In America there has been yet another shooting and the common denominator has been the presence of psychiatric medication. Clearly better diagnosis of people is not what is needed, better outcomes are. Medications are wildly over-prescribed and they don't work very well. For some patients, a nicotine patch is as effective as medication after two months.

Treatment has to get better, finding the right page in DSM 5 with which to label someone doesn't matter if a good medication would cover a lot of diagnoses anyway. The National Institute of Mental Health estimates that nearly one in five Americans suffers from mental illnesses as defined in the Fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. They won't use the Fifth Edition as anything more than a glossary because it is such a mishmash of competing segments, qualifications and demands for inclusion in order to get insurance coverage. 

Creating better treatment is where psychiatry exits the stage. It is the only area of medicine that still practices symptom-based diagnosis so it is well behind the more rigorous fields, and a lot of pop therapy practitioners want to keep it that way, they even advocate against medicine, and that makes it hard for pharmaceutical companies to do more than try to solve a problem that moves every time a new therapist speaks. A new program at least hopes to solve the problem, by over-diagnosis.

Mark Zimmerman, M.D., a clinical researcher at Rhode Island Hospital and director of the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, and colleagues compared unstandardized, unstructured interviews to standardized, structured interviews used by clinicians across the country. They found that the semi-structured interview provides more diagnoses, a finding that was replicated in other studies. While several of the initial reports from the MIDAS project identified problems with the detection of disorders, with regards to the diagnosis of bipolar disorder the researchers observed an opposite phenomenon--clinician over-diagnosis.

"Even if misdiagnosed, patients' outcomes may not be worse because the medications prescribed are effective for a variety of conditions," said Zimmerman. "Most outpatients will find relief via antidepressant or antipsychotic medications. Medications such as selective serotonin reuptake inhibitors (SSRIs), and serotonin-norepinephrine reuptake inhibitors are effective for depression, almost all anxiety disorders, eating disorders, impulse-control disorders, substance use disorders, attention deficit disorder and some somatoform disorders. Thus, it is possible that accurate and comprehensive diagnostic evaluations are not as critical once the provider determines the gross diagnostic distinction (i.e., distinguishing between psychotic, mood and/or substance use disorders)."

While a diagnostic determination is an important function of the intake evaluation, it is not the sole objective, opined Zimmerman. Comprehensive diagnostic evaluations may be associated with greater patient satisfaction and adherence to prescribed courses of treatments, he pointed out.

Published in the Journal of Clinical Psychiatry.