Clinicians’ Opinions on the Reliability of Psychiatric Diagnoses in Clinical Settings

by Ahmed Aboraya, MD, DrPh

Dr. Aboraya is Clinical Associate Professor of Psychiatry at West Virginia School of Osteopathic Medicine, Director of the Young Adults Program at William R. Sharpe Jr. Hospital, and Director of the World Health Oganization (WHO) SCAN Training and Reference Center at West Virginia University, Morgantown, West Virginia.

Introduction

In my column published in the January issue of Psychiatry 2007, I raised the point that the reliability of psychiatric diagnoses in clinical settings is still poor, even after the introduction of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III).[1] While not claiming the contrary (i.e., that there is solid evidence that diagnostic reliability among clinicians since the advent of DSM-III is good), Dr. First’s counterpoint was that there is very limited evidence available to speculate on the reliability of diagnoses in clinical settings.[2] The readers of Psychiatry 2007 were invited to give their opinions on this issue through two questions: In your opinion, are psychiatric diagnoses unreliable? If so, what are the important reasons for diagnostic unreliability among psychiatrists and clinicians? Responses from clinicians comprise the Clinicians’ Opinion Study, which is summarized in this article.

Results

The editorial staff of Psychiatry 2007 and Dr. Aboraya received 28 responses to the survey: 24 psychiatrists and four mental health professionals. Clinicians were given the opportunity to cite more than one reason for diagnostic unreliability. In response to the first question, whether psychiatric diagnoses are reliable or not, one clinician said psychiatric diagnoses are reliable (3.5%), three clinicians reported there was no evidence to support either (10.5%), and 24 clinicians stated that psychiatric diagnoses are unreliable (86%).
In response to the second question about reasons for diagnostic unreliability, clinicians added 10 more reasons to the original 14 reasons mentioned in my column. Causes of diagnostic unreliability were grouped into three categories—nosology factor, patient factors (8), and clinician factors (15). Clinicians gave 74 citations for diagnostic unreliability—11 citations were for the nosology factor (14.9%), 16 citations were for patient factors (21.6%), and 47 citations were for clinician factors (63.5%). Table 1 summarizes causes of diagnostic unreliability by each category.

Discussions

It must be acknowledged that the Clinicians’ Opinions Study has serious limitations given that it only reflects the opinions of those who responded directly to the journal or to the author. Also, the number of clinicians who responded is small (28).

However, since there is very limited information on the topic, the information provided by the clinicians in this study is very valuable. Those who responded are practicing clinicians, including professors of psychiatry and department chairs. It is striking to note the degree to which clinicians cite serious shortcomings in their own practices; out of the 10 new causes of diagnostic unreliability added by clinicians themselves, seven are clinician factors (9–15 in Table 1) while only three are patient factors (4–6 in Table 1).

In 1962 before the advent of the DSM-III, Ward, et al., studied the reasons for diagnostic disagreement among psychiatrists in 40 cases. They found that the nosology factor was the highest (62.5%), where patient factors were the lowest (5%), and clinician factors were 32.5 percent.[3] Although we cannot make a direct comparison, the Clinicians’ Opinions Study shows that in this sample, the nosology factor is the least likely cause of diagnostic unreliability. In my opinion, this is a testimony from clinicians that the publications of the DSM-III and its subsequent versions have played a major role in removing the inadequacies that the older DSM versions had regarding nosologic clarity.

Clinicians themselves admitted in their responses that clinician factors are the most common reasons for diagnostic unreliability. Hence, improving clinical practice must be seen as a key component of its remedy. My previously outlined “DR.SED” paradigm is offered once again as a useful tool to improve the reliability of psychiatric diagnosis. “DR.SED” refers to Diagnostic Criteria, Reference Definitions, Structuring the Interview, Clinical Experience and Data.[4] Experts of nosology have achieved great progress in improving and refining psychiatric nomenclature and they continue to improve and perfect the DSM and International Classification of Disease (ICD) systems. However, clinical skills, too, must keep pace with these advances, so that the real world practice of psychiatry and our patients can reap the benefits. No matter how perfect the DSM or ICD systems are, unless clinicians step up to the plate and do their share, the problem of diagnostic unreliability will continue to be with us for a long time to come.

References
1. Aboraya A. The reliability of psychiatric diagnoses: Point—Our psychiatric diagnoses are still unreliable. Psychiatry 2007;4(1):22–5.
2. First MB. The reliability of psychiatric diagnoses: Counterpoint—There isn’t enough evidence available to speculate on the reliability of diagnoses in clinical settings. Psychiatry 2007;4(1):22–5.
3. Ward CH, Beck AT, Mendelson M, et al. The psychiatric nomenclature: Reasons for diagnostic disagreement. Arch Gen Psychiatry 1962;7198–205.
4. Aboraya A, Rankin E, France C, et al. The reliability of psychiatric diagnosis revisited: The clinician’s guide to improve the reliability of psychiatric diagnosis. Psychiatry 2006;3(1):41–50.