Showing posts with label checklist diagnosis. Show all posts
Showing posts with label checklist diagnosis. Show all posts

Sunday, July 21, 2013

Why A Checklist is Not A Psychiatric Diagnosis

I was inspired by a post by Massimo Pugliucci on his excellent philosophy blog Rationally Speaking, to start using concept mapping software to describe some of the things that psychiatrists do and rarely get credit for.  There is the associated problem (as I have posted here many times) of checklists being seen as the equivalent of a psychiatric diagnosis.  That has been carried to the extreme that some have said rating scales are actual "measurements" or validating markers of psychiatric diagnosis.  Any cursory inspection of the combination of parallel and sequential processes that actually occur during an interview will demonstrate that is not remotely accurate.

Click on this link for the actual concept map.  A click on the diagram will zoom it for viewing.  Another click will zoom out.  Navigate by mouse wheel or scroll bars.  It should print out onto one standard sheet of paper in a landscape view.

I am interested in feedback from psychiatrists on what aspects they would modify.  If you have suggestions about what should be modified post them in the comments section or send me an e-mail.

Concept Map



The concept map may also be useful for explaining some findings that are commonly held up as "problems" with the diagnosis such as low reliability.  A common ( and purely hypothetical) example would be the 35 year old patient with a clear diagnosis of depression as a teenager, no history of remission of symptoms and multiple antidepressant trials who develops a polysubstance dependence (alcohol, cocaine, heroin) problem who is being seen in various states of withdrawal for the treatment of depression, insomnia and suicidal ideation. At this point does the patient have major depression, dysthymia, substance induced depression, or depression due to withdrawal symptoms?  What would tell you more about this patient's problems - a psychiatric diagnosis or a PHQ-9 score?  What would be more helpful in developing a treatment plan?

This answer to that question is the difference between medical quality and a term that is frequently substituted by governments and managed care companies.  That term is "value".  Governments and managed care companies apparently believe that giving someone an antidepressant medication for a PHQ-9 score is a better value than a psychiatric evaluation.

George Dawson, MD, DFAPA

Tuesday, May 22, 2012

Adult ADHD treated by Internists

I caught this eye-opening quote in the AMNews the other day: "ADHD is common enough that the average internist has 20-80 patients with this disorder".  The physician interviewed for the article suggest getting collateral data, making the diagnosis over several visits, getting an adequate family history, using a screening instrument and not prescribing stimulants on the first visit.  The final pearl in this column is:"Any patient who gets mad that you are not prescribing a stimulant after one visit should be a red flag."  With about 150,000 internists and another 130,000 family physicians that represents a lot of adults being treated for ADHD.

The physician suggested approach in this case is fairly comprehensive and includes corroborating symptoms in childhood and adolescence, obtaining collateral information, and using a standardized checklist. There is no mention of screening for addiction, discussing prior exposure to stimulants, or the use of performance based testing as opposed to diagnostic checklists. There is also the frequent scenario of a clinic that is set up to do expensive test batteries referring patients to physicians for the purpose of prescribing stimulants and advising the referred patient that they have in fact made the diagnosis of attention deficit hyperactivity disorder.

These are not insignificant problems given the flood of stimulants available on college campuses these days and at least one cultural viewpoint using stimulants as "cognitive enhancers" rather than medications to treat a specific diagnosis. There is also no accounting for clinician to clinician variability in terms of who is prescribed stimulant medication. The largest dividing point is persons with a history of addiction and the associated politics of believing that a stimulant should not be denied anyone with the appropriate diagnosis as opposed to a person with an addiction being placed at risk by stimulant prescription.

The best approach is a network of interested clinicians who have access to uniform diagnostic and treatment methods and who are dedicated to consistent treatment practices that include not treating at least some people with stimulants and using non-stimulant approaches to the treatment of attention deficit hyperactivity disorder.

George Dawson, MD, DFAPA

Christine S. Moyer.  Orchestrating Drug Management.  American Medical News.  May 21, 2012. 55(10): 12-13.

Sahakian B, Morein-Zamir S. Professor's little helper. Nature. 2007 Dec 20;450(7173):1157-9.

