DR. RIOLO WEIGHS IN
If Dr Moffic wrote his letter regarding limiting who can make a DSM diagnosis 10 or even 5 years ago rather than this month, I would have led the ranks of many of my non-physician mental health providers in protest. For years, I fought for the right for us to use the DSM, obtain third party reimbursement, and practice independent of the medical profession.
However, I am now not quite so sure. The problem is that—since my retirement from clinical practice—I have become a consumer advocate and have found numerous problems in the way DSM is used, which harms patients in the long run. Many mental health professionals I have encountered do not use the DSM as it was intended and often don’t believe it is reliable, valid, or useful. They may have a point—however, despite their skepticism regarding DSM’s accuracy or utility, they continue to diagnose people, giving them labels which may or may not fit. Such incorrect diagnoses can be harmful in many ways.
Some providers are quietly open in admitting that they use the DSM, only because it is the only way to get third party insurance to pay for their services . Some admit to picking a diagnosis without scrupulously seeing if the criteria are present, while others will “up-code” or increase the severity of the diagnosis simply to get insurance companies to pay for more treatment.
Now, of course, psychiatrists are not necessarily immune from these practices. However, when one considers mental health practitioners, all claiming the right to diagnose mental illness, reducing the numbers who legitimately are able do so will be a safeguard to patients and help minimize abuse.
READER RESPONSE, BY JARED DeFIFE, PhD:
I hope to convey my response to your blog with professionalism and a great deal of respect for your ideas, credentials, and body of work in the field. At the same time, I am astounded, disappointed, and, dare I say, to a significant degree, offended by your remarks.
My reaction is primarily to your suggestion that a Cautionary Statement be written along these lines: "This diagnostic manual is derived mainly from the expertise of psychiatrists. Given the importance of general medical knowledge in making an accurate psychiatric diagnosis, the appropriate use of this manual is for psychiatrists to certify the official diagnosis. The exception would be those who are specially trained and supervised by the American Board of Psychiatry and Neurology."
Indeed, the DSM is produced by the American Psychiatric Association. At the same time, such a statement strikes me as flagrantly dismissive and neglectful in recognition of the significant contributions of psychologists (among other disciplines) to the research and criteria upon which the DSM is built, not to mention the multidisciplinary approach to mental health care in the community. The DSM is a multidisciplinary creation, and should be utilized in that same spirit.
As a personality researcher, I will speak to the Axis II diagnostic system, although the contributions of psychologists to Axis I are just as intricately linked to the manual. The proposed criteria for personality disorders (which I hope the classification of personality disorders is recognized as useful to the mental health field) are not only based on a body of research conducted by psychologists in coordination with psychiatrists, but are in fact actually written by psychologists (some of whom I work with).
I would never suggest that a diagnostic system for mental illness be used without advanced clinical expertise. At the same time, I am nearly speechless at the level of disrespect to a large body of people who have contributed extraordinary efforts and lifetime career achievements to this field. It is my profound hope that you would reconsider if not just your position on this issue, but at least your presentation of them to the greater community
Jared DeFife, PhD
Departmen tof Psychology
Dr Moffic replies to Dr DeFife:
I appreciate your feedback and am not surprised by it. In fact, I would expect somebody from psychology or social work to protest strongly what I have said.
I'll try to justify my reason for doing this a bit more, given the space limitations of the blog. Indeed, I have always worked in, or led, multidisciplinary clinics and have had some of the experiences of Dr Huffine, as he described in his comments. In the book I co-edited, A Clinician's Manual on Mental Health Care: A Multidisciplinary Approach, I expressed concerns that linger today, and the following are some of them:
1. The diagnostic skills of many leave a lot to be desired, and the current DSM—both the "cookbook" approach and the lack of criteria for the diagnostician—are the major problems. Medical contributions are more often missed by non-psychiatrists, though I think primary care physicians are inadequately equipped to use DSM for other reasons.
2. Psychiatrists are losing our identity.
3. The manual is published by our APA; it is not a multidisciplinary product, although it could be. For that matter, psychologists could put out their own diagnostic manual. It might be interesting to compare both. Certainly, a greater usage of psychological testing and psychological research criteria might produce a different sort of manual.
4. Virtually all the heads of the committees working on the different diagnoses for DSM-V are psychiatrists, though psychologists do contribute.
5. Part of the motivation for leaving the criteria so open for being a diagnostician are financial; DSM manuals have made the APA a lot of money.
6. How would you operationalize "advanced clinical expertise"?
It's striking to me that, at least as far as I know, there have been no studies comparing the diagnostic skills of the different disciplines. I had wanted to do so years ago when I began to lead a large capitated system, but was overruled for financial reasons. Wouldn't this be a good time for some large organization to conduct such a study?