During the past month, the news has made the public aware of what mental health professionals have long been aware: the diagnosis of mental disorders is inexact, and treatment often proceeds without a known etiology. In the real world of patient care, clinicians measure success in terms of empirical progress; has my patient improved, plateaued, or worsened? The answer is derived by objective observation and the patient’s self-reporting. But even objective observation contains an element of uncertainty.
Insurance and Pharmaceutical Influences in Diagnosis
The International Classification of Diseases’ diagnostic codes govern the reimbursement of all care. Insurance companies require ICD-9 (and 10) codes from the DSM-IV-TR before they will authorize the evaluation or treatment of any mental disorder. Psychologists and psychiatrists must choose a code that most closely matches the symptoms. A depressive episode is coded and further refined by duration, intensity of symptoms, single episode versus recurrent, and weighed against alternative diagnoses. The accuracy of diagnosis is largely dependent upon honest and complete disclosure from the patient.
But diagnoses fall in and out of favor; in favor they are overly utilized and can result in excessive labeling. Such labels facilitate insurance reimbursement and garner the attention of pharmaceutical companies. Recall when Ritalin was the only drug for ADHD replete with side effects and adverse reactions. Pharmaceutical companies took notice and funded extensive studies and trials that resulted in more targeted drug regimens. More funding and medication options in turn resulted in more ADHD diagnoses. And so on.
The DSM-IV-TR vs the DSM-V
Since its inception in 1952 and throughout its revisions, the accuracy and validity of the Diagnostic Statistical Manual (DSM) for classification of psychological symptoms has been challenged. Dr. Allen J. Frances, professor emeritus at Duke University, chaired the DSM-IV-TR task force (year 2000 Text Revision) and publicly objects to the impending release of the DSM-V.
An active blogger for the “Huffington Post,” he urges clinicians to ignore it’s changes altogether, asserting that the new version is vaguer than ever and will lead to labeling healthy individuals with its lowered threshold for criteria. In one of his blogs he states that the DSM-V is “offering its untested new diagnoses that will mislabel millions of the worried well as mentally ill.” Parents of autistic children have the opposite concern, that their child will no longer fit in that diagnostic category and be denied access to medication and therapy.
Frances states that the DSM-V offers no leeway in differentiating, for instance, alcohol addiction versus dependence versus social use. The manual’s authors counter that early recognition will result in early intervention, but many practicing clinicians fear that the endpoint will be over-diagnosis that defies normal variations in behavior.
The National Institute of Mental Health (NIMH)
On July 3, 1946, President Harry Truman signed the National Mental Health Act, which called for the establishment of a National Institute of Mental Health. The process of diagnosing without etiology is the fundamental distinction between the DSM’s function and the conceptual model now proposed by the National Institute of Mental Health.
NIMH rejects all DSM versions and is devoting its considerable financial and scientific resources to the premise that all psychological conditions are biologic or chemical in nature, originating in specific regions of the brain, and thus amenable to medical intervention. The stakes are significant for insurance reimbursement, financial grants for research, pharmaceutical financing, and, one hopes, the well-being of patients.
Citing the difficulty in properly diagnosing mental health disorders when forced to choose an ICD code, in 2008 NIMH implemented its Strategic Plan, a diagnostic process using Research Domain Criteria.
This plan utilizes a matrix of Constructs (rows) that are grouped into five Domains of Functioning, and seven classes of Variables (columns) with an eighth column for paradigms. The goal is to classify mental disorders along a continuum of biologic and genetic markers, neurological circuitry and specific regions of the brain. The attempt is not to diagnose a mental disorder by looking at the overall patient presentation, but to find one symptom that is present across a variety of disorders, eventually pinpointing the physical location of the symptom. This intersection would identify the origins of disease, and science (psychopharmacology) would intervene to avert mental disorder. This theory ignores the empirical research on the greater efficacy of "talking therapies" either alone or in combination with psychopharmacology, and even NIMH agrees that this lengthy research offers no immediate relief to patients.
Opponents to RDoc fear that severe illness (schizophrenia, bipolar disorder) may go untreated if the affected individual does not express a specific gene. They question the validity of research that is conducted solely in laboratories and does not involve practitioners in the field. NIMH counters that RDoc is an open document for which they have sought input from the medical community.
How do you think NIMH’s decision will affect psychiatric nursing practice? Leave a comment below, I’d love to hear from you!
(Disclosure: I have worked fulltime for 20 years and now part time in a clinical psychological practice. As a nurse and patient advocate interfacing with physicians, nurse case managers and attorneys, dealing with insurance reimbursement was once 5 percent of one day a week; now it is closer to 20 percent of every day. Personal experience flavors objectivity in all of us.)