Penn’s Psychiatry chair is helping to re-envision how mental illness is diagnosed

As Chair of Psychiatry and Ruth Meltzer Professor of Psychiatry at the Perelman School of Medicine, Maria Oquendo, MD, PhD, has plenty of experience with the Diagnostic and Statistical Manual of Mental Disorders. So authoritative that it’s often described as a “bible” for psychiatry, the DSM (as it’s popularly known) serves as the mental health field’s definitive guide for the diagnosis of mental disorders.

Oquendo, whose research focuses on suicide, uses the manual as a guide through the diagnostic process in her clinical work. But she saw a way to make the DSM even more precise. In 2013, Oquendo and several colleagues succeeded in getting suicidal behavior added as a standalone diagnosis to the appendix of the most recent edition, the DSM-5-TR. “It's a very laborious process because you need to basically write a thesis about why this is the right thing to do,” she said.

It’s just one example of how the manual, which lives online as well as in print form, is an evolving document. Its next iteration may carry forth that progress.

New research in the field of psychiatry, a greater understanding of how environmental factors and social determinants of health (such as economic security or a safe place to live) impact stress and mental health, and the possibilities presented by artificial intelligence, are all reasons why the American Psychiatric Association (APA)—which publishes the DSM—is considering whether there may be a better way to identify and classify mental illness.

In 2024, the organization appointed Oquendo to chair the committee tasked with reimagining what the next DSM could and should be. With a background as a thought leader in the field as well as a clinician and a researcher, Oquendo is well-suited to addressing big-picture concepts for reworking the manual, plus the ground-level details that matter to practitioners. In addition to her faculty roles at Penn, Oquendo in 2016 became the first Latina to serve as APA’s President; she is also a member of the National Academy of Medicine.

“Because of the DSM’s preeminence as the go-to guide for understanding and diagnosing mental disorders, the individuals who lead its production must unequivocally be among the best and brightest in psychiatry,” said APA CEO and Medical Director Marketa M. Wills, MD. An alumna of the medical school, she praised Oquendo as a “groundbreaking researcher” who can help ensure that the DSM “continues to be an essential tool for mental health clinicians in a changing health care environment around the world.”

Indeed, Oquendo stresses the importance of having a living, listening diagnostic manual, which adapts to new scientific findings and changes to meet the moment and the needs of those who use it. “It’s such an important project for the association and for the field,” she said. “We're at a watershed point. This is about the strategy for the next generation as opposed to sitting down and determining, OK, what are the criteria for this particular diagnosis going to be now?”

That’s why the Future of DSM Task Force has been asked to take a step back to look at the manual as a whole—what works, what doesn’t, and how can it be fundamentally improved? Is it time for more than incremental change in the diagnosis of mental illness?

Potential directions for change

Up for discussion are several new ways of thinking about diagnoses. For instance, in addition to considering social determinants of health as part of the diagnostic process, Oquendo noted other areas the team is considering as it weighs how to shape the diagnostic process in the future. Perhaps the most obvious is evaluating the inclusion of biomarkers for certain conditions, such as schizophrenia and anxiety, which have come to the fore in recent years. And pharmacogenomics grants providers a clue as to which medications may work best for an individual, pointing the way toward a more personalized treatment plan.

Oquendo is passionate when highlighting the value of a “dimensional” approach to organizing the manual, as opposed to the rigid categories that currently make up its architecture. Consider the case of sensory processing issues. What if the book, rather than listing disorders and outlining their criteria, instead focused on symptoms common to multiple disorders, and pointed diagnosticians to ways of gauging which one (or more than one) might be in play?

“It might be better for patient care if we take a more dimensional approach to thinking about illnesses and mental health issues,” said Oquendo. As opposed to the current rubric: “OK, you have schizophrenia. Yes, or no? You have bipolar disorder? Yes or no, right? That might be more limiting.”

Oquendo also wants to consider expanding diagnostic criteria for some conditions to include patients who, in the terms of psychiatry, don't show a high degree of dysfunction. Their condition may be so mild as to not cause significant issues functioning in day-to-day life—yet. By way of comparison, Oquendo points to non-psychiatric ailments such as high blood pressure, which is often “silent” in the early stages and doesn’t overtly impair patients—but is still a huge focus of prevention and treatment efforts, to head off long-term problems. “So should psychiatry be different and have a requirement for dysfunction?” she asked. “You know, people oftentimes have no idea they have diabetes. But it can cause a lot of damage, even if the person doesn't perceive that they’re suffering.”

The other side of this coin is the idea of “subsyndromal” illness—not having the right combination of symptoms to merit a defined diagnosis. “Let’s say that you have three symptoms of depression that bother you a lot,” Oquendo offered. “You don’t meet criteria for the disorder, and it’s going to be very difficult for you to get treatment, because it’s not the five symptoms that the diagnosis requires.” In other words, according to the current DSM, this patient would not be considered to have depression. “And yet you may really want help or need help with it, but you might not get the care you need. We could have more flexibility in terms of how people can access care,” she added, noting that health insurers often use the manual’s diagnostic criteria to determine what care they will cover—or not cover.

Turning the battleship

The visioning process to consider these challenging yet vital questions launched in May 2024. Oquendo and her colleagues have established subcommittees to work on these different topics, with the goal of spurring dialogue among experts, surveying existing research, publishing findings, and hosting conferences, all in the name of holding the ideas up to scrutiny. But the task won’t be easy, or fast.

Besides the enormity of the undertaking—the analogy of painstakingly turning a battleship comes to mind—making big shifts in the way the DSM is put together, and what it includes, necessitates overcoming some resistance from entrenched interests. “People have very strong feelings about this stuff, especially in the academic community,” Oquendo remarked. “If you study a particular diagnosis, any change to the way that diagnosis is made has an impact on the relevance and validity of your life’s work.”

Oquendo hopes that by 2026, any directional changes in diagnosis—the roadmap, as she put it—will be settled, and the APA can begin thinking through actual changes.

What will that eventual book look like when it lands on the desk of a practitioner? “It will include, of course, signs and symptoms as we have today,” Oquendo said, “but ideally at least some of the diagnoses will have biomarkers, many of them will have evaluations of the impact of social determinants of health, and if we end up going with dimensions, that’ll also be very critical in terms of how we think about the presence of a condition.”

Bottom line, she added, “What I’m hoping is that we will be able to make evaluations that are more holistic.”