Who decides whether you’re clinically depressed or anxious, suffering from schizophrenia or living with a trauma-related disorder? In the UK, GPs diagnose milder forms of depression and anxiety but psychiatrists make the call when it comes to more severe and protracted forms of mental ill health. In the US, the handbook that sets out the criteria for diagnosis is the Diagnostic and Statistical Manual of Mental Disorders, now in its fifth incarnation (DSM-5). In Europe, the broadly similar WHO International Classification of Diseases (ICD) is more commonly used.
But a new study from the University of Liverpool has analysed five key chapters of the DSM-5 on schizophrenia, bipolar disorder, and depressive, anxiety and trauma-related disorders and found so much scope for variation that the authors question whether diagnosing distinct mental health disorders such as schizophrenia is valid or helpful at all.
The authors point out that psychiatric diagnoses all use different decision-making rules, symptoms such as agitation are common to several diagnostic labels, diagnoses don’t reflect the role of trauma or adverse events, and, most importantly perhaps, a diagnosis says little about an individual person and which treatment approach may be helpful. The current system of diagnostic labelling may represent “a disingenuous categorical system”.
Lead researcher Dr Kate Allsopp says: “Although diagnostic labels create the illusion of an explanation they are scientifically meaningless and can create stigma and prejudice.” She hopes these findings will encourage mental health professionals to think beyond diagnoses and consider other explanations of mental distress, such as trauma and other adverse life experiences. And her colleague and co-author, Prof Peter Kinderman, adds: “This study provides yet more evidence that the biomedical diagnostic approach in psychiatry is not fit for purpose. Diagnoses frequently and uncritically reported as ‘real illnesses’ are in fact made on the basis of internally inconsistent, confused and contradictory patterns of largely arbitrary criteria. The diagnostic system wrongly assumes that all distress results from disorder, and relies heavily on subjective judgments about what is normal.”
So are specific diagnoses for mental health conditions defunct? Or do people in the depths of mental distress find some relief in having a concrete label and plausible reason for their anguish? Is getting a diagnosis stigmatising and reductive? Or does it provide a framework for treatment, protection in law against discrimination and a requirement for authorities to provide support?
Psychiatrist Prof Simon Wessely says that this latest salvo is part of a long-standing dispute between academics who are “strongly against the diagnoses we use and the treatments we use and don’t give the impression of being too keen on psychiatry and psychiatrists in general”. Diagnosis in psychiatry is always a work in progress; it’s not like diagnosing thyroid disease on the basis of a blood test. “But a diagnosis is just the start of ongoing encounters (between patients and psychiatrists) and doesn’t preclude a much more complex formulation of their individual needs.”
Wessely says the DSM-5 is used in the US because the insurance companies won’t pay up without a diagnostic category. In the UK, where 90% of mental health problems are seen by GPs and where you don’t need a label to qualify for treatment, the DSM-5 is rarely used. As a GP, I must say that I’ve never seen a copy, let alone used one.
But it’s quite a leap from pointing out the inconsistencies and limitations of a handbook to rejecting the whole notion of diagnosis. Wessely says that diagnosis is essential to the practice of medicine; “anorexia is not the same as schizophrenia” and different conditions require different therapeutic approaches. Clinical trials to identify and test new treatments would be impossible without some standardisation of diagnostic criteria. “In 50 years’ time, we’ll be using different criteria, but there will still be criteria,” he predicts.
Allsopp and Kinderman have previously written in the Lancet that instead of recording a diagnosis of, say, “moderate personality disorder”, clinicians could record the series of adverse events and mental health difficulties that the person is experiencing, such as personal history of sexual abuse, partner violence and low income which lead (understandably) to anger, depressed mood and self-injury. This avoids “unnecessary pathologisation” and could lead to better clinical services.
Back in my day job as a GP, I wonder what purpose is served by this over-heated “debate” about diagnosis v non-diagnostic formulations. At least half of the people I see have a primary mental health problem and there’s a psychological component to every single interaction that I have with patients, even if they’ve come in with a physical problem. Sometimes a label is useful, sometimes it isn’t. There’s no debate about whether or not it’s OK to say that your abdominal pain is caused by gallstones; obviously the diagnosis is just a starting point in formulating a plan of action that is acceptable to patient and doctor alike. Diagnosing schizophrenia should be like gallstones: a starting point for action to alleviate suffering and improve wellbeing.
But I get what Kinderman says too: a diagnosis is a one-word intro, it’s not the story. Doctors, patients and families can all become distracted by the label and forget what’s inside. People are never “a diabetic”, “a schizophrenic” or “a manic depressive”. Everyone knows that but it’s easy to forget. Kinderman et al may overstate their case, but it’s a useful corrective to our over-medicalised approach.