So what are the most important things to consider in making a psychiatric diagnosis?
Frances: First off, the more severe and more characteristic the presentation, the easier the diagnosis. So we can be reliable in diagnosing disorders like schizophrenia, obsessive-compulsive disorder, and major depression. The five percent of the population that has a severe psychiatric disorder can be most accurately diagnosed. In those cases, the rule of thumb is to diagnose quickly and treat them immediately, because the sooner you provide treatment, the better their long-term prognosis.
But when a presentation is milder, often you’re seeing the patient on the worst day of that person’s life. Whatever happens in the next week, they’re usually going to be better. A month later, they may look very different. Making a diagnosis on that first visit may completely miss the point. So the single most important lesson is to take time. You can’t do it in seven minutes, and often you can’t do it in one meeting. Sometimes you can’t do it in a month. When in doubt, wait, watch, provide support, normalize the situation, see what resources there are from within the individual’s own resiliency. All sorts of simple things, including reducing stress, will often make a diagnosis and medication unnecessary.
What are the cases that are most often misdiagnosed?
Frances: We’ll start with kids. In a Canadian study that included over a million kids, the best predictor of attention deficit disorder (ADD) was whether you were born in December or born in January. Especially for boys, being the youngest kid in the class made you almost twice as likely to get the diagnosis of ADD. It’s absolutely crucial with kids to recognize that there are individual differences, developmental differences, family stresses, school stresses, environmental problems, all of which can create behaviors that will be mistaken for psychiatric illness. This is especially true today with the reduction of physical education in schools and the increase in class sizes. Instead of inflicting a medical diagnosis on these kids and treating them with stimulants when they don’t need them, we should be spending money on having smaller classes and more physical education.
We also jump too quickly to a psychiatric explanation with the elderly. There’s a remarkably a high percentage of people in nursing homes who are getting antipsychotic medications, which actually reduce life expectancy. Because the elderly take an average of six medications, it’s difficult to evaluate the degree to which psychiatric symptoms are due to medication side effects. They don’t clear medications and don’t metabolize them nearly as well as younger people do. These medicines often have interactions, and it’s not uncommon for psychiatric symptoms to be caused by the medications that are being given to prevent them. Furthermore, the symptoms may have more to do with the staffing and nursing team than any other factor. If someone gets agitated, for instance, it could be that his bladder’s full, and he has no way of getting to the bathroom.
So you have to understand the environmental factors that are involved before jumping to a diagnosis. The less classical the presentation, the younger or the older the patient, the likelier you are to get overdiagnosis and mistreatment with certain medication.
What changes in the insurance industry would you like to see that would help address the problem you’re describing?
Frances: I think the insurance industry has made a basic error by requiring a diagnosis for reimbursement on the first visit. It would be much better if there were a period of time in which the physician would get paid for evaluating patients without diagnosing them. Of course, the insurance companies don’t want doctors seeing patients for nonmedical problems. While that may seem like a potentially wasteful procedure, the current system is costlier in the long run. Once a person gets a diagnosis, it tends to stick for life. It would be a lot cheaper in the long run to support more detailed evaluations than to have premature diagnoses that often lead to a lifetime of unnecessary treatment.
The placebo response rate for most mild problems in life is 50 percent or more. In other words, if people see a doctor on a particularly bad day of their lives and the doctor says they’re depressed, or have an anxiety disorder, and starts them on a medication, half of those people will have a positive response to that visit—but we don’t know what in particular got them better. Although patients may think the pill made them better, a lifetime of treatment can easily be based on a placebo effect.
You’re a big opponent of drug company advertising. But this is America! Shouldn’t we let the free market do its thing?
Frances: I believe that the single biggest improvement we can make in the mental health system is to place more controls on drug company advertising. Uniformly, when the diagnostic system gets loosened, the major economic effect is a dramatic increase in the sales of medications. And with the dramatic increase in sales of medications comes a tightening on the psychotherapy benefit. So as the diagnostic system gets looser, it paradoxically makes it harder for people to get psychotherapy because so much money gets funneled into the drug companies.
In contrast, there’s no psychotherapy advertising industry. Psychotherapists are mom-and-pop operations. There’s no budget for advertising the value of psychotherapy. The drug companies are spending $70 billion advertising their products. In the battle for the airwaves, the drug companies are in absolute control, in spite of the fact that psychotherapy for mild to moderate conditions is just as effective as drug treatment, with longer effects. So it’s probably more cost effective.