Where is Psychiatry Going?

By Jonathan Bauman, M.D., LFAPA

Over the past few months three articles in the Psychiatric Times by Nassir Ghaemi, MD and Mark Ruffalo, MSW, DPsa have described some interesting and provocative ideas regarding the diagnostic foundation of our specialty and how it needs to change (see The Concept of Mental Illness and Why the DSM Approach Is Wrong, Psychiatric Times 12/3/25; What Happened to Psychopathology, 12/5/26; Diagnostic Validators and the Question of What Really Exists, 3/23/26).  

These articles started me wondering about what psychiatry might look like with major changes to nosology in the not-to-distant future.  How might this affect our relationship to the ICD, to payment systems for services, and to treatment?  Not having the extent of knowledge necessary to form a coherent vision of what such changes would look like, I decided to ask my friend, Chat-GPT.  Here’s my query:

S. Nassir Ghaemi, MD and Professor of Psychiatry at Tufts University School of Medicine writes extensively about how the DSM's reliance on subjective distress and functional impairment diverges from scientific medicine’s clinicopathological approach to diagnosis. How would psychiatric nosology change if psychiatry adopted a clinicopathological approach to diagnosis? How would such a change impact the ICD? How would it affect insurance coverage for psychiatric disorders? How might

it impact treatment? 

And here’s Chat’s response, in italics and lightly edited:

1) What a clinicopathological approach would actually mean

In scientific medicine, diagnoses are ideally based on:

• Etiology (cause)

• Pathophysiology (mechanism)

• Biomarkers or objective findings

• Course and prognosis

In psychiatry diagnoses are largely:

• Syndromic (clusters of symptoms)

• Cross-sectional

• Validated by reliability rather than biological validity

A clinicopathological shift would require:

• Identifying biologically distinct disease entities

• Moving away from purely descriptive categories 

• Replacing symptom thresholds with pathophysiologic subtypes

2) How psychiatric nosology would change

A. Many existing disorders would likely fragment or disappear:

• “Major depressive disorder” → multiple biologically distinct subtypes

• “Schizophrenia” → a spectrum of different neurodevelopmental or

    neurodegenerative diseases

• “Bipolar disorder” might survive intact due to a stronger biological signal

(This aligns with Emil Kraepelin’s longitudinal/course-based approach to diagnosis)

B. Rise of biologically anchored subtypes such as:

• “Inflammatory-mediated depression”

• “Glutamatergic dysregulation syndrome”

• “Synaptic pruning disorder with psychosis”

(This resembles initiatives like NIMH’s Research Domain Criteria)

C. Reduced role of “distress/impairment” (key to Ghaemi’s critique): 

• Currently a condition is not a disorder unless it causes distress/impairment

• In a clinicopathological model a disease exists whether or not it causes distress

• Some psychiatric conditions could be diagnosed before subjective suffering emerges (as with asymptomatic hypertension or early multiple sclerosis)

• Others conditions (e.g., mild anxiety) might not qualify as diseases at all

3) Impact on the International Classification of Diseases

The ICD serves a broader global/administrative function than the DSM, so:

A. ICD would likely lag behind DSM shifts

B. Dual-track system likely:

• A clinical/pragmatic track (symptom-based, for global use)

• A research/biological track (for advanced systems)

C. Eventual convergence if robust biomarkers emerge

4) Impact on insurance coverage

 A. In current system (DSM/ICD-based) insurance depends on:

• Coded diagnoses

• Demonstrated distress/impairment

B. Under a clinicopathological model:

1. Some patients could lose coverage, such as individuals with distress but no identifiable pathology (e.g.: adjustment reactions, mild anxiety, existential distress).  These might be reclassified as “non-disease states” or non-reimbursable medical conditions.

2. Others conditions might gain earlier coverage, such as

• Preclinical or biomarker-positive individuals

• Example: “prodromal psychosis with neurobiological markers”

This parallels:

• Pre-diabetes

• Early-stage cancer screening

3. Greater stratification of reimbursement

• Treatments tied to specific mechanisms

• Insurers may require biomarker confirmation or treatment matching

Psychiatry currently captures a wide swath of human suffering, but a clinicopathological shift might push some conditions into:

• Psychology

• Social services

• Coaching or non-medical care

5) Impact on treatment

A. Instead of trial-and-error SSRIs and antipsychotics we’d see a move toward precision psychiatry:

• Mechanism-specific treatments

• Biomarker-guided prescribing

For example

• Inflammatory depression → anti-inflammatory agents

• Dopaminergic dysregulation → targeted neuromodulators

B. Fewer “broad-spectrum” diagnoses, fewer generalized treatments

• SSRIs might be used only in specific subtypes

• Antipsychotics prescribed based on pathophysiology, not just symptoms

C. Reduced non-specific psychotherapy for biologically driven illness 

D. Increased role of longitudinal course

• More emphasis on trajectory (as per Kraepelin)

• Less cross-sectional diagnosis

6) Conceptual and philosophical consequences

A. Psychiatry becomes more “medical”:

• Closer to neurology

• Less dependent on subjective report

B. But risks losing part of its domain:

• Exclude meaningful suffering that lacks biomarkers

• Undermine psychiatry’s role as a bridge between medicine and the human condition

Bottom line if psychiatry adopted a clinicopathological model:

• Nosology would shift from syndromes to biologically defined diseases

• DSM categories would fragment or disappear

• ICD would adapt slowly, likely maintaining dual systems

• Insurance would become more biomarker-driven, potentially excluding some currently covered conditions

• Treatment would become more precise, less trial-and-error

• Psychiatry would gain scientific validity—but risk narrowing its scope and

abandoning parts of human suffering that are real, but not (yet) biologically

classifiable.

ChatGPT then contrasted Ghaemi’s position to another thinker in the field: Kenneth Kendler, MD, a professor at the Virginia Institute for Psychiatric and Behavioral Genetics:

—Ghaemi’s position is that psychiatry should approximate the rest of    medicine.  As previously noted: 

• the DSM diagnoses are just a collection of symptoms that lack validity as discreet diseases 

• ‘distress/impairment’ is arbitrary and not a scientific criterion

• diagnosis should be based on etiology, pathology, and longitudinal course

—Kendler, on the other hand, asserts that psychiatric diagnoses: 

• are multifactorial, bio-psycho-social constructs that can’t, as yet, be reduced to biological mechanisms  

• though DSM diagnoses are imperfect, they provide useful constructs where ‘distress/impairment’ is a necessary feature  

• Psychiatry should therefore embrace multiple explanations and not wait for pathological mechanisms that may never be discovered

—In summary, Ghaemi is pushing psychiatry towards scientific purity and medical validity and Kendler supports pragmatic pluralism that embraces imperfect categories as the best available tools.

Right on time, the March edition of the Psychiatric Times focussed on where we should go from the DSM-5-R.  An article by Awais Aftab, MD, clinical assistant professor at Case Western Reserve University, contained a summary of proposed changes to the DSM, which are significant.  I encourage you to read the article and won’t repeat the changes here, except for one:  that the name of the DSM would change from Diagnostic and Statistical Manual to Diagnostic and Scientific Manual.  To me, ‘Scientific’ sounds aspirationally premature and pretentious in light of how wide the gulf is between current practice and ‘scientific purity’. Assuming that this controversy will be with us for quite some time, why not just leave the name as Diagnostic Manual of Psychiatry?

Jonathan Bauman, MD

June 2026

Dr. Bauman is an Emeritus ASAP Member and currently serves on the Board of The American Board of Adolescent Psychiatry (ABAP), hosted by ASAP, and is its newsletter Editor.