Synopsis: A correct psychiatric diagnosis is critical to depression and anxiety getting better faster. This article includes a story about a person who had an incorrect psychiatric diagnosis throughout his lifetime, showing how the wrong diagnosis can lead to the wrong treatment. A thorough approach is one of the best means of obtaining a correct diagnosis and getting the right treatment.
BY LEN LANTZ, MD, author of unJoy / 1.1.2020; No. 1 / 6 min read
Disclaimer: Yes, I am a physician, but I’m not your doctor and this article does not create a doctor-patient relationship. This article is for educational purposes and should not be seen as medical advice. You should consult with your physician before you rely on this information. This post also contains affiliate links. Please click this LINK for the full disclaimer.
What is Psychiatry?
Psychiatry is one of the most important specialties in the field of medicine. 1 in 5 people develops a mental illness in their lifetime. As I’m a physician, I have learned that getting to an accurate psychiatric diagnosis for a patient is different and far more challenging in some cases, than other medical diagnoses. Most diagnoses in modern medicine are made based on something that can be measured (such as blood pressure) or observed (such as a tumor).
Can’t you just run a brain scan, genetic test or laboratory blood screen to figure out what is wrong?
I cannot put an “emotional thermometer” up to someone’s head and say, “It looks like you have 47% depression…here’s a prescription for Sad-icillin…please make sure to take all 10 days’ worth of the prescription.” Psychiatric diagnoses are basically patterns. The patterns are collections of thoughts, behaviors and emotions. If symptoms fit a pattern and they cause problems, we give them a name. That’s it. I hope that someday we will have more scientific ways to diagnose mental illness. It would be great if we could do an EEG (a test which measures the brain’s electrical activity), a cheek swab to look at genetics and possibly a blood draw to look at someone’s hormones to see what type of mental health condition they have.
Either an undiscovered diagnosis or an inaccurate one can have serious consequences. Here’s an example (by the way, some details have been changed in this story to protect patient privacy):
The guy who hated psychiatrists
An older gentleman came to me once asking for help. He struggled with severe depression and suicidality since age 4. He had seen over a dozen psychiatrists, tried over a dozen antidepressant medications, electroconvulsive therapy (ECT), talk therapy, intense exercise and had spent up to $10,000 each year on vitamins. So, when he asked me for help, I was not surprised to hear that he hated modern medicine and psychiatrists. Something that interfered with a correct diagnosis is that he could not provide me the history that he needed for me to understand what his illness was. As a psychiatrist, I frequently need to hear from not just the patient, but also from family members and other people in the person’s life to get enough information to be confident in a diagnosis.
Wrong diagnosis = wrong treatment
This 74-year-old gentleman had been sick and tired of his 70 years of depression and he asked me for help because his depression became severe. I asked if I could speak with his spouse to see what she observed. It turned out that this man did not have major depression. All of the medications he previously was prescribed either didn’t help or caused his depression to worsen. Why? Because of the following equation: wrong diagnosis = wrong treatment. He had bipolar II disorder, which is similar to severe recurrent depression, but is distinctly different from major depression especially in regards to which medications work and which do not. I started him on one of the best-known medications for bipolar II disorder, Lamictal. Thankfully, he tolerated the medication well and got to remission of his depression for the first time in his life with one medication. Can you imagine? Can you imagine being depressed for 70 years with no relief? After he was free of depression, he said, “You have no idea what it feels like to not be depressed!”
Can’t you just enter all this information into a computer and have it spit out the correct answer?
Well, I think computers can be helpful in terms of screening. There are different quizzes/tests you can take that can let you know of your likelihood of a mental health condition, but a computer cannot relate to you as a person can. A computer cannot decipher the context of what you report to it. Dissociation (it’s like extreme daydreaming) or Obsessive-Compulsive Disorder can be mistaken for psychosis. Mania can be mistaken for schizophrenia. A sleep disorder can be mistaken for ADHD. How could a computer integrate your symptoms with the rest of your life story, gauge your reaction to questions, know what you look like or – not to be weird – what you smell like? Could a computer care enough to never give up until you have real answers and are fully better?
