¹University of Groningen, Groningen Institute for Evolutionary Life Sciences, Groningen, Netherlands, ²NIMH, RDoC unit, Bethesda, United States, ³University of Illinois, Department of Psychiatry, Chicago, United States, ⁴Albert Einstein College of Medicine, Department of Psychiatry and Behavioral Sciences, New York, United States, ⁵American Psychiatric Association, Division of Research, Bethesda, United States, ⁶NIH, NIDA, Baltimore, United States, ⁷Emory University School of Medicine, Department of Psychiatry and Behavioral Sciences, Atlanta, United States, ⁸University of Toronto, Department of Psychiatry, Toronto, Canada, ⁹Icahn School of Medicine at Mount Sinai, Translational Medicine, New York, United States, ¹⁰Johns Hoplins University, Bloomberg school of public health, Baltimore, United States, ¹¹Mclean Hospital, Division of Psychotic disorders, Massachusetts, United States, ¹²UT southwestern, Department of Psychiatry, Dallas, United States, ¹³Columbia University, Department of Psychiatry, New York, United States, ¹⁴Yale School of Medicine, Department of Psychiatry, New Haven, United States, ¹⁵Stony Brook University, Department of Psychiatry, New York, United States, ¹⁶University of Pennsylvania, Department of Psychiatry, Philadelphia, United States

Background: The Diagnostic and Statistical Manual of Mental Disorders (DSM) has historically relied on phenomenological, symptom-based descriptions to define psychiatric disorders. Advances in neuroscience and biomarker research offer the potential to ground diagnostic categories in biological mechanisms, yet validated biomarkers remain limited, and challenges persist in ensuring scientific rigor, clinical utility, and ethical implementation. The American Psychiatric Association’s Future DSM Strategic Committee convened the Biomarkers and Biological Factors Subcommittee to develop a structured approach for integrating biological measures - ranging from fluid and imaging biomarkers to behavioral signatures and digital phenotyping - into future DSM iterations while attending to cultural, ethnoracial, and contextual considerations.

Aims & Objectives: This initiative aims to (1) outline a dynamic framework for incorporating candidate biomarkers and biological factors into DSM diagnostic criteria; (2) propose principles for developing flexible diagnostic algorithms that evolve with emerging evidence; and (3) identify essential ethical, cultural, and scientific considerations necessary for achieving a biologically informed, clinically meaningful, and equitable diagnostic system.

Method: The Subcommittee reached out to the field with a survey to provide examples of current biomarker science in psychiatry, including fluid, neuroimaging, functional, digital, and behavioral indicators, and evaluated existing validation standards and gaps in clinical applicability. The committee synthesized these findings to outline criteria and processes for listing candidate biomarkers within the DSM, emphasizing adaptability, transparency, and scientific rigor.

Results: Findings indicate that restricting DSM inclusion to fully validated biomarkers - currently limited to Alzheimer’s disease - would impede progress toward biologically informed diagnosis. Instead, the Subcommittee proposes a tiered, evidence-based system for incorporating candidate biomarkers, enabling the DSM to function as a living document that reflects emerging knowledge. Furthermore, meaningful incorporation of cultural and ethnoracial considerations is essential, given the influence of environmental exposures, structural inequities, and differential sociocultural contexts on biological and behavioral measures. Inclusion of diverse populations in biomarker research is critical to avoiding inequities and enhancing diagnostic validity. Collectively, these strategies aim to enable identification of biologically distinct subtypes within broad psychiatric categories, and advancing personalized care.

Discussion & Conclusions: A structured, dynamic process for integrating biological markers, behavioral indicators, and contextual factors into the DSM represents a transformative shift toward precision psychiatry. The proposed framework supports more accurate, mechanistically grounded diagnoses and lays the foundation for individualized treatment selection. By establishing criteria for incorporating candidate biomarkers now - despite incomplete validation - the DSM can evolve in parallel with scientific discovery. Next steps include defining formal criteria for candidate biomarker listing, piloting flexible diagnostic algorithms, and fostering cross-disciplinary collaboration to translate biomarker research into practical diagnostic tools. This approach marks a pivotal advance toward a more personalized, equitable, and scientifically grounded psychiatric practice.