DSM-5 proposals for mood disorders: a cost–benefit analysis

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Abstract
The Diagnostic and Statistical Manual of Mental Disorders (DSM)-5 revision is underway. The review examines draft proposals for changes in mood disorders (posted February 2010 on DSM-5 web site), explains their rationale, and considers relative costs vs. benefits. Proposals covered include recommendation for a comorbid anxiety dimension; addition of a new disorder, mixed anxiety depression; replacement of mixed manic episodes with a 'mixed features' specifier applicable to manic, hypomanic, and major depressive episodes; addition of severity dimensions for manic and major depressive episodes; and removal of the bereavement exclusion in major depressive episode. Although some proposals (particularly the anxiety dimension and the use of Patient Health Questionnaire-9 (PHQ-9) as depression severity dimension) may improve clinical and research utility, others have a high potential for false positives (e.g., addition of mixed anxiety depression, removal of bereavement exclusion), unclear clinical utility (e.g., mixed features specifier for depressive episodes), or problematic implementation (e.g., use of Clinical Global Impression (CGI), which requires prior experience of treating bipolar patients, for rating manic episode severity). A cost-benefit analysis of mood proposals yields mixed results, with some having significant benefits and others carrying the risk of significant problems. Only proposals in which benefits outweigh costs should be included in the final DSM-5.