One of the biggest problems facing the mental health system today is slipshod diagnoses — diagnoses made too quickly, without obtaining enough information, and checking for reasonable alternative diagnoses. Professionals sometimes complain that they are overworked and need to make a diagnosis quickly in order to be reimbursed for the interview. I say that’s rubbish and puts people’s lives in jeopardy, in pursuit of quick treatment, quick payment, and quickly moving onto the next patient.
Don’t get me wrong — most mental health professionals take their time, explore rule-out diagnoses, and always seek to ensure the person in front of them really fits the diagnostic picture for a given disorder. But as we reported today, bipolar disorder may be overdiagnosed in real life practice, where nearly half those initially diagnosed with bipolar disorder didn’t actually meet the criteria for that diagnosis.
Imagine any other scientific field where you can be wrong half the time and still be considered “scientific” in any sense of the world.
Via Philip over at Furious Seasons today, I learned of one college student’s mental health journey, published in the college newspaper as, To hell and back. While long, it’s an interesting story of a college student’s experience with various psychiatrists and grappling with mental health issues while in college. And it shows just how badly professionals can work to misdiagnose an individual, over and over again. (Keeping in mind, of course, that this is just one side of the story; the story the professionals mentioned in the article may tell of this person might paint a very different picture.)
Diagnosis is part art, part science. While there are structured clinical interviews that can take much of the “art” and guess-work out of diagnosis, such structured interviews are rarely used in everyday clinical practice because they take too much time (and one might argue, too much effort on both the clinician’s and patient’s parts). So most clinicians rely on their experience and training to diagnose. After seeing dozens or hundreds of people with depression, a professional can start to feel they can spot “depression” a mile away.
But an initial interview with a person who is seeking mental health services should take time and patience. In an outpatient setting, it is typically about 75 to 90 minutes in length, and this is on purpose. It is an information-gathering session and one that, if rushed, much can be lost in obtaining a balanced picture of the person’s life. By the end of that first session, most experienced clinicians have a pretty good sense of what might be going on with the client and can reliably formulate an initial diagnosis.
Sometimes, a professional will defer a diagnosis because the picture is still not clear. It may take another session or two before they feel like they have enough information to provide an accurate diagnostic label. Other professionals don’t care as much how reliable or accurate their diagnosis is, feeling either the actual diagnosis isn’t all that important (oblivious to how such labels will follow the person around for the rest of their lives on their medical charts), or that it’s “good enough” for the patient’s current complaints.
In hospital settings, such an interview can be rushed and completed in as little as 20 minutes. Professionals feel they can do an adequate job in such a short period of time, but likely fail miserably in their ability to produce reliable and accurate diagnoses for their patients.
Sadly, I don’t think that Thor Nystrom’s college story is all that unique. And his struggle to be accurately diagnosed shows a not uncommon failing within our hodge-podge mental health system. This struggle is typical when multiple professionals get involved in a single person’s life, all offering their own unique view of the patient’s issues. And all rarely agreeing on what the “real” diagnosis or problem is.
There’s no clear solution here, outside of mandating and instituting structured clinical interviews for all. But I doubt that will happen, even when research shows our current diagnostic procedures are failing miserably, because professionals (and insurers who pay for all of this) are invested in the current system.
No matter how broken it may be.
6 comments
This is an eerie and frightening story. I feel I could diagnose this man better than that shrink who said “schizophrenia”, and I have all of one undergraduate course in clinical psych. Even without time for a structured interview, it’s nothing less than malpractice to fail to take into account this young man’s substance use (beer and Rx)!
It’s also eerie because I can relate somewhat, though thankfully not with a horror story. Since I was diagnosed with depression, I have had to fight against pdocs treating me as if I have bipolar — even though I’ve never been formally diagnosed and even though I have absolutely no history of anything resembling mania — based on a family history of bipolar and on the fact that I was once prescribed (off-label for my depression) a bipolar med (which didn’t work). I feel as if I have to be my primary doctor and the supervisor of every pdoc I see. Now my pdoc is talking about an antipsychotic. And he keeps hinting that maybe I should try that bipolar med again, even though it didn’t work and it had extrapyramidal side effects. And he’s a good pdoc compared to ones I’ve had before.
I’m not anti-psychiatry, but I am growing more cynical with time.
The first diagnosis was especially difficult to read — it made my skin crawl. The doc obviously didn’t care (from his account) and seemed to spend far too little time with him drawing out what he meant by his responses.
From what he said, it seems apparent he likely never suffered from schizophrenia.
Imagine that this sort of slipshod diagnosing is going on not just once in awhile, though, but hundreds or thousands of times each and every day. And then it starts to get really frightening…
But why does it matter what diagnosis a person is diagnosed with if diagnosis doesn’t make a difference to treatment (as you suggest in your post on financial interests in the DSM committee)?
Umm, that’s not what I said. I suggest you re-read what I wrote, which said the DSM is not a treatment manual (which is a simple statement of fact).
Obviously diagnoses have an impact on treatment choices. More importantly, I would suggest that sloppy diagnoses lead to sloppy treatment.
This is a very important topic, needless-to-say. Are there statistics that can give a more objective view? Who looks into mis-diagnosis, what agency? How many mis-diagnosis are not such but the anger and confusion of the patient? How do you separate the chaff from the wheat in order that we do not go on wild goose chases?