The DSM and Depression: Flawed Labeling Leads to Misdiagnoses and Increased Stigma


The DSM has long been hailed as psychiatry’s “bible”; clinicians across the country have used the Diagnostic and Statistical Manual as their guide to identifying mental illness. However, in recent years, the reliability of the DSM has been called into question by psychiatrists and doctors alike. For depression, specifically, the DSM falls short in field tests, with test-retest reliability being extremely questionable. Depression screening and treatment is currently based on an extremely flawed set of standards, and this is providing a basis for misdiagnoses and false positives (Nemeroff et. al., 2013). Furthermore, although the compartmentalization of mental illnesses into specific categories may be necessary for treatment, strict categorization is contributing to an increased number of diagnoses per patient, which is creating labels and causing negative stigma (Szalavitz, 2013).

The DSM V lists nine criterion for depression, and goes on to put these symptoms under one of two categories: 1) depressed mood and 2) loss of interest or pleasure. It states that five (5) of these nine criterion must be met in order for a patient to have depression. The manual goes on to list 4 more categories that specify conditions that must be met in order to make sure the patient has depression (APA, 2013). There are two main issues with this approach. Firstly, the symptoms proposