By Dov Michaeli MD, Ph.D

In a September 6 posting (Bipoar Diagnosis in Children: another epidemic?) I posited that because of the fuzzy definition of this and other psychiatric disorders, physicians tend to take an expansive view of the disorder, for a variety of reasons (not the least of which is monetary)—resulting in a forty (40!) fold increase in diagnosis in eight years, from 1994-1995 to 2002-2003. One week later, the New York Times of September 13 published an excellent op-ed by Sally Satel, a psychiatrist and resident scholar at the American Enterprise Institute and co-author of “One Nation Under Therapy”, which deals with the same problem.

“ We still don't know how much of this increase represents long-overdue care of mentally ill youth and how much comes from facile labeling of youngsters who are merely irritable and moody”.

Dr. Satel point out that Part of the confusion stems from the lack of a discrete definition of juvenile bipolar illness in the diagnostic manual. But there is a deeper problem: despite the great progress being made in neuroscience, we still don't have a clear picture of the brain mechanisms underlying bipolar illness -- or most other mental illnesses . ”

Fair enough. To borrow a baseball metaphor (I can’t believe I am using it) we are at the beginning of the first inning; we barely scratched the surface of this enormously complex organ, and understand even less how it works and why it malfunctions. So yes, we cannot define a disease with the same accuracy as we define, say, a myocardial infarction or a bacterial infection. But surely we could do better. Even in the days when the pathophysiology underlying a heart attack was not known, the symptoms were clearly defined and diagnosis was made quite reliably.

Part of the problem of relying on symptoms to define a disease is that many patients meet several diagnostic definitions at once. Roughly half of children with a diagnosis of ADHD, for example, also have symptoms that fit the definition of bipolar disorder. Do these patients actually suffer more than one illness, or do they just appear to? Conversely, very diverse patients often qualify for the same diagnosis. Children with depression, anxiety, irritability, moodiness or plain exuberant personality can all fit the diagnosis of ADHD.

What’s to be done?

Earlier this summer, the American Psychiatric Association announced that a 27-member panel will update its official diagnostic handbook, the Diagnostic and Statistical Manual of Mental Disorders. The fifth edition, which is scheduled to come out in 2012, is likely to add new mental illnesses and refine some existing ones. Dr. Satel proposes to define each disease as a continuum, allowing the physician to make a more refined and more nuanced diagnosis. Excellent idea! But I would say: not enough. I would add to each diagnosis several illustrative case studies, maybe in the form of an accompanying workbook. Such case studies could describe the classical presentations of a given disorder as well as its extremes, both mild and severe. This would illustrate the breadth of a diagnosis, and hopefully avoid much of the confusion that is common today.

The current state of psychiatric diagnoses reminds me of the Talmudic proverb, “the breach invites the thief”, by which it meant that the lack of clear definition and boundaries invites all sorts of bad behavior. Hopefully, the new Manual will close that breach.

Dov Michaeli MD, Ph.D is in the Biotech industry.