defiant behaviour, vindictiveness, callousness and aggression.

"If you have a disruptive employee in the workplace, and they’re either acting out with their fellow employees or they’re insubordinate, acting out with their supervisor, it would be very easy now to be able to peg them with one of these mental health issues," said Heywood.

"Then their behaviour might be considered non-culpable — you can’t discipline and you have to accommodate."

Operational defiant disorder sounds like it may medicalize juvenile behaviour in the workplace, said Phillips.

"There’s a serious concern there," he said. "Does the DSM-5 now medicalize a lot of normal human emotions and human behaviour?"

A worker diagnosed with such a disorder may also require medication, said Phillips.

"So we could have more diagnoses, more absences, more duty to accommodate and more direct costs for benefits."

Another "alarming" development, according to Heywood, is the fusion of substance abuse with substance dependence into a single disorder measured on a continuum from mild to severe.

"Formerly, one involved an addiction and one involved bad choices for which you could hold people accountable. Now the line may not be so clear and accountability may be harder to establish," he said.

It used to be that if there was a dependence, an employer knew what was needed to accommodate, said Phillips.

"Now they’re going to be placed on a spectrum… and it really remains to be seen how the addiction specialists are going to adapt to that and if they say it’s a mild disorder, what is that recommended treatment?" he said.

"HR practitioners, lawyers in the field, union leaders are going to have to sort through what this all means. We’re going to be captive to the addiction specialists now and how they’re going to apply the DSM."

But the move to bring the severity of a substance use disorder to moderate or severe is a good thing, according to Ash Bender, head of the psychological trauma program at the Centre for Addiction and Mental Health (CAMH) in Toronto.

"It allows people to be focused on identifying a problem and making sure they’re getting the right kind and intensity of treatment that they need."

Also appropriate is a change around bereavement, said Bender. Previously, clinicians were told to refrain from diagnosing major depression in individuals within the first two months following the death of a loved one, but this exclusion has been removed.

People often go on short-term and long-term disability because of grief, said Bender.

"That is an appropriate distinction that they’re making, because labelling something as bereavement sometimes led to a delay in people getting treatment and prolonged leave."

But the DSM-5 has made natural grieving a psychological condition, said Heywood.

"It’s normal to feel down when you’re grieving — it doesn’t mean you’re sick. It has the potential for extending bereavement leave and so on."

It’s estimated 20 per cent of people in grief meet the criteria for depression and this could put more people in disability status, said Malain.

"Even if they don’t ask for accommodations from their employer, potentially the costs — insurance and other kinds of employer costs in terms of medication and the… health system — may go up."

DSM-5 criteria for post-traumatic stress disorder (PTSD) differ significantly from the previous version. They are more explicit with regard to how an individual experiences an event and there are now four symptom clusters instead of three.

There’s more of an understanding that first responders can develop PTSD from repeated exposures, said Bender, even though they’ve had training and may not respond right away.

Another important change — but potential drawback — is the DSM-5 no longer uses a multi-axial approach to diagnosis, said Bender.

"It was one of the helpful things around the DSM-IV because it was a way to really get an overview of a client or patient pretty quickly."

And the removal of the GAF (global assessment of functioning) scale is also troublesome, he said, as this rating is used to make decisions around disabilities.

"Part of that is fine because it wasn’t a very good scale. But, at the same time, most people aren’t familiar with the other instrument they recommended, the Disability Assessment Schedule (WHO-DAS)," said Bender.

"All the nuanced stuff really needs to be reflected now in written form rather than just giving a score. So that’s going to be one of the trickiest issues… there’ll be a big learning curve for non-medical people such as insurance reviewers being comfortable with not seeing the GAF and not seeing multi-axial presentation."

Other new disorders of interest to employers include caffeine withdrawal, cannabis withdrawal, mild neurocognitive disorder and premenstrual dysphoric disorder, said Phillips. And, going forward, the DSM-5 could open up a lot of disputes.

"It’ll be interesting because arbitrators may end up having to try to sort through competing theories and competing diagnoses," he said.