“If sanity and insanity exist, how shall we know them?”
Those are the opening words of a classic paper in the history of psychology, David Rosenhan’s famous “pseudopatient” study (pdf), published in the prestigious journal Science in 1973. In his experiment, Rosenhan and seven other people—none of whom had a mental illness—went to 12 different hospitals and complained of “hearing voices.” They explained to hospital staff that the voices said “empty,” “hollow,” and “thud.” They reported no other symptoms.
Surprisingly, all patients were admitted. And even though, upon admission, they denied hearing voices any longer, they all received antipsychotic medication (Rosenhan had instructed his pseudopatients to “cheek” their meds and spit them out later) and were hospitalized for anywhere from 7 to 52 days (average = 19 days). They behaved normally, yet all of their behaviors—for example, writing notes in a notebook—were interpreted by staff as manifestations of their disease. All were discharged with a diagnosis of “schizophrenia in remission.”
Rosenhan’s experiment was a landmark study not only for its elegance and simplicity, but for its remarkable conclusions. Specifically, that psychiatric diagnosis often rests solely upon a patient’s words, and, conversely, that “the normal are not detectably sane.”
Would a similar experiment performed today yield different results? Personally, I think not. (Well, actually, admission to a psychiatric hospital these days is determined more by the availability of beds, a patient’s insurance status, and the patient’s imminent dangerousness to self or others, than by the severity or persistence of the symptoms a patient reports, so maybe we’d be a bit less likely to admit these folks.) At any rate, I’m not so sure that our diagnostic tools are any better today, nearly 40 years later.
In a very controversial book, Opening Skinner’s Box, published in 2003, journalist Lauren Slater claimed to have replicated Rosenhan’s study by visiting nine psychiatric emergency rooms and reporting a single symptom: hearing the word “thud.” She wrote that “almost every time” she was given a diagnosis of psychotic depression and was prescribed a total of 60 antidepressants and 25 antipsychotics (that’s an average of 9.4 medications per visit!). But her report was widely criticized by the scientific community, and Slater even confessed in the November 2005 Journal of Nervous and Mental Disease, that “I never did such a study: it simply does not exist.”
While I’m deeply disturbed by the dishonesty exhibited by Slater, whose words had great power to change the public perception of psychiatry (and I am offended, as a professional, by the attitude she demonstrated in her response to her critics… BTW, if you want a copy of her response—for entertainment purposes only, of course—email me), I think she may have been onto something. In fact, I would invite Slater to repeat her study. For real, this time.
Here’s what I would like Slater to do. Instead of visiting psychiatric ERs, I invite her to schedule appointments with a number of outpatient psychiatrists. I would encourage her to cast a wide net: private, cash-only practices; clinics in academic medical centers; community mental health clinics; and, if accessible, VA and HMO psychiatrists. Perhaps she can visit a few family practice docs or internists, for good measure.
When she arrives for her appointment, she should report one of the following chief complaints: “I feel depressed.” “I’m under too much stress.” “I see shadows out of the corner of my eyes sometimes.” “My mood is constantly going from one extreme to the other, like one minute I’m okay, the next minute I’m all hyper.” “My nerves are shot.” “I feel like lashing out at people sometimes.” “I can’t pay attention at work [or school].” “I sometimes drink [or use drugs] to feel better.” Or anything similar.
She will most certainly be asked some follow-up questions. Maybe some family history. Maybe a mental status exam. She will, most likely, be asked whether she’s suicidal or whether she hears voices. I encourage her to respond honestly, sticking to her initial, vague, symptom, but without reporting anything else significant.
In the vast majority of cases, she will probably receive a diagnosis, most likely an “NOS” diagnosis (NOS = “not otherwise specified,” or psychiatric shorthand for “well, it’s sort of like this disorder, but I’m not sure”). She is also likely to be offered a prescription. Depending on her chief complaint, it may be an antidepressant, an atypical antipsychotic, or a benzodiazepine.
I don’t encourage otherwise healthy people to play games with psychiatrists, and I don’t promote dishonesty in the examination room. I also don’t mean to suggest that all psychiatrists arrive at diagnoses from a single statement. But the reality is that in many practice settings, the tendency is to make a diagnosis and prescribe a drug, even if the doctor is unconvinced of the seriousness of the patient’s reported symptoms. Sometimes the clinic can’t bill for the service without a diagnosis code, or the psychiatrist can’t keep seeing a patient unless he or she is prescribing medication. There’s also the liability that comes with potentially “missing” a diagnosis, even if everything else seems normal.
