Integrating Social Determinants of Health Into Clinical Formulations: The Need for a Biaxial System in the DSM and Psychiatry

What is it about?

In the paper, the authors discuss three important developments with respect to the DSM and Social Determinants of Health (SDOH) and offer a solution that we hope will be considered for eventual inclusion in DSM-5. These developments include: The recent recognition across medicine of the importance of coding SDOH has driven various health care organizations to encourage clinicians to include the ICD-10-CM Z codes for SDOH into diagnostic formulations to enhance clinical care; the critical need to improve communication among all healthcare providers regarding SDOH and psychosocial concerns; and pilots that support reimbursement for the treatment of complex patients with incentivizing the reporting of SDOH. The DSM multiaxial system, which had separated psychosocial and environmental factors from both psychiatric and non-psychiatric medical conditions, was particularly well-suited for facilitating the assessment and recording of SDOH. However, the removal of the multiaxial system from DSM-5 in 2013 meant a critical framework for highlighting SDOH was also eliminated. We believe this change in 2013 needs to be rectified. The lack of a provision for highlighting critical psychosocial and environmental factors is not commensurate with current best practices and reduces crucial understanding of primary psychiatric diagnoses (i.e., one could argue that an individual with schizophrenia and stable housing / supports will be managed differently than an individual with schizophrenia who is undomiciled). In recognition of the impact of SDOH on the complexity and cost of care over the past few years, a growing number of national and regional health care organizations and professional societies are promoting the increased use of the ICD-10-CM codes for SDOH through mandates, educational opportunities, and financial incentives. Moreover, including ICD-10-CM SDOH Z-codes as part of the list of submitted diagnostic codes has been demonstrated in pilots across the nation to impact the Medicare payments that hospitals and clinicians receive for their service. For example, including the ICD-10-CM code for homelessness per studies result in a higher payment to reflect the increased use of hospital resources. As such, the authors propose reintroducing a simplified form of the multiaxial system back a second axis for diagnosis of SDOH factors using codes that are readily available in the DSM-5 and all electronic health records. We believe this is essential to improving health outcomes in psychiatry and other medical fields.

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