Is it time to reconsider traditional ideas around mental health diagnosing?

Mental health specialists often diagnose patients with more than one condition. For example, someone might be assigned both major depression and general anxiety disorder. Or, she might meet criteria for both substance abuse issues and bipolar disorder.

When this happens, the two diagnoses are called comorbid. This generally means that the clinician believes both are occurring at the same time. Or, at least that the diagnosis meets the criteria found in the DSM-5, the diagnostic manual used to guide assignment of mental health disorders.

Sometimes the symptoms of the disorders seem to overlap frequently, and often occur together. For example, up to 70% of people diagnosed with major depression also meet criteria for one or more anxiety disorders.

Inaccurate Mental Health Diagnosing

With such high occurrences of comorbidity in certain disorders, many believe this is more than coincidental. Perhaps having depression, for example, also means having some anxiety.

Guidelines for diagnosing have discouraged this type of flexible thinking. Clinicians are sometimes cornered into choosing diagnoses based on what the DSM-5, and therefore insurance companies, will recognize.

This rigid system may have interfered with our understanding of mental health conditions and leads to many challenges for mental health diagnosing. For many patients, anxiety could be a normal part of feeling depressed, rather than a sign of a second disorder. The pressure to separate out diagnoses could have led to a bias that prevented this broader understanding.

In other cases, conditions may change over time, or may generalize into other symptoms. If someone has severe anxiety that prevents him from leaving home, he could develop depression symptoms. Likewise, having mood issues could prevent one from socializing, eventually leading to anxiety around others.

Increased symptoms could also represent a worsening of mental struggles over time. As issues go unaddressed, or stressors increase, new symptoms may present.

Symptoms can also mimic each other. For example, symptoms of attention-deficit/hyperactivity disorder (ADHD) could reflect attention tendencies, or could reflect an unknown stress on a child or a major life disruption.

Likewise, physical conditions can mimic mental health issues. Brain injuries, hormonal imbalances, increased stress, cancer, and other conditions sometimes generate symptoms commonly associated with mental illness. These conditions could cause temporary mood problems, psychosis, anxiety, or depression.

Psychiatric clinicians are technically trained to consider such medical conditions. However, the culture of mental health treatment encourages clinicians to look for boxes to put symptoms into quickly. Recommended referrals and assessments are not always completed.

Furthermore, cultural factors may lead patients to believe their symptoms are only psychiatric. They may even be put on psychiatric medications by psychiatrists or general physicians before underlying causes are examined.

Broader Problems with Comorbidity 

This issue of fragmented mental health diagnosing is one reason the comorbidity concept is a problem. One specialist describes the bias this practice can create:

“Artificially splitting a complex clinical condition into several pieces may prevent a holistic approach to the individual, encouraging unwarranted polypharmacy, and may represent a new source of diagnostic unreliability because clinicians may focus their attention on one or other of the different ‘pieces’, especially in those clinical contexts in which coding in those clinical contexts in which coding of only one diagnosis is allowed.”

The general idea of focusing more on labels and less on the whole person is a problem in and of itself. Because insurance payments are based on this process of identifying a problem quickly, treatments may be based on inaccurate information.

Therapists are typically expected to identify a working diagnosis within a first meeting with a patient. While ideally these diagnoses are updated later, that often is not the case.

In community settings, patients often see one clinician initially and then are transferred to another. Since an assessment and diagnosis have already been completed, the new clinician may not question it.

Inaccurate diagnoses are problematic, because the therapist may be helping with the wrong issue. For example, recommended treatment for bipolar depression is different than that for major depression. The same symptoms could also be due to a misdiagnosed hormonal issue, part of a trauma reaction, grief, or a postpartum response.

Or, it could be any combination of these things. Zooming in on one particular cause can blind both the mental health specialist and the patient to other possibilities. The patient may be in need of a medical intervention, or could already be on a medication that’s causing the problem.

What are Alternatives to Traditional Diagnosing?

Clinicians often begin with screens or assessments that follow only a brief conversation with a patient. Simply choosing particular screens could bias a therapist’s initial understanding of someone’s condition.

This can lead to a road of more and more fragmentation. Rather than working within the limited diagnostic system, it is more productive to begin with the whole person. A more holistic assessment can help individuals as well as organizations and professionals better understand an overall state of functioning.

The Mental Health Quotient (MHQ) examines the overall wellbeing of an individual, rather than beginning with such fragmented pieces. You can learn more about the assessment here, or take it for yourself. Rather than identifying isolated pieces, this framework looks at the integrated self.