And on the patient’s side, too, the forces are often in favor of receiving a diagnosis. Sure, there are some patients who report symptoms solely because they seek a Xanax Rx or their Seroquel fix, and other patients who are trying to strengthen a disability case. But an even greater number of patients are frustrated by very real stressors in their lives and/or just trying to make sense out of difficult situations in which they find themselves. For many, it’s a relief to know that one’s troubles can be explained by a psychiatric diagnosis, and that a medication might make at least some aspect of their lives a little easier.
As Rosenhan demonstrated, doctors (and patients, often) see things through lenses that are colored by the diagnostic paradigm. In today’s era, that’s the DSM-IV. But even more so today than in 1973, other factors—like the pharmaceutical industry, the realities of insurance billing, shorter appointment times, and electronic medical records—all encourage us to read much more into a patient’s words and draw conclusions much more rapidly than might be appropriate. It’s just as nonsensical as it was 40 years ago, but, unfortunately, it’s the way psychiatry works.
Thought Broadcast 
“I don’t encourage otherwise healthy people to play games with psychiatrists, and I don’t promote dishonesty in the examination room.”
Of course, not. Nobody likes deceit. But how else can Rosenhan’s experiment be replicated?
Wait, but it’s a silly accusation to say, “Look, everyone who goes to a psychiatrist gets a diagnosis, that shouldn’t be.”
Insurance companies won’t reimburse a psychiatrist or a patient without one, so the NOS version seems reasonable. It’s a cyclic argument: if you undid the financial issues and allowed R/O diagnoses or “consider”, people wouldn’t always get diagnosed with illnesses.
Can you imagine saying to a patient, fine to come see me but if you don’t meet criteria for certain specific psychiatric disorders (which you can’t know if you will in advance) then the bill is on you. If you have headache and the scan shows nothing, they don’t make you pay because you guessed wrong.
The honest thing to do would be to say: “Your symptoms are within the range of normality, sounds like maybe you should get some more exercise, get more sleep, stop eating junk food, reduce stress, and stop worrying about your mental health. I can’t bill your insurance company for this, how about $100 for my time?”
Oh, but instead psychiatrists are “forced” to concoct a diagnosis, bill fraudulently, and throw prescriptions at the patient! What is this profession about, anyway?
dinah, I absolutely understand the games we must play to get reimbursed for our work, and I think most reasonable people (like iatrogenia, according to her response to your comment) would agree that a professional’s time and expertise does deserve compensation, even if the professional’s assessment is that the patient has a more or less “clean bill of health.”
My problem with writing a diagnosis (even the “NOS” diagnosis) is that it now becomes established in the chart, where it takes on a whole new meaning. I may write “bipolar NOS” (god, I hate that term!) to get reimbursed, but the next person who sees that chart– a nurse, a therapist, another psychiatrist, the patient herself– may draw incorrect conclusions about the patient after seeing the “B” word.
By the way, this is another reason why I think Allen Frances’ recent editorial about psychiatric epidemiology is right on the money.
Back to the main article — The Slater gambit already is being replicated. This is the way college students are getting Ritalin prescriptions to sell every day.
The problem too is that for insurance to cover you often need to see a psychiatrist rather than psychologist; that necessitates a psychiatric dx. Costs for the “walking well’ to get therapy are often unmanageable absent using their insurance (which often only pays for only so many visits regardless of need or progress.)
Thanks for the links, Steve. Do you agree with Lillienfeld, et al?
“Rosenhan’s (1973) poorly supported conclusion that most or all psychiatric diagnoses are invalid products of the social context can again be safely put out to pasture (Ruscio, 2004; Spitzer, 1975)”
And what are we to make of this from Spitzer, et al?
“[A]t discharge, all of the pseudopatients were diagnosed as being in remission, indicating that the mental health professionals
recognized that they were currently free of psychopathology.
Contra Rosenhan, these professionals were quite successful at
distinguishing psychopathology from normality.”
I’m just a stupid pediatrician, but to me, a disease “in remission” is still a disease. The pseudopatients in Rosenhan were never sick.
I remember when, instead of “diagnosis,” we wrote “impression.” That way we could change our minds when we got more data.
Some insurance companies (for a short time) would not pay for a psychiatric evaluation if you gave the patient a clean bill of health. As if you knew that before you even started the evaluation! I would immediately resign from any insurance panel that tried to do that. I have not had to yet.
