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Diagnosis of Mental Illness
One of the great advances of medicine in the 20th century was the ability to accurately diagnose patients. It is something we take for granted today. Indeed, when the story is about a misdiagnosis, it makes the news “I was told I had bug bite, now it is Stage IV Cancer!” The New York Post loves these. We know if we can get a correct diagnosis, there can often be the correct treatment, or at least, we know there is no good treatment but the knowledge itself confers power. This works great for many medical issues. It does not work as well for mental illness.
What we diagnose today as mental illnesses are really syndromes. A syndrome is defined as a group of symptoms that consistently occur together, or a condition characterized by a set of associated symptoms. That’s not really the same as swab culture and finding out you have a strep throat infection. The symptoms of strep throat together are the syndrome. The definitive diagnosis comes from the test. Now, doctors don’t need the test, because, let’s face it, the symptoms of strep throat are pretty similar between people, but we can be sure.
In a mental illness, there is no blood test. There is no brain scan. There is no looking at neurotransmitter levels. There are symptoms. Oh, brain scans can show “features associated with …” and we know that increasing serotonin tends to increase mood. In some people. For some depressions. Maybe. Of course, the level in serotonin varies from person to person, and one person can have lower levels than another and not be depressed. What we have is a cluster of symptoms as a starting point. These get redefined. When I started out 30 years ago, doctors talked about “Agitated Depression.” This was when someone had low mood, lack of interest in pleasure, and often hopelessness but did not have depression’s normal lack of energy. This is not called “Agitated Depression” any longer. Today that is “Bipolar Mixed State.” Same group of symptoms, different syndrome.
When it comes to treatment, there is a wide range of various medications and therapy techniques. We can start with our diagnosis and try various things to see what works. It is not a science. Why is it that one antidepressant works for every member of a family but one? No one can really say. We have some gene testing that can point to how a person will be expected to metabolize some medications, but that is hyped more than it is actually effective. Finding the right medication is an art of trial and error. Of course, with therapy, there are many evidence-based practices that have a variety of proven effects. None of which will matter if the fit between the therapist and the client is poor (which is its own post, I think). Sometimes finding that right fit is also a challenge. And sometimes, the secondary benefits from the mental illness are “too good” to give up. Even when some people are miserable, they can hang on to the devil that they know.
This leaves us in a situation that is oddly modern and ancient. Before modern medicine, there was little good way to diagnose illness, and even when they got it, well, the treatments often ranged from ineffective to deadly. We are better off than that in mental health these days, but remember, lobotomies were a “Best Practice” in the mid-20th Century. Medical providers and therapists work with their clients to find the right approach. The client ends up doing the heavy lifting. Working on one’s mental health is not a passive experience.
As a therapist, I take mental health diagnoses by another provider as a starting point. Yes, I have to diagnose to make third-party payers (insurance) happy (though not for self-pay clients). Yes, it can be useful to know “This client has Bipolar I.” It will guide the questions I ask them about the past and inform the education I give them. It will not, however, be how I see them. They are not “Bipolar,” they have a “Bipolar disorder” and my job is to help them both learn to manage that illness and all the other parts of their life that are not reduced to meaningless due to a diagnosis.
I hope this rather high-level view helps. If you have specific questions, please ask them, and I am happy to respond.
Image from Jumpstory to which I have an account.
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This is a really great post. I agree with everything.
Bryan, thank you for an insightful post.
These are complicated and difficult patients. For example, I saw a patient recently whose mental illness was first diagnosed as a reactive depression. Treated with an antidepressant (I forget which one) which brought out suicidal thoughts. PTSD added to her diagnosis, antidepressant stopped and a new drug, Wellbutrin, started. This new drug induced mania and she became non-functional.
She finally saw a psychiatrist. New diagnosis, type 1 bipolar. While on Depakote treatment for this she developed visual hallucinations. New diagnosis, type 1 bipolar with OCD. Two more drugs started, Abilify and lithium.
She is now stable on triple drug therapy (having dropped the Wellbutrin) and counseling.