Monday, May 21, 2012

DSM5 - NEJM Commentaries


I highly recommend the two commentaries in the New England Journal of Medicine this week.  The first was written by McHugh and Slavney and the second by  Friedman.  Like Allen Frances they are experienced psychiatrists and researchers and they are likely to have unique insights.  I may have missed it, but I am not aware of any of these authors using the popular press to make typical political remarks about the DSM.  Those remarks can be seen on an almost weekly basis in any major American newspaper.

McHugh and Slavney focus interestingly enough is the issue of comprehensive diagnosis and opposed to checklist diagnoses.  It reminded me immediately that the public really does not have the historical context of the DSM or how it is used.  It also reminded me of the corrosive effect that managed care and the government has had on psychiatric practice with the use of "templates" to meet coding and billing criteria in the shortest amount of time.   Finally it reminded me of the bizarre situation where we have managed care companies and governments combining to validate the concept of a checklist as a psychiatric diagnosis and court testimony by experts suggesting that it is negligent to not use a checklist in the diagnostic process.

McHugh and Slavney summed up in the following three sentences: “Checklist diagnoses cost less in time and money but fail woefully to correspond with diagnoses derived from comprehensive assessments. They deprive psychiatrists of the sense that they know their patients thoroughly. Moreover, a diagnostic category based on checklists can be promoted by industries or persons seeking to profit from marketing its recognition; indeed, pharmaceutical companies have notoriously promoted several DSM diagnoses in the categories of anxiety and depression.” (p. 1854)

In my home state, the PHQ-9 is mandated by the state of Minnesota to screen all primary care patients being treated for depression and follow their progress despite the fact that this was not the intended purpose of this scale and it is not validated as an outcome measure.  The PHQ-9  is copyrighted by Pfizer pharmaceuticals.

The authors go on to talk about the severe limitations of this approach but at some point they seem to have eliminated the psychiatrist from the equation. I would have concerns if psychiatrists were only taught checklist diagnoses and thought that was the best approach, but I really have never seen that. Politicians, managed care companies, and bureaucrats from both are all enamored with checklists but not psychiatrists. They also talk about the issue of causality and how that could add some additional perspective. They give examples of diagnoses clustered by biological, personality, life encounter, and psychological perspectives. Despite its purported atheoretical basis, the DSM comments on many if not all of these etiologies.

Friedman's essay is focused only on the issue of grief and whether or not DSM5 would allow clinicians to characterize bereavement as a depressive disorder. That is currently prevented by a bereavement exclusion and DSM-IV and apparently there was some discussion of removing it. He discusses the consideration that some bereavement is complicated such as in the situation of a bereaved person with a prior episode of major depression and whether the rates of undertreatment in primary care may place those people at risk of no treatment.

There can be no doubt that reducing a psychiatric diagnosis to a checklist loses a lot of information and probably does not produce the same diagnoses. There is also no doubt that the great majority of grieving persons will recover on their own without any mental health intervention. Both essays seem to minimize the role of psychiatrists who should after all be trained experts in comprehensive diagnoses (the kind without checklists). They should be able to come up with a diagnostic and treatment formulation that is independent of the DSM checklists. They should also be trained in the phenomenology of grief and the psychiatric studies of grief and realize that it is not a psychiatric disorder.  If they were fortunate enough to be trained in Interpersonal Psychotherapy they know the therapeutic goals and treatment strategies of grief counseling and they probably know good resources for the patient.

The critiques by all three authors are legitimate but they are also strong statements for continued comprehensive training of psychiatrists. There really should be no psychiatrist out there using a DSM as a "field guide" for prescribing therapy of any sort based on a checklist diagnosis. Primary care physicians in some states and health plans have been mandated to produce checklist diagnoses.  The public should not accept the idea that a checklist diagnosis is the same as a comprehensive diagnostic interview by psychiatrist.

That is the real issue - not whether or not there is a new DSM.

George Dawson, MD DFAPA



McHugh PR, Slavney PR. Mental illness--comprehensive evaluation or checklist?
N Engl J Med. 2012 May 17;366(20):1853-5.

Friedman RA. Grief, depression, and the DSM-5. N Engl J Med. 2012 May
17;366(20):1855-7.
http://www.nejm.org/doi/full/10.1056/NEJMp1201794?query=TOC