I’ve also seen internists put down a diagnosis before they had enough information. Later the patient would be denied insurance coverage for that diagnosis by a new carrier, even though they never even had it!
So don’t just bash psychiatrists for being wusses in this regard. There’s also plenty of craziness going around in the legal profession, accounting – whatever. This does not excuse the wussess, but I’m not willing to blame all of society’s excesses on one group.
I think Dinah makes a good point about headache being reimbursed when the scan is negative and there not being any issue with that. It does seem like a bit of a double standard. It reminds me of the swine flu hysteria which I sheepishly admit to getting sucked into. It just so happened that i caught a cold right around the same time and had all the same symptoms and being a bit on the dramatic side my hypochondria overpowered my logic.
I’m tired of having 102 fever so I swallow some tylenol and drag myself to the doctor. My flu test is negative and I’m now afebrile and feeling completely ridiculous. The physician politely tells me I have a cold and I slink out of there without a prescription because I don’t need one and of course recover with my cherry cough drops.
So, basically I didn’t need medical care, but I didn’t know for sure. Insurance paid. Should they have paid for me overreacting? The answer is I don’t really know. I’m not a doctor so I wasn’t sure exactly how long to let the 102 fever go on. I don’t know that that’s much different than a patient who shows up for symptoms that get labeled as depression when maybe it’s just stress at work and then having insurance cover it.
Of course, if I had my way insurance would be more for the major stuff and people would pay out of pocket for the minor, routine stuff. But, that’s a whole ‘nother debate.
Leslie
Perhaps clinical psychiatry should lobby for “normal” to be included in the DSM-5.1 so psychiatrists can be reimbursed.
Wouldn’t that make critics’ heads spin!
The DSM is getting ever closer to diagnosing being human as a psychiatric condition anyway.
Iatrogenia,
Actually, the DSM does have a code for no psychiatric disorder. I’ve never seen it used!
Most people who come through my door have a psychiatric disorder. Actually, pretty much all of them. Why would someone who is not in any distress go to a psychiatrist?
On a completely different note, Steve, I think you’re post is basically saying that we are influenced by the culture in which we live. If that culture says it’s abnormal to hear voices saying “empty, hollow, thud” and that call such hallucinations “psychosis,” and that we admit people for further observation, treatment, and assessment when we’re not sure what’s going on, then that is what we do. If our culture teaches us that someone who arrives at a psychiatrist’s office complaining of low mood may be depressed and that we treat such psychic distress with medicines….well. (see my post, btw, on Is This Depression)… As doctors, I don’t think we’re unique in that we believe what we’ve been taught, and live within the context of a culture and those things change and evolve.
i’m glad you agree that it’s reasonable for a psychiatrist to agree to one amount of money if there is a diagnosis, and a lesser amount of money if there isn’t. Not sure how long you spend with a new patient, but I spend 2 hours, often followed by communication with others and a written report. I think y’all have now valued me at $33-$50/ hour. Thank you.
“Most people who come through my door have a psychiatric disorder. Actually, pretty much all of them. Why would someone who is not in any distress go to a psychiatrist?”
There’s distress and there’s distress, and then there’s television advertising. Your reasoning is like the Russian courts: Anyone who is arrested must be guilty.
If customers who do not deserve a psychiatric diagnosis are so rare, why not reduce your income expectations for those few occasions (and your pride) rather than your ethical standards?
Or did you mean to say anyone who visits you gets a psychiatric diagnosis a priori? That would confirm the currency of Rosenhan 1973, and the arbitrariness of psychiatric diagnosis.
Iatrogenia,
Because it’s wrong. If you fall on your arm and it hurts, you can go to the doctor and they may well xray it. If it’s not broken, you’re insurance pays. If your stomach hurts, you can go to the doctor and then a specialist and then have a zillion dollars in scans and upper GI test and lower GI tests and biopsies and empiric trials of antibiotics and ulcer medications and your insurance will pay even if every single test is completely negative. And even if the fee is markedly reduced, if you’re going to the doctor with the expectation that you’re making a $30 (? or $50-) copay, then why should it be sprung on you that you now have to pay $100? What if you don’t have that? And why should a doctor reduce their fee if they believed they were being paid a certain amount and you believed you were paying a certain amount. What if the patient is a lawyer who bills at $600/hour. Why should my fee now be reduced to $33/hr because he thought he might have a disorder and I don’t agree? My washing machine repairman charges $110 to walk in the door, and doesn’t reduce the fee because I forgot to plug the machine in. (Sorry for the simplistic example, but in early in my marriage, I discovered my husband likes to unplug major appliances before we go on vacation). I’m not arguing with the idea of reducing fees for certain circumstances, but usually in medicine we save our charitable moments for those of limited means and don’t make the statement that our time is worth less depending on the patient’s condition. Would the idea also be that it’s a one-time event, an evaluation just to tell the patient who comes in distress that they don’t have a psychiatric diagnosis so they don’t need treatment so they certainly can’t come back? That seems callous. Why people don’t like being told their crazy, most people who come in are suffering and don’t want to hear there is nothing wrong with them–it comes off as being dismissive.
There are diagnoses that people fit into that allow reimbursement and don’t imply a major mental illness or mandate a need for medication or life long treatment. Things like “adjustment disorder” or “anxiety, nos.” I know, Steve doesn’t like these things, and I’m just playing the game with the rules I’m given.
dinah, I’m going to have to agree with Iatrogenia on this one. And BTW, I don’t think she was literally suggesting you charge a lower fee to patients with less severe (or no) diagnoses; I read her comment as a tongue-in-cheek suggestion.
Here’s the deal: Unless you work in a tertiary referral center, or you’re lucky enough to work in a group setting in which talented therapists or social workers (whose clinical acumen you trust) refer the more complicated patients to you for a psychiatric evaluation, then no, I don’t think that everyone who sees a psychiatrist has a disorder. And even among those who do meet DSM criteria, surely there are some who are less “severe” than others with that diagnosis. The DSM is a field guide, and variations on its themes do exist.
I wrote this post to highlight the fact that Rosenhan’s results, if his experiment were performed today, would be magnified tremendously in the outpatient setting, where the “bar” for diagnosis and treatment is set much lower. We have to give a diagnosis to get paid, but we psychiatrists are also biased to see people as having psychiatric disorders simply because they walk in our doors “in distress.” I don’t think that’s necessarily the case. I could think of nothing more satisfying (and more empowering for my patients) to diagnose a few V71.09’s every once in a while. [Thanks, David.]
Steve,
I think Iatrogenia literally did mean that psychiatrists should charge a lower fee if the patient doesn’t have a diagnosis. I could be wrong, we will wait for her (?) input.
Of course there are more severe and less severe problems/disorders/distress. Since most psychiatric symptoms exist on a spectrum with normal human emotions, for the most part the act of defining a disorder is just drawing a line in the sand. I’ve chosen to let the patients decide if they are patients. Since I’m a psychotherapist, I don’t feel terribly pressured to get it right at the evaluation. Some people start with therapy and we later decide to add medicine. It’s not that often, with this type of practice, that I am the first stop and most people walk in the door already on medications.
I agree, the bar is set fairly low, and some people come because they’ve decided they need something for a disorder a relative may think they have.
The Rosenhan study is interesting to talk about, especially if you like setting shrinks up to be idiots. And I don’t doubt that most people who walk into a psychiatrist’s office saying “I feel sad” don’t walk out with an SSRI.
Dinah, I apologize for taking so long to reply. I can see the point about compensation really distressed you.
When I suggested charging $100 for a null diagnosis Hey, in cases where no diagnosis is warranted that would not be covered by insurance, I was thinking that would be the amount most people would be able to pay out of pocket without complaint or hardship. I was remiss in not thinking of the doctor’s finances first.
(For a null diagnosis, perhaps Dr. Allen was thinking of V71.09 No Diagnosis on Axis I and V71.09 No Diagnosis or Condition on Axis II?)
In terms of your hours spent, I would think you would spend much less time probing a patient with no psychiatric disorder, and relatively little time in documentation. You could spend allocated uncompensated time catching up on other patients, or going home early to spend time with your family. Win-win-win!
As long as we’re talking about coding, insurance, and psychiatrist compensation, you and Ronald Pies both wrote articles claiming that a lot of psychiatrists provide therapy as well as medication management because data from health insurance plans show they bill for psychotherapy.
Allow me to point out that every one of the half-dozen psychiatrists I’ve seen has billed for the higher-paying psychotherapy CPT code rather than lower-paying medication management, even though he or she never spent more than a half-hour with me (more often 15 minutes), and did nothing in any way resembling psychotherapy.
So much for honesty in billing insurance companies and inferences about clinical practice derived thereof.
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