I have enormous admiration for the Docs who can sort out these suffering patients and bring them relief. In my lady’s case, it took almost a year. This is much harder than endocrinology; in my specialty, either you have too little of a hormone, too much of it, or just enough.
I have seen this all too often. My rule of thumb for clients is that your GP gets one crack at it, and if that does not work, find a specialist in the art.
I am a huge fan of Abilify and the other most modern atypical antipsychotics. They are poorly named. They do so much more for mood regulation than just being antipsychotics. Also a big fan of Lamictal. And, I am a fan of aggressive changes if you are not getting something in 6 weeks.
Amen. And it is more art than science, which of course is the point of your post.
This might enlighten, if you dare.
Your experience is with those who are able, conscientious and patient with their patients. There are those who are casual and removed: a professional friend experienced a profound life event, became radically depressed, saw a psychiatrist who prescribed a couple of drugs. And didn’t see her again for 6 months – over which time she too became non-functional, personally and professionally. Her husband urged following doc’s orders (give it time) but daughter got brave and intervened and she finally got sorted. But misery was obvious to friends. We friends thought: it’s not supposed to get terribly worse.
I’ll say the brain is mysterious and those who suffer its malfunction really do suffer. Those who want to help and can help make a real difference in people’s lives. It is very hard work, often without happy outcomes.
Thank you @bryangstephens for a kind and gentle essay.
Well, Franco, I have actually seen that before, so I don’t suppose I am going to spend another two hours of my life watching it again.
Let me hit that with two broad points:
1 I would think it is clear from my post above, that I do not see diagnosis of mental illness as the end all of treating a person. I have described it, as best, as a starting point, and treatment is best with both talk therapy and medication. I have been clear I see the use of medication as much art as it is science. I certainly think the ICD-10 Coding of snake bites down to what snake bit someone is silly. And, I am not thrilled with making everything into a “Disorder”.
2. What I can speak too is the actual use of mental health medications and how I have seen them work in real life. It is not about studies of people, but what we see in individuals. Doctors often use medications “off label” based on their experiences of what works and what does not work. This is not dictated by the pharmaceutical companies. It is called the practice of medicine. I have watched it make huge differences in the lives of my clients for 30 years.
I frankly find your posting a 2 hour youtube video with the phrase “This might enlighten, if you dare.” to be insulting. Despite my clear post not seeing diagnosing as the end all and be all, you come in acting as if I am part of some big conspiracy, if I know it or not. Either you are implying I am not acting in good faith, or you are implying I don’t know enough about the last 30 years of my work to know what I am talking about. I would ask, that if you want to have a discussion on how big pharma is conspiring with doctors make a post to that effect and I will be happy to join into that post and argue with you there.
I don’t want to get into that here. I want to be able to educate people on the difficulty and reality of mental health diagnosing, which I would have thought, based on this video, is something you would have supported, instead of turning this into an attack on, if not my profession, me prescribing peers.
You are welcome.
These is where I like a far more aggressive approach. If that were my client, I would help her find a new provider. “Here are some meds and I will see you in 6 months” is not good psychiatry. 6 weeks at the longest after the first appointment, if not a month.
Are you seeing more of it now than before?
From the parent post:
People should have been more skeptical of the simplistic “serotonin hypothesis” from the beginning – SSRIs raise serotonin levels quickly, but generally take at least 4 weeks to reduce depression.
I’ve done some fascinating reading recently that may explain why this is so. There appears to be a relationship between the serotonin systems and factors that enhance nerve growth, particularly the sinister-sounding brain-derived neurotrophic growth factor (BDNF). From the abstract to that article:
In plain english, SSRIs may actually work by enhancing the growth, development, and differentiation of the nerve pathways involved in depression. The fact that this takes time would explain why they take weeks to be effective.
That is a complex question. The foolish covid lockdowns have damaged all of us, some more than others. No one was unscarred. That event has most certainly increased depression, suicides and addictions. Also, seeking treatment has become far more acceptable to a lot of people.
