Why A Good (Correct) Diagnosis Is So Important
One of the most important things in treating mental illness successfully is a correct diagnosis. That can sometimes be a difficult task since there are some medical issues that can present as a mental illness or a psychiatric symptom. Diagnosis is also challenging because a psychiatric symptom can be present in more than one psychiatric disorder. Why is a correct diagnosis so important? Because a correct diagnosis helps the psychiatrist formulate the most effective treatment that will result in remission. For example, one symptom like irritability can be a common presentation in depression, anxiety, Attention Deficit and Hyperactivity Disorder, mania, hypomania, impulsive disorders, Post Traumatic Stress Disorder and even in Obsessive Compulsive Disorder, to name a few. Sadness, another common psychiatric complaint can be a sign of a Major Depressive Disorder or Bipolar disorder, and be seen in Schizophrenia in some cases; all severe mental illnesses with completely different types of treatment.
Examples of Misdiagnosis
To illustrate some of the challenges in forming a diagnosis, I have a couple of examples from our Clinic.
A 29 y/o male was referred by his therapist for an evaluation after increased concern that he might have Bipolar Disorder. The patient described periods of time when he worked more than 60 hours per week, reporting that people close to him would notice that he was increasingly irritable and also had a decreased desire for sleep. He did not have any concerns about his behavior but said his family was increasingly worried about his mood swings, and his proneness to get into fights. He had sought Christian counseling at his father’s urging. During his examination, he was very polite, friendly, but somewhat reserved and slow in establishing rapport. He reported that he was previously diagnosed and treated by his Primary Care Doctor for ADHD for many years and was treated with a number of medications over the years, but said he preferred Adderall XR. After the interview process and a routine check of his prescription across Texas database, we discovered that he was prescribed 30 mg of Adderall XR twice a day, with no early refills. However, we also learned that he was using the entire 30-day supply during a 7-10 day period each month, amounting to an average of 180-270 mg of Adderall per day. When I spoke with him about it-he was truthful, saying that he was not addicted to the direct effects of Adderall but to how much work he was able to accomplish during that time. Given this additional information, the correct diagnosis was not Bipolar Disorder and as a result he did not need a mood stabilizer. The correct diagnosis was amphetamine drug use, and substance-induced bipolar disorder that needed an addiction treatment and reevaluation of his prior diagnosis and treatment for ADHD.
A 48 y/o, divorced, mother of one child, employed professional, was treated for depression with fluoxetine. Her symptoms responded to an initial dose of 20 mg of fluoxetine and almost got to remission with an increased dose of 40 mg. She continued to complain of persistent tiredness and lack of energy in doing things that she was interested in. Her blood work report did not show anything significant except for a low T3 on the Thyroid function panel and a high C reactive protein. As a psychiatrist, I recommended supplementation with liothyronine, which improved her energy level dramatically. At the same time, she was referred to an endocrinologist for further testing that came back suggesting an autoimmune thyroiditis disease. A new treatment plan was created to target both her depression as well as her thyroid condition.
A 32 y/o recently married woman was referred for worsening mood that was not responding to the lamotrigine and bupropion that were started a few months prior to her initial visit to a psychiatrist by her Primary Care Doctor. She was in couple’s therapy to address difficulties in her relationship that started a month prior to her wedding. The therapist suggested a mood stabilizer because the patient had increased irritability, insomnia, and crying spells as the wedding was approaching. The response to the medication was minimum, she continued to be depressed, still cried a lot, felt anxious, and the tension in the relationship was not helping her symptoms. A new medication, Wellbutrin, was added to lamotrigine and her mood was slightly better. After the wedding her mood continued to be unstable, initially with insomnia and then she started having panic attacks. In my initial psychiatric interview, she appeared to be very anxious but there was no history of clinical symptoms of mania, nor any history of bipolar disorder in her family. Her pattern of insomnia was suggestive of an anxiety disorder that neither medication addressed. We discussed options and I recommended that she add Trintellix and start a slow tapering of her Lamotrigine first and then her Wellbutrin. Over the next two appointments, both her anxiety and depressive symptoms were in remission and she said that she finally felt like she got back to feeling like her normal self, despite the continued difficulties in her marriage on which she continued to work in therapy. In this situation, it was clear that she was misdiagnosed with a mood disorder and the treatment that was chosen was not addressing her anxiety which was her main presenting problem.
Prevent Undue Suffering By Getting A Proper Diagnosis Quickly
Any delay in obtaining a correct diagnosis can prolong the period that the patient suffers, and, in some situations, the treatment that is chosen for a different condition can worsen the presenting problem, like in the last case where the medical provider was treating a depressive episode of a bipolar disorder with an antidepressant. Please note that even though people might have the same diagnosis each person’s experiences and health conditions are different- so what works for one person may not work for another. Any diagnosis of mental illness should include a full history of your both your mental and physical health.
Research indicates that if you get the right diagnosis early in the treatment process you will get better faster and experience fewer treatment-induced side effects.
If we can help in any way- call us at 713.426.3100 to schedule an appointment.