As a psychologist trained to use the slim DSM-II, a 134-page, 6-by-9-inch, mustard-colored, spiral-bound compendium, I was intimidated by the new and expanded DSM-III in 1980. We now had five axes for making a diagnosis and many more mental disorders to choose from in this 494-page, green-colored bible of classification.
An explosion of treatment programs for many of these disorders occurred in the 1980s, especially inpatient programs for troubled adolescents and chemically dependent patients. These programs became big business because health insurance plans—rather than patients—were paying for this treatment. As costs soared, another type of business came into being, the managed behavioral healthcare organization (MBHO).
Both managed care and the DSM (now version IV-TR) are still with us, but market forces are driving some significant changes today, and managed care is about to seek a divorce from the DSM. While managed care still has a very warm regard for the DSM, this divorce is grounded in a desire to grow.
Managed care companies are seeking to expand their services to new populations and grow their annual revenues, and an ongoing commitment to the DSM's diagnosis-based model is overly restrictive. MBHOs traditionally have provided treatment for people seeking care for the mental and substance use (M/SU) disorders found in the DSM. While millions of people each year with M/SU disorders are not receiving the specialty care they need, even more people without a formal DSM diagnosis need to change their behavior in some way to maintain their health. MBHOs are strategizing how to reach these people. They do not simply represent an avenue for growth; these potential patients need the very skills that behavioral healthcare professionals possess as core capabilities: that is, to help people change behavior.
Behavioral healthcare professionals spend years in training programs focusing on techniques for helping people, and they tend to think of these techniques or services as the “product” they bring to market. If one instead focuses on the results to be produced, it might be said that their real product is clinical change. This may entail changing self-defeating thoughts, as are commonly found with mood disorders; negative behaviors, as are found with externalizing disorders such as conduct disorder; or an unhealthy lifestyle, as can be found to some degree in almost all of us. An unhealthy lifestyle can range from an unhealthy diet and inadequate exercise to the hazardous consumption of drugs and alcohol.
Another behavior problem is not following the doctor's orders. Millions of people each year fail to take medications as prescribed, follow special diets as ordered, or complete recommended clinical tests or procedures. One need not have a mental disorder (or a DSM diagnosis) to engage in any of these problematic behaviors, and their consequences can be severe. One common example is the person with diabetes who risks loss of major bodily systems and premature death as a result of noncompliance with treatment recommendations.
This focus on behavior change in the broader healthcare arena has been well recognized and, in fact, for the past decade disease management (DM) companies have been working with patients with chronic disease states such as diabetes to follow doctors’ orders and embrace a healthy lifestyle.
So what is motivating MBHOs to seek a divorce from the DSM? New scientific discoveries in behavioral healthcare are not driving this change. We have understood for decades how the mind and body are connected in illness, whether seen through the alarming comorbidity rates of depression with chronic medical diseases or how maintaining a healthy diet is critical in managing disorders such as diabetes and congestive heart failure. The main question now is who should take charge of helping people change the behaviors that threaten their health, and the answer lies more with market forces than with science.
The behavioral healthcare industry finds itself today at the crossroads of need and opportunity. We need to control spending on healthcare in the United States. Medical costs continue to climb and are projected to consume 20% of the gross domestic product in ten years, with employers such as GM insisting that healthcare costs are one of the major factors affecting their profitability. Medical costs are high for many reasons, but two clear components are relevant to the behavioral healthcare industry in this discussion: (1) extremely high-cost patients with comorbid medical and behavioral disorders, and (2) patients who don't change their problematic behaviors and continue to need expensive medical treatments as a result.
The opportunity for the industry is that no systems are in place to adequately address these needs. This is an opportunity that could reduce overall healthcare costs and improve patient outcomes.
One might argue that this opportunity requires us to embrace the DSM as we seek to identify undetected cases of depression and anxiety, and put treatment in the hands of licensed behavioral healthcare professionals rather than primary care doctors who have had mediocre results. Or should we not simply encourage DM companies to enhance their DSM capabilities and have their nurses address all comorbid conditions in their contacts with patients and doctors?
These options represent one possibility, but the alternative is for the behavioral healthcare industry to assert its expertise in the realm of behavior change in a global way. In other words, rather than training medical professionals to better understand DSM disorders, patients might be better served by having behavior specialists focus with patients on achieving health-promoting changes.