It begins with misdiagnosis. When it comes to mental health maladies, we — as a collective group of clinicians and practitioners regardless of our specific discipline — do occasionally get it wrong. Physical medicine of course, gets it wrong too, but this branch of medical treatment is aided by technology to confirm or deny diagnosis in ways unavailable to us on the mental health side. For example, to better determine a diagnosis of depression that we clinically believe a particular client is experiencing, where in the brain would we conduct a scan? The answer to this question is not yet even on the horizon.
Recurrent misdiagnosis then morphs into overdiagnosis of certain disorders — the three most prevalent of which are major depression, bipolar II, and adult ADHD. For the sake of clarity, all three of these clinical conditions are underdiagnosed as well, but have also been advanced toward diagnostic inflation.
So what’s going wrong here? Part of the problem is not utilizing the DSM-5 criteria at all, or misinterpreting its criteria. Also, the criteria are difficult to memorize and often overlap from one disorder to another, making differentiation more difficult. Another reason is that increasingly, clinicians of all stripes are more rushed, elevating the possibility that key elements pursuant to diagnostic accuracy are missed.
Major Depression
Close to 50 percent of patients diagnosed with depression by their primary care physician, don’t meet criteria for this diagnosis. I’ve consulted with hundreds of PCPs over my many years in practice, and most are unfamiliar with the DSM and aren’t inclined to employ it as a resource. Instead they rely on patient self-report and clinical observation. But even if they were to use the criteria, the DSM-5 sets a pretty narrow and confining threshold for major depressive disorder. Here’s what I mean: the criteria specify that 5 of 9 symptoms have to have been present during the same 2-week period. Why is there a 2-week period in the first place, and how can we clinicians observe for this? The reality is that depression runs along a continuum, and we make diagnostic decisions at some point along that continuum, but where we make those decisions is not grounded in anything “evidence-based.” Many depressions resolve on their own after a few weeks, so why even put it on a 2-week period in the first place?
Another issue is that the DSM combines both mild and severe cases of depression under the umbrella of “major depressive disorder,” yet there is good reason to separate the two. This is because those who seek treatment through primary care – which is most often the case – are prescribed antidepressants regardless of whether the depression is mild or severe. Yet the efficacy of antidepressants is unquestioned only in cases of severe depression, whereas in mild cases they’re hardly better than placebo. Prescribing antidepressants for mild cases are simply unwarranted – void of any evidence for doing so. I’ve long said that antidepressants are the antibiotics of physical medicine from a prescribing standpoint.
Bipolar Disorder
In this instance, the overdiagnosis problem is not with classic presentations of Bipolar I. The mania exhibited in a textbook case of Bipolar I should be unmistakable, no trained mental health clinician should miss it, but the criteria for bipolar II aren’t necessarily clearly discernable, particularly hypomania. But people who screen positive on the MDQ (Mood Disorder Questionnaire) may just as likely have borderline personality disorder as they do bipolar, because a prominent feature of borderline is mood swings. This factor can pose a confused picture for many clinicians.
Adult ADHD
As you may well remember, it was once thought that ADHD symptomatology didn’t extend into adulthood, because children “grew out of it.” That was never really true, but we learn as we go, right? But no more, today the childhood-onset requirement is often just simply ignored in practice, and adults are presenting to us with symptoms of ADHD, with no evidence whatsoever of having had the disorder in childhood, claiming that their symptoms are “new-onset.” However, in very credible studies, most patients with “adult-onset” ADHD have a history of mood, conduct, anxiety, or substance use disorders that better explain their “adult” symptoms. Conclusion: in adults with no paper trail, so to speak, of symptoms dating back to early childhood or mid-adolescent years, why call it ADHD at all? As a result of ADHD diagnostic inflation, stimulant use has experienced a ten-fold increase compared to 20 years ago.
A couple of months ago a gentleman named “Martin” presented to my office claiming he had adult-onset ADHD. After conducting a thorough assessment, I told him he didn’t, and I was as certain of this as I am that I don’t have, and have never had, ADHD. He was outraged. I asked him if were possible that he’d come to identify with ADHD as part of a way that he currently sees himself. Interestingly, he said yes. Over the next couple of sessions, he divulged that just before coming to me, he had received a promotion at work that made him very anxious – believing that he wasn’t up to the new tasks. We worked together on this for 3 additional weeks. He successfully reframed his thinking, regained confidence in his capabilities, adapted to the new responsibilities and is thriving in the position. Good for “Martin.”
Be prepared for some people to express disbelief and become angry when hearing that they don’t have a particular psychiatric disorder or that their presenting problems don’t require medication.
Identification with the sick role can be rather powerful for some.
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.