The health profession and patient advocates have complained it takes a rigid, United States-centric approach to psychiatry.
They say it treats some normal conditions as disorders and leaves out some disorders altogether, as Kerri Worthington reports.
The latest edition of the Diagnostic and Statistical Manual of Mental Disorders, known as DSM-5, is huge.
At around 900 pages, it attempts to outline all recognised mental health conditions and their associated symptoms.
The American Psychiatric Association publication, primarily for mental health practitioners in the United States, is written with that country's medical system in mind.
But practitioners in Australia and elsewhere will adopt the manual, even though the World Health Organisation has a parallel manual, the International Classification of Diseases.
The development of the latest DSM edition has proved highly controversial, with around 15,000 signatories to a petition calling for the whole process to be reconsidered.
One signatory is Associate Professor Tim Carey, of the Centre for Remote Health in Alice Springs.
Dr Carey says he is uncomfortable with how the manual assesses mental illness based on clusters of symptoms.
"The DSM diagnoses don't actually explain anything. And, unfortunately, a lot of people do get a lot of comfort out of being told that they've got depression or social anxiety or obsessive compulsive disorder or something, and they feel like being given that label has told them something about what's going on for them. But, actually, the DSM, in its own documentation, is designed to be non-aetiological. So it's not about causes or where things come from. It's purely a description of patterns of symptoms, if you like."
The executive director of the Black Dog Institute, Professor Helen Christensen, concedes there are limitations to the DSM approach.
But she says people with mental illnesses find describing their symptoms as disorders helps reduce a perception they should just pick themselves up and get on with normal life.
Professor Christensen says the DSM classification system is a model of knowledge open to change as more is learned about mental disorders.
"We have to have a classification scheme in order to have a shared language and, also, partly to be able to know what the right sort of questions are to ask in our research. In Australia, talking about different disorders is the basis of our whole program around mental-health literacy. We make distinctions between depression and anxiety, and so on."
Critics of the DSM-5 say it encourages over-diagnosis and treats some normal behaviours as disorders.
Neuropsychiatry professor Perminder Sachdev, of the University of New South Wales Centre for Healthy Brain Ageing, denies that.
Professor Sachdev is a member of the Neurocognitive Disorders Workgroup of the DSM-5.
He says having a DSM diagnosis is not an exaggerated response to normal behaviour and does not -- as some critics have suggested -- label people as insane.
"Insanity, in fact, is a legal term, and mad or crazy are stigmatising lay terms that do not apply to the vast majority of people with a DSM diagnosis and should not, in fact, be used for anybody. Many individuals, including physicians, find it difficult to accept that mental illness, not unlike physical illness, is common -- and most of it is not madness or insanity. And it is appropriate for citizens of advanced societies to identify and deal with milder forms of it."
But University of New South Wales psychiatry professor Gordon Parker says the way the DSM deals with depression is troubling.
He says it inexorably leads to medicating more and more people who do not need pharmacological treatment.
Professor Parker says the DSM model offers a nebulous, non-specific diagnosis.
He says it effectively groups a range of biological, social and psychological conditions into major, minor and subclinical depression and a new condition, mixed-anxiety depression.
He says that has led to depression diagnoses escalating dramatically from a 5 per cent likelihood of having the condition in the 1950s.
"And if, in fact, you then undertook a community study and were to quantify the number of people who would meet criteria for major depression, minor depression, sub-syndromal depression or mixed-anxiety depression, now clinical depression becomes a 100 per cent virtually lifetime risk. And that is a dramatic difference from the 5 per cent risk -- which was probably too low -- in the 1950s, but (which) is now far too high."
Professor Parker says expanding psychiatry into normal states through what he calls the flawed DSM model has compromised the research and management of depression.
He says the model does not differentiate between types of depression or its causes.
"So, as a generalisation, you go with Depression Type X, you see a GP or psychologist, you'll probably get an antidepressant drug. Go with the same depression to a psychologist, you'll probably get cognitive-behaviour therapy. Go to a counsellor, you'll probably get counselling. Go to a lady wearing a kaftan, you'll get crystal therapy. Now, in my mind, that is absolutely out of kilter with medicine -- which seeks to say, 'What is the condition? What's its cause? And what's its preferential treatment?' -- and is, in fact, more a procrustean model (arbitrary standard), where the patient is actually being fitted to the paradigm or the discipline of the trained practitioner."
Tim Carey, the psychologist from the Centre for Remote Health in Alice Springs, says the DSM cements a western cultural approach to mental health.
"One of the biggest problems with DSM is that it's transporting a very Western idea of mental health and mental health problems to other cultures and other parts of the world where it may not be appropriate. And it's usurping, if you like, the existing understandings of mental health and mental well-being and mental distress. So other cultures have their own ways of understanding life and living, and problems that occur, and their own ways of dealing with that."
Dr Carey says Australian Indigenous communities could benefit from a less rigid treatment regime.
"Aboriginal people have quite sophisticated ways of understanding psychological distress and mental health problems. One language group that I'm aware of, for example, has 15 different words for anxiety. So when we come in with a western framework of what anxiety disorders are, for example, and we have in our heads that these are real things like diabetes or heart disease, and they're things that need to be identified and treated, I think we can ignore other cultural explanations."
But the director of the University of New South Wales' Traumatic Stress Clinic, Professor Richard Bryant, defends the DSM.
He says cultural issues have been at the forefront of updating the US psychiatry manual.
Professor Bryant was on a working group examining how the manual would deal with post-traumatic stress disorder and related conditions.
And he is also involved with the World Health Organisation's next update of the International Classification of Diseases. (ICD)
He says the ICD has to suit mental health professionals in countries as diverse as Afghanistan, Rwanda and Papua New Guinea.
And he says the DSM authors were similarly aware of the international reach of that publication and wrote criteria accordingly.
"DSM-5 certainly has tried to do it, in that, in our committee, everything was then reviewed by certain people with cross-cultural expertise, and this would come into play in terms of clinical presentation of a disorder. You might have a certain presentation in traumatic stress where people have trance-like phenomena. Now, in some cultures, that's actually seen as adaptive and culturally suitable. We're not going to call that pathological. Of course, anything that is going to be deemed abnormal has to be seen as abnormal within its social context."
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