And, Americans like their drugs. Many people would prefer to avoid the work of therapy and just take a pill. Drugs companies are happy to provide those pills. However, a combination of both is often the best approach.
I am glad you have the plain English!
It highlights how we just don’t know how these things work. Let’s look at the use of anticonvulsants for treatment of bi polar disorder. This was an accident. We still are sure how this works. But, thanks to it, a whole new way of treating the disorder opened up. I knew a man with a seizure disorder who was put on Lamictal and he reported his mood was “the best it has ever been in my life”. He does not meet the criteria for bipolar but this seemed to have helped him be more even tempered.
I have some errands to run but will be back later today
We read Ricochet for several distinct reasons. Our writers share beautiful things, like their life experiences, or poetry, art, or music. They also engage in emotional sharing: sorrows, fears; joys, hopefulness; compassion. Or the give their opinions on issues they feel strongly about, and arguments for those beliefs.
This article is written for one of the other reasons.
It is meant by an expert in a specialized discipline, one with–in addition–the temperament and literary skill of a teacher, to help us all to gain a deeper understanding of his area.
Brian, you did that very well, as can be seen by reading the comments!
Thanks.
It should not shock anyone to note that there are some truly terrible psychiatrists out there, as well as a fair number that are no better than mediocre. I recommend to patients that they not be afraid to shop around a bit, to find someone they are comfortable with.
Of course, you can go too far the other way. Many patients, especially the more seriously ill, have difficulty accepting the diagnosis, and tend to dismiss what any psychiatrist says, no matter.
Wonderful comment, Doc! Thx.
In 2019, Before The Covid, I had a travel nurse assignment at a pych hospital with an adolescent unit (among others). The census then ranged 10-16 patients. I believe it was capped at 16, by state law.
When I returned in 2021, During Covid, there were typically 25 patients there. I was told that, at the height, there were something like 35 kids jammed in that unit. The pandemic lockdowns really hit the kids hard.
I know someone who told his psychiatrist, I want Pristiq! and if you don’t give me Pristiq I’m going to a different psychiatrist!
He got his Pristiq, and then was shocked and awed by the price.
That’s interesting to read. Thirty years ago, a few years after my son was born, my obstetrician-gynecologist prescribed a hormone treatment for me rather than doing a hysterectomy, which many doctors would have done under the circumstances. I was elated–a pill and not surgery? Yay!
It was, and remains, the best year of my life. My migraines disappeared for a while, and it was a complete mood makeover. I had a general sense of well-being that I really had never experienced before. The best thing of all? Everyone who knew me kept asking me what I was doing because I looked “so beautiful.” I guess my face wasn’t quite as puffy–and until I started taking that drug, I hadn’t realized it was puffy.
That hormone treatment was an amazing experience. My recollection was that it was progesterone, but I was just scanning the internet for that information, and from what I’m seeing today, I’m not sure it was. The doctor described it to me thusly: I had some type of “hormone imbalance,” and this medication was “the opposite of estrogen.”
I became fascinated with the relationship between hormones and physical and mental health for that year–I lived in the medical stacks at our local community college library. Wish I could remember all the cool stuff I read back then. The history of hormone research is, in and of itself, a fascinating story.
I’m not a doctor or a scientist, but I’m guessing there is a lot more to hormones and mental health than we may realize. :-)
Yes. Kids hurt the worst.
My father (praise God he is still with us after the heart attack two weeks ago and the first diagnosis which was wrong), is a retired OBGYN. He was a big believer in replacement hormones for women post menopause.
I actually had the opposite problem: way too much estrogen. Long story. :-) I would like your dad. :-)
Everyone does. He is the most kind hearted man I know, other than maybe his grandson.
They are so much alike it is amazing. Some Genetics are strong, even if they skipped expression in Dad.
The brain is amazing.
We are still very much in the “collect the dots” phase of knowing anything about anything relating to consciousness. Yet problems exist now, not tomorrow. It is good that there exist a multitude of approaches. Some are obviously abused, sometimes in avarice, sometimes in ignorance.
