The Importance Of A Correct Diagnosis of Mental Illness

Why A Good (Correct) Diagnosis Is So Important

Good Diagnosis

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.

Patient A.

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.

 

Patient B

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.

 

Patient C

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.

Integrative Treatment In Psychiatry: A Path To Wellness

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Case Study N.Y.

Main Symptoms

When N.Y. 20, came in for an evaluation with her family, her main complaint was that she could not retain information and was worried about starting school and her performance in college. Her family noticed that she was also very tired, slept a lot and did not seem to follow through on her goals. She complained of very low energy and increased appetite, and was concerned about the weight that she gained and could not lose. She felt sad and worried most of the time- especially about her starting school again and not feeling up for it.

History

N.Y. was never seen by a psychiatrist before and was not aware of any mental illness running in her family. She had been a good student in her country of origin, came to United States when she was in 9th grade and once here, her academic performance gradually deteriorated. She found that she needed more time to accomplish her tasks; she was easily distracted in class, and seemed that she worked twice as hard as her peers to achieve the same results.

Diagnosis

During the first meeting with her-it became clear that based on the clinical history and the self-reported questionnaires that she was suffering from significant depression and anxiety symptoms. At the same time, while her concentration could have been impaired by the presence of an affective disorder, I considered the presence of a comorbid ADHD. At the same time, her lethargy, decreased energy and mental cloudiness could have been explained by an atypical form of depression but I was also concerned about the possible comorbidity with a thyroid deficiency, vitamins deficiencies, or anemia.

I created a customized treatment plan and discussed the plan with N.Y. and her family and decided to start the treatment for the most obvious complaint, the low depressed mood, and test for ADHD when the mood was better through a Continuous Performance test. At the same time, I recommended we run a set of lab tests to address possible biological causes of her symptoms.

The laboratory results confirmed my clinical suspicions by showing signs of microcytic anemia, and significant deficits in Vitamin D, B12, and folate, with an increased homocysteine level that is a marker for a generalized inflammatory state.

The Continuous Performance Test (CPT) test for ADHD showed that she was having a lot of difficulties with maintaining attention, and increased distractibility.

Integrative Psychiatric Treatment For N.Y.

We created a customized Integrative psychiatric treatment program which began to help N.Y. see improvements. N.Y. showed significant improvements on a combination of a medication (an SSRI) for her depressive symptoms and anxiety, Strattera (for ADHD) and targeted supplementation including Vitamin B12, Vitamin D, folate(Vitamin B9), and B-Complex. She was also referred for further testing and follow up with her primary care physician for her microcytic anemia. I also recommended that she start exercising by going for a walk regularly, at least 25 minutes a day at a fast pace. To help her lose the extra weight she wanted to lose we talked about her trying a low-glycemic index diet.

It is possible that with an improved regimen of regular exercise, improved nutrition and supplementation with the appropriate vitamins she might be able to get off the antidepressant in about 6 months. At that time- we plan on repeating the CPT test to assess her ability to concentrate on and off medication, and decide if further treatment is necessary.

Integrative treatment in Psychiatry is becoming more and more popular and effective because it provides a more comprehensive analysis of the potential factors that may influence an individual’s health and mental health. It also provides a more customized plan of treatment that incorporates the interplay of body, mind and spirit and therefore can be much more effective than traditional medicine which takes a narrower view.

If you like this article on integrative treatment in psychiatry, or have questions, schedule your first session by calling us at 713.426.3100.