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CLPsych has an interesting post on a study that found that among patients with Medicaid in Oregon who were prescribed antipsychotic medication, only a minority actually had a diagnosis of a psychotic disorder or bipolar disorder (15% vs 27%). The rest had diagnoses of depression, anxiety, or PTSD. I think I’d like to add to this the fact disorders are often diagnosed for the medication as I’ve written about before (On Diagnosis, Symptoms, and Medication; Diagnosing for the Medication). In other words, there are times when the diagnosis is given in order to justify the medication that is prescribed. This doesn’t happen all the time, but it does happen.
http://clinpsyc.blogspot.com/2008/09/atypical-antipsychotics-for-all-oregon.html
There is one thing that is virtually guaranteed….if you go to a mental health center, you will probably see a psychiatrist for medication. In my private practice probably 10-15% of my patients take medication. When I worked at a mental health center, it was closer to 90-95%. What accounts for this vast difference?
1. In a mental health center, the assumption is that patients will be referred for medication. It is the basic assumption. There is also a financial insentive. Mental health centers get paid more for the services of psychiatrists than therapists or psychologists. Funding is ALWAYS a very important issue in mental health centers.
2. In private practice, most of the responsibility falls on me (instead of a system). I explain the options to my patients, that they may be interested to try medication, but as long as the problems do not represent a serious risk (loss of job, harm to self, ect…), medications may not be warranted. Although it is a very individual decision. So far, every patient I have seen that comes to me first without being on medication, does not start on medication. The majority of those who are intially on medication are able to get off of the medication eventually.
3. Expectations… All shrinks are human beings. They have different expectations of their patients. They have different expectations about what is possible with psychotherapy. They have different levels of knowledge. They have different levels of comfort. They have different views of human nature. These factors are critically important in how psychotherapy unfolds with a patient.
4. What seems to be much more important than diagnosis is a willingness on the part of the patient to keep coming in to treatment, to think about what is discussed in session between sessions, and to have a genuine motivation to make changes. Now, certain diagnoses sometimes make these things less likely (severe schizophrenia, severe bipolar disorder, or severe personality disorders for example). However, if these things are present (the positive factors), the diagnosis is much less significant.
5. Psychiatrists often “diagnose for the medication.” The FDA approves drugs for specific diagnoses. Nobody likes to be sued. So, psychiatrists often bend or distort the diagnosis in order to justify the medication they want to try. See my previous post, Diagnosing for the Medication.
So, while the desired medication is more important than symptoms at times for psychiatrists, for some therapists and psychologists, what is more important is a willingness to seriously consider what is talked about in-session, a willingness to follow through with recommendations, and a willingness to believe that psychotherapy may be helpful. To a great extent, the actual symptoms a person has are less important than these factors.
Now, I’ve seen some folks with the most rigid belief systems (such as blantant paranoia and fantasies of revenge), that are only addressable on a spritual basis. Absolutely nothing else works at all–believe me, I’ve tried. But, when they consider their thoughts in the context of their belief in God, they are willing to acknowledge the distortion and errors in their thinking. There are times when a person’s difficulties can be addressed in nothing other than a spiritual realm.
When I worked at a mental health center, I often found myself scratching my head as to the diagnosis that was given to a patient by a psychiatrist. I had diagnosed one individual with an Adustment Disorder, which is anxiety and depressed mood related to a difficult situation in life. The psychiatrist diagnosed, schizoprenia, paranoid type. I was left utterly scratching my head as to why the psychiatrist had diagnosed schizophrenia, whereas I diagnosed an adjustment disorder. After looking at the medications that were prescribed, I found the reason, Abilify….an antipsychotic medication. Even though this patient did not meet the diagnostic criteria for Major Depression, let alone schizophrenia, the psychiatrist wanted to try Abilify; therefore diagnosed schizophrenia. That was the only conclusion I could come to. I saw this on numerous occasions. The diagnosis didn’t fit, and the medication was an antipsychotic. So, the diagnosis would be Bipolar Disorder, or a psychotic disorder.
As the Last Psychiatrist noted:
“You might argue the diagnosis leads us to the treatment, but in most cases, meds are used across all diagnoses, and more often than not a diagnosis is created to justify the medication.”
I had one patient, who for 14 years, was diagnosed with depressive disorder, NOS and personality disorder, NOS, until the psychiatrist wanted to try an antipsychotic. Suddenly, the diagnosis became schizoaffective disorder.
You may think that the diagnosis doesn’t have implications for treatment, but it does. If you are psychotic, you are not responsible for your behavior. The patient diagnosed as schizoaffective, was seen as psychotic by his wife and his psychiatrist. Therefore, he was not responsible for his Borderline, manipulative, aggressive and passive aggressive behaviors. This was the way the psychiatrist and his wife saw his behavior. I did not see the behavior this way because I was his psychologist. So, this puts me in a difficult position. I see him as responsible for the choices he makes, but the psychiatrist and wife see him as “mentally ill” when he engages in unsual behavior. I have to set limits and tell him that I would “find him a therapist who expects less” of him when the psychiatrist and husband justifies his behavior.
You see, I also do evaluations related to “sanity” and “fitness to stand trial.” This particular individual would likely be seen as incompetent and insane for his inappropriate behavior by the psychiatrist, but would be seen as perfectly sane by me who sees him as having a different diagnosis. You can say the diagnosis has no implications, but it really does in terms of personal responsibility and therapeutic issues with respect to psychotherapy.
So, this is one reason that I see diagnostic accuracy as being an important issue for treatment. My personality testing, interviews, and observations yield a diagnosis of a primary personality disorder, whereas, the psychiatrist’s desire to prescribe an antipsychotic yields a diagnosis of a psychotic disorder. So, it comes down to a situation where the patient has to decide to believe a professional who believes that they have control over their decisions versus a professional who believes they have no control or responsibility for their decisions. So far, when faced with this decision, my patients go with me, who believes that they have control and responsibility for their decisions. When they are legitimately psychotic, that’s one thing, when they are not, that is another. The diagnosis has real world implications in terms of personal responsibility and psychological treatment. Fortunately for most patients, when push comes to shove, they would rather believe that they are responsible for their behavior and have a desire to make efforts towards changing their maladaptive behavior. Unless they truly are psychotic….then the issue of personal responsibility has less meaning to them, because their reality contact is impaired.
So generally, when one of my patients is seeing a psychiatrist, the diagnosis has real world implications. And when they are not, the diagnosis has less meaning. Only the individual factors that contribute to the person’s difficulties are relevant. When the psychiatrist renders a diagnosis, then there are real world implications that affect the patient and their family.
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