I think that there has been an excess of “you’re not broken, you just have too much / too little of a certain chemical” as if this were certain knowledge. Well-intended as de-stigmatization, and even sorta well-founded, it’s not as though they checked your dipstick. The whole darned thing is mysterious despite some pretty well-validated chains of logic and treatment.
Shifting gears, the most vicious mental maladies are those with a component which erodes trust, precluding participatory recoveries.
Good post, Bryan.
Great post. Thank you, Bryan.
Two points; First, that there are bad psychiatrists but a bigger problem is no psychiatrists. At all. There are so few of them in my neck of the woods that it is difficult to find a provider, even just to monitor and prescribe a well-tolerated and effective meds regimen, unless you’re “in crisis.” Which, of course, is just what the patient is trying to avoid!
Second, the difficulty of diagnosing and finding the best treatment for a given patient is precisely why de-institutionalization was such a horrible idea, and why “institutionalizing” the mentally ill should be brought back, preferably under the title (and spirit) of “providing long-term, supportive care with the goal of eventual recovery.”
Tip: In retrospect, one thing I could’ve used when my own loved one was in the middle of a psychotic break was someone saying “you know, she will get better.” Because I literally thought that she was going to be like this—-hallucinating, delusional, thinking she’s Jesus—forever. When the lithium finally took hold, and she looked at me with normal eyes and greeted me in her normal voice, I burst into tears. I truly didn’t know that even this—let alone the recovery she is enjoying now— was possible…let alone more or less to be expected?
Treatment works. It’s long, and complicated, and resource-intensive, but it works.
Your Brain is More Than a Bag of Chemicals
edit: sorry, was a bad link
1. I wonder how much the rise of secularism has to do with this. Are we hardwired to need religion as a natural medicine? The secular left calls it “the opiate of the masses” yet can’t survive without it, needing to cling to global warming as its religion. It is a poor substitute and the left is generally a miserable lot.
2. Do we have too much time on our hands and a utopian expectation of what pleasures we are entitled to in life? Hunter gatherers were consumed with survival and got a lot of physical activity doing so. People today are far more idle, producing fewer endorphens and having more time to think about their current condition. Social media reinforces their sadness.
3. It is hard to believe our brains are devolving from generation to generation to a less perfect body part, yet there is a growing problem.? … caused by what?…. or are there better diagnostic techniques?
I couldn’t agree more. Just because it was (sometimes? frequently?) abused or done poorly in the past doesn’t mean it shouldn’t be done. For a limited subset of those with mental illness, of course.
Right now, the care at inpatient psychiatric hospitals is targeted only to acute illness, and increasingly so. Interventions other than medication are minimal, and still disappearing. The “psych ward” now is only a place where someone can go to be kept physically safe while medications are initiated or adjusted.
Now don’t misunderstand; this is a very important thing to do. And outpatient services are able to provide help for most people who do not need that acute level of care. The problem is that there are still many many people who absolutely need care, but will only get it if they are compelled. If you have delusions, you kind of by definition do not believe you need help.
People with schizophrenia or bipolar disorder will often only get inpatient treatment under court order, and will, once they transition to outpatient services, stop taking their medications and not show for appointments. This is particularly unfortunate in the case of bipolar I; each successive manic episode only makes the disorder harder to treat.
Clearly, compulsory treatment is difficult, ethically. I absolutely empathize with my patients who are subject to it. But it is sometimes necessary.
I very much considered what I do spiritual. When I am with someone for an hour, I see it as a sacred space. It is a special place where people can be witnessed and explore, safe from the profane world.
Responsibility is needed for meaning and happiness. The idle rich reach for more and more outlandish pursuits in order to feel.
Part of what is happening is we have the luxury to work on this stuff since other needs are met. None of this matters if you don’t have food. It is like having late life aging issues. Not a problem if most people are dead by 50.
I don’t know how Brian feels about Alice Miller. She is controversial, but I can tell you almost everybody needs an “enlightened witness” if they are going to more or less fix these types of difficulties. If you are really screwed up you need a good psychotherapist and probably somebody that will have a more ordinary relationship with you that is highly informed about your situation in some way.