Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Primary Care Version

Strong evidence exists that primary care physicians underdiagnose psychiatric disorders and substance abuse in their patients. Over half of patients with depression, for example, are misdiagnosed by their doctors.1 The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Primary Care Version (DSM-IV-PC) goes a long way toward helping doctors identify these common problems in their patients. Future editions would benefit from a number of revisions and additions that would help the primary care physician make correct diagnoses. The authors of the DSM-IV-PC have managed to condense and rearrange the 800-page DSM-IV into a format that busy primary care physicians can easily use to help them diagnose psychiatric disorders. The manual is laid out so that the physician faced with a patient suffering from, say, depressed mood can turn to a “quick reference algorithm”—a flowchart with minimal diagnostic criteria and information—or to a section with more detailed information to begin considering likely diagnoses. Alternatively, the physician can go to an index, find a symptom, and be directed to several parts of the manual to explore various diagnostic possibilities. There is a separate chapter on the diagnosis of disorders typically first seen in infants, children, and adolescents. All of the DSM-IV-PC algorithms begin by advising the physician to rule out medical illness or substance abuse as a cause of a patient's psychiatric symptoms. The manual includes a section on clues that will alert the physician to the possible presence of a medical masquerade of psychiatric symptoms. It would be wise to highlight and add to this section in future editions. Anyone using the DSM-IV-PC (or the DSM-IV, for that matter) must keep in mind that DSM-IV labels are not etiologic diagnoses. Patients with psychiatric symptoms need to have their physicians do a thoughtful and thorough differential diagnostic workup to rule out organic illness. The flowcharts in the DSM-IV-PC are useful for helping the physician make diagnostic decisions. In future editions, the authors of the DSM-IV-PC should provide physicians with more specific advice on the type of information they need to gather to make an expert differential diagnosis. For example, it will be especially important to revise the depressed mood algorithm. Physicians should be explicitly advised to consider the possibility of bipolar disorder when a patient presents with symptoms of depression. As it now stands, step 1 of the depressed mood flowchart merely suggests that the physician consider “another mental disorder” to explain a patient's depressed mood. If the doctor does not consult the more detailed information after the flowchart and is not aware that a large proportion of affectively ill patients in primary care may suffer from bipolar illness,2 he or she might diagnose a patient with bipolar depression as suffering from unipolar depression. This is a potentially serious error. Primary care physicians are prescribing antidepressants more often, and there is now a growing body of evidence that treating bipolar patients with antidepressants alone can adversely affect the nature and course of their illness. Antidepressants can induce mania in vulnerable individuals, precipitate rapid cycling and mixed states with irritability, and lead to treatment-refractory depression.3,4 Even if physicians consult the more detailed information following the flowchart and turn to the section on manic symptoms, the lack of information provided on unique signs of bipolar depression could lead them to fail to consider the diagnosis of bipolar disorder. The DSM-IV-PC authors make only brief mention of the need to look for “a history of elevated, expansive, or euphoric mood,” and then direct physicians to the section on manic symptoms. It would be better if the manual first advised physicians to ask patients directly about periods of hypomania. Most patients view these periods as normal and will not spontaneously mention them.5 In addition, the manual should advise physicians to interview family members. Bipolar disorder is underdiagnosed by a factor of 2 if family members are not interviewed.6 Finally, other clues suggestive of bipolar depression should be mentioned in the manual: seasonal variation in symptoms (typically winter depression and summer hypomania), multiple generation family history of depression and irritable mood, stormy relationships, chaotic life histories, and, most importantly, the presence of atypical symptoms and psychomotor retardation.7 The flowchart for unexplained physical complaints should be revised so that the physician is advised to consider depressive illness as a diagnosis. As it now stands, the chart merely alludes to the need to consider another mental disorder and buries information about depression in the text, where the busy physician can easily overlook it. The substance abuse algorithm could be improved as well. The algorithm advises physicians to consider substance abuse if there is a history of problematic use of alcohol or drugs. But what questions should they ask to determine if there has been problematic use? The DSM-IV criteria for substance abuse, at best, merely imply that physicians should look for persistent or recurrent social or interpersonal problems. The manual should advise physicians to ask specific questions, such as, Has your spouse or boy/girlfriend ever complained about your drinking or your behavior when you drink? Do they ever say you get embarrassing, nasty, or depressed, for example? Have you ever decided to quit drinking or cut down on your drinking? Did you ever regret anything you said or did while drinking? With added information on how to detect medical mimics of psychiatric symptoms, the importance of medical differential diagnosis, and how to diagnose substance abuse, this manual could fulfill a critical need for improved diagnostic skills in psychologists, social workers, marriage counselors, and employee assistance and substance abuse treatment professionals, as well as the primary care physician. Nonmedical therapists have not been trained to consider the possible role of medical illness in their patients' presenting symptoms. In addition, they are often not familiar with psychiatric differential diagnosis and the psychiatric conditions that are responsive to medication. A revised manual geared toward nonmedical therapists as well as primary care physicians would help improve the quality of mental health diagnosis and treatment across the board.