Why can’t you just treat my symptoms without having to label them with a diagnosis?
The 74-year-old guy in the story above had some very well-meaning psychiatrists who were treating the wrong mood illness, and you saw how it worked out for him. There are times in psychiatry when we will specifically go after a target symptom prior to having complete clarity about a person’s diagnosis. This tends to happen in emergency situations. For example, if someone showed up in the emergency room and was hallucinating (and it was proven that the hallucinations were not due to a medical condition), a person may receive a medication that helped both bipolar disorder and schizophrenia. Once the person’s diagnosis was clarified over time, their treatment could be tailored more specifically. There’s another problem that happens when you chase symptoms without understanding the larger picture of your diagnosis. That problem is polypharmacy (ending up on lots of medications rather than one or two) as you are going after symptoms without understanding the larger picture. Some psychiatric medications help one condition but may worsen another. For example, Wellbutrin can help depression, but in some cases, it can worsen anxiety.
By the way, this may seem like it goes against everything I’ve said above, but I’m not overly fixated on psychiatric diagnoses as labels. I strongly believe that accurate diagnoses lead to far better treatment. Yet, the diagnostic labels themselves can create stigma and block people from accessing care. If this is a concern that you have, please also consider reading my article “Psychiatric Stigma and a 2018 Game Changer.”
Can’t you just prove that someone has a certain diagnosis if they get better with treatment?
If Ritalin helps you stay awake and focus better, that does not prove that you have ADHD. Taking a medication to stop a hallucination does not prove that you have schizophrenia any more than taking a broad-spectrum antibiotic proves what type of bacteria has infected you. It would be helpful if we could reverse-diagnose by just finding medications that help, but it is very hard to conclude that just because the medication helps a person, the person has a given diagnosis.
Why does psychiatry stink at this?
Yes, I’m a psychiatrist but I’m not going to waste my time trying to defend the field as a whole. All of modern medicine fails people sometimes. For example, how good is western medicine at treating chronic pain? Doctors still have delays in diagnosing cancer. People are being told that they have asthma and are put on inhalers when really they have vocal cord dysfunction. The list goes on.
I will say that there appears to be a significantly wide spectrum of quality of psychiatric care out there. I think it also is important to point out that 90% of psychiatric care is provided by primary care providers, not psychiatrists. We have limited testing and measurements to classify mental illness and this makes quality treatment hard to standardize. I think approaching psychiatric illness in the same way we best approach medical illness – by being thorough – leads to greater accuracy of diagnosis and better treatment overall.
It’s not enough to prove what illness you have. Being thorough means checking for many types of illnesses, and proving what illnesses you don’t have.
Imagine the benefits of a correct psychiatric diagnosis
Get better faster as you start to get good care with real answers
Determine if a medical condition is causing anxiety or depression
Function at your peak ability with better concentration, energy and motivation
Improve your confidence
Pursue a new friendship or romantic relationship
Search out a better paying job
Go back to school to get trained in a new field
Change your living situation to have a better house or apartment
Final thoughts
As you can see, a correct psychiatric diagnosis matters a great deal, and getting it right can be challenging. Getting a psychiatric diagnosis wrong can lead to misery, wasted time and wasted money. You can set yourself up for success by seeking out a thorough and responsive psychiatrist who listens to you and does not give up until you have clear answers and achieve the goals you have set for yourself in treatment.
For further reading, check out:
My article “Psychiatric Stigma and a 2018 Game Changer”
My article “Finding a Good Psychiatrist”
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) by the APA (See Len’s Book Review)
Shrink Rap: Three Psychiatrists Explain Their Work by Drs. Miller, Hanson and Daviss (See Len’s Book Review)