The Perils of Checklist Psychiatry

It’s no secret that doctors in all specialties spend less and less time with patients these days.  Last Sunday’s NY Times cover article (which I wrote about here and here) gave a fairly stark example of how reimbursement incentives have given modern psychiatry a sort of assembly-line mentality:  “Come in, state your problems, and here’s your script.  Next in line!!”  Unfortunately, all the trappings of modern medicine—shrinking reimbursements, electronic medical record systems which favor checklists over narratives, and patients who frequently want a “quick fix”—contribute directly to this sort of practice.

To be fair, there are many psychiatrists who don’t work this way.  But this usually comes with a higher price tag, which insurance companies often refuse to pay.  Why?  Well, to use the common yet frustrating phrase, it’s not “evidence-based medicine.”  As it turns out, the only available evidence is for the measurement of specific symptoms (measured by a checklist) and the prescription of pills over (short) periods of time.  Paradoxically, psychiatry—which should know better—no longer sees patients as people with interesting backgrounds and multiple ongoing social and psychological dynamics, but as collections of symptoms (anywhere in the world!) which respond to drugs.

The embodiment of this mentality, of course, is the DSM-IV, the “diagnostic manual” of psychiatry, which is basically a collection of symptom checklists designed to make a psychiatric diagnosis.  Now, I know that’s a gross oversimplification, and I’m also aware that sophisticated interviewing skills can help to determine the difference between a minor disturbance in a patient’s mood or behavior and a pathological condition (i.e., betwen a symptom and a syndrome).  But often the time, or those skills, simply aren’t available, and a diagnosis is made on the basis of what’s on the list.  As a result, psychiatric diagnoses have become “diagnoses of inclusion”:  you say you have a symptom, you’ll get a diagnosis.

To make matters worse, the checklist mentality, aided by the Internet, has spawned a small industry of “diagnostic tools,” freely available to clinicians and to patients, and published in books, magazines, and web sites.  (The bestselling book The Checklist Manifesto may have contributed, too.  In it, author-surgeon Atul Gawande explains how simple checklists are useful in complex situations in which lives are on the line.  He has received much praise, but the checklists he describes help to narrow our focus, when in psychiatry it should be broadened.  In other words, checklists are great for preparing an OR for surgery, or a jetliner for takeoff, but not in identifying the underlying causes of an individual’s suffering.)

Anyway, a quick Google search for any mental health condition (or even a personality trait like shyness, irritability, or anger) will reveal dozens of free questionnaires, surveys, and checklists designed to make a tentative diagnosis.  Most give the disclaimer “this is not meant to be a diagnostic tool—please consult your physician.”

But why?  If the patient has already answered all the questions that the doctor will ask anyway in the 10 to 15 minutes allotted for their appointment, why can’t the patient just email the questionnaire directly to a doc in another state (or another country) from the convenience of their own home, enter their credit card information, and wait for a prescription in the mail?  Heck, why not eliminate the middleman and submit the questionnaire directly to the drug company for a supply of pills?

I realize I’m exaggerating here.  Questionnaires and checklists can be extremely helpful—when used responsibly—as a way to obtain a “snapshot” of a patient’s progress or of his/her active symptoms, and to suggest topics for discussion in a more thorough interview.  Also, people also have an innate desire to know how they “score” on some measure—the exercise can even be entertaining—and their results can sometimes reveal things they didn’t know about themselves.

But what makes psychiatry and psychology fascinating is the discovery of alternate, more parsimonious (or potentially more serious) explanations for a patient’s traits and behaviors; or, conversely, informing a patient that his or her “high score” is actually nothing to be worried about.  That’s where the expert comes in.  Unfortunately, experts can behave like Internet surveys, too, and when we do, the “rush to judgment” can be shortsighted, unfair, and wrong.

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12 Responses to The Perils of Checklist Psychiatry

  1. moviedoc says:

    Don’t blame DSM for psychiatric providers spending too little time with patients. It is not a check list despite the fact that some may use it that way, and it is vastly superior to DSM-II which was almost entirely based on mythical concepts like neurosis. I suspect most of us rarely refer to it in connection with a diagnostic evaluation. Besides, most of us know to take it with a grain of salt, not necessarily Lithium carbonate. It mostly helps with choosing a first line of treatment. When we find a treatment that works nobody but the payer care much what the diagnosis is. I believe we too often assume that “meeting criteria” implies one has the illness. In fact the criteria are necessary but not sufficient. Read the cautionary note in the front of the book. First a psychiatrist much judge the patient to suffer from a mental disorder. DSM just helps classify it.

    The point of psychiatry is not to be “fascinating” to the psychiatrist, but to treat the patient’s illness. Finding, really postulating, alternative “explanations” for pathology may be an interesting intellectual exercise, but what matters to the patient is whether they get well or not.

    I understand you can already (unfortunately) order drugs online with little more than a credit card and a check list. You can buy diphenhydramine, a drug often prescribed by psychiatrists, from a grocery store with neither.

  2. Mounir Belcadi says:

    Can’t wait to read your next article about the perils of practising ‘fascinating psychiatry and psychology’…….and fyi checklists don’t necessary lead to pills; look up for example the options you have based on phq-9 results :
    http://www.depression-primarycare.org/clinicians/toolkits/materials/forms/phq9/

  3. Jill says:

    I suggest reading the literature. Here’s what you said: “As it turns out, the only available evidence is for the measurement of specific symptoms (measured by a checklist) and the prescription of pills”

    There is an evidence base for Cognitive Behavioral Therapy. This has been all over the literature and in the popular press. CBT alone can be as effective as pills alone. So, people who don’t want to pop pills DO have an evidence-based alternative option.

    • stevebMD says:

      Jill, you are correct. My statement (and, in fact, the whole purpose of this post) was really meant to emphasize the diagnostic side of things, rather than the treatment. There is indeed an evidence base for CBT– in fact, I trained with David Burns and he made this very clear!!– but the process of diagnosing patients is gradually becoming less of a process and more of a “cut-to-the-chase” assessment of the patient’s acute symptomatology. And what better tool to do this than a checklist. (As you probably know, Burns even has his own for depression, the BDC.)

  4. mohiuddin says:

    Interesting reading. If possible, please notify me of new posts. Thanks

  5. […] valued.  In fact, these age-old skills are being shoved to the side in favor of more expedient, “checklist”-type medicine, often done by non-skilled providers or in a hurried fashion.  If the “ideal” […]

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