The importance of psychiatric diagnosis

The College of Psychiatrists of Ireland, Spring Conference, Virtual Meeting, 25-26 March 2021

Prof Tom Burns, Professor Emeritus of Social Psychiatry at the University of Oxford, spoke at the conference about the importance of diagnosis in psychiatric care. Prof Burns began by highlighting to the audience the fact that clinical psychiatry is a relatively new discipline, emerging less than 50 years ago. Psychiatry is different to other subspecialties within medicine, he explained, as it evolved alongside medicine and then joined it, as opposed to emerging from within, like other subspecialties.

Prof Burns pointed out that diagnosis is a core feature of being a doctor. Providing a diagnosis allows for the direction of interventions and treatment. However, making a diagnosis is an art, not a science. Prof Burns argued that medicine is a set of skills that evolve over time. These skills are obtained through an apprenticeship training. Most of medical training is about learning by being shown and being supervised, with an emphasis on repetition. The repetition of these skills allows them to be carried out automatically. In turn, this “frees up the brain to think about the individual you’re formulating a treatment plan for”.

He also highlighted that when training to become a psychiatrist, one must firstly learn how to recognise depression, but then also learn how to recognise depression in an individual who doesn’t normally express their emotions. Again, this is done through repeating the skill of diagnosis in different contexts. Essentially, he said “diagnosis is not an intellectual exercise, but pattern recognition”.

In fact, diagnoses within psychiatry are often made within minutes of starting an interview, and the rest of the time is spent formulating a treatment plan, Prof Burns said. A current challenge facing psychiatry is the question of whether the practice of psychiatric clinicians should be determined by academics, or whether academics should work to improve the needs of clinicians. The rise of evidence-based research has led to the need for accurate diagnoses in order to obtain a meaningful result from clinical trials.

As a result of this, subtypes of mood disorders have increased dramatically. In 1968 there were eight official subtypes of mood disorders in the Diagnostic and Statistical Manual of Mental Disorders (DSM). By 1980 there were 30, by 1987 there were 97, and by 1994 there were 2,655.

Prof Burns also pointed out that as new treatments and medications become available, diagnoses evolve. Medicine is full of arbitrary dimensions – at what point does a patient become hypertensive? The answer is based on the treatments available. It is usually at the point where treatment can improve the outcome of a patient. Diagnoses are social constructs, and are context dependent. For example, with the increase in drugs for depression, such as SSRIs, which do not tend to have severe side-effects, the diagnosis for depression has widened. Prof Burns said that it is important to accept that diagnoses can change over time as treatments improve.