Psychiatric Over-Diagnosing

Human nature being what it is, the prevalence of any psychiatric diagnosis will rise artificially whenever it is a gatekeeper to something valuable.  In a simpler world, psychiatric diagnosis was once based only on perceived clinical need.  But now that it has gained powerful (and unwelcome) influence on many administrative and financial decisions, these decisions have also reciprocally obtained a powerful influence on the rates of diagnosis.  Diagnostic inflation is promoted whenever a physician provides an “up-diagnosis” to help a patient gain access to something valuable—like disability benefits or school services.  If autism, ADHD, or pediatric bipolar disorder is a prerequisite to being admitted to a small class with lots of individual attention, equivocal cases get shoehorned into these categories, and soon an epidemic is born.

In like fashion, “mental disorder” increases whenever there is a high unemployment.  Some of the people laid off will get a new diagnosis because they have developed symptoms, others because it will make them eligible for disability.  Because veterans’ benefits require a diagnosis of PTSD, PTSD gets over-diagnosed.  There is a paradox—trying to help by providing a diagnosis may wind up hurting.  Many returning vets from Iraq and Afghanistan are having trouble landing jobs because of the stigma associated with their diagnosis of PTSD.  And over-diagnosis distorts allocations across the system, reducing resources and benefits for those who most need them.

The most senseless drive of diagnostic inflation is the way medical insurance works in the United States.  To get paid, the doctor must make an approved diagnosis.  This is intended to prevent frivolous visits.  But the unintended effect is just the opposite of prudent cost control.  A premature rush to a reimbursable psychiatric diagnosis often results in unnecessary, potentially harmful, and often costly treatment for problems that would have disappeared on their own.  It would be a lot cheaper and better for insurance to reimburse the doctor for watchful waiting and counseling, rewarding him for not jumping to diagnostic conclusions that are very costly in the long run.  This perfectly sensible solution is the policy in the rest of the world.

Allen Frances, M.D, "Saving Normal," pp.84-85