LAUSR

World Psychiatry 20:3 October 2021 assessments, but had an open question where psychiatrists could note factors not surveyed. Factors suggested included: previous diagnoses, age, cognitive function, risk or history of suicide or violence, forensic history, legal status, cultural background, social networks, work history, family involvement, insight, acceptance of illness and treatment, preferences among treatments, rapport between doctor and patient, and financial resources. While our survey was being completed, a worldwide screen of expert opinion from mental health clinicians, assessing the value of ICD-11, which is similar to DSM in its categorical approach and content, was published. This global survey addressed all the categories in the ICD and DSM, exploring the relative use of ICD/DSM for administrative purposes, managing treatment, communicating with other treaters, and teaching. Our survey targeted only US psychiatrists, focused on psychotic disorders, and obtained relative rankings of the use of DSM diagnoses versus other clinical findings in choosing and guiding treatment. Thus, the two studies were partially overlapping. Consistent with our project, the authors of the global survey concluded that the ICD and DSM categories are most useful for administrative and billing purposes and for communicating with other clinicians. They are least used and substantially less useful for choosing individual treatments or advising on prognosis. Our results suggest that, among patients with psychotic disorders, the DSM-5 diagnosis is less important than identifying other individual features of illness, especially type and severity of symptoms, but also comorbidities and some aspects of personal history. Relevant factors noted by other investigators include suicidality, recreational drug use, obstetric complications, early or recent adverse events, social cognition and neurocognition. The use of these factors allows more flexibility in description than categories alone. Course can be included as well. Notable for interpreting the responses, we only contacted clinicians at well-known academic centers. The majority (70.5%) of respondents had hospital-based practices, but this might be expected for those who treat many patients with psychotic disorders. The results represent opinions of clinicians who teach and perform research, in addition to their clinical practices. Most psychiatrists did not respond. Nonetheless, the response rate (22.8%) was typical of online surveys. Possibly, those who did respond were interested in the subject and might have thought about the matters raised. We are not suggesting that responders were representative of US psychiatrists, but it might be noted that the suggestions, made a century ago, on which ICD and DSM are based, were also from clinical observations, largely from clinicians in select sites. They were not made or since have been confirmed on the basis of other validators. Lastly, an argument has been made that changes in DSM and ICD should strive to improve utility and accuracy. Accuracy in choosing treatments and predicting outcome might be enhanced by incorporating factors that clinicians cite as most important into formal diagnostic systems. That these factors are already in use for making clinical decisions shows that they are practical and suggests that they may be valid. An improved system might incorporate both categorical entities and additional features, such as those provided by recognizing individual symptoms and severity of those symptoms, in new models. Such models can be tried and tested, then implemented if they show advantages compared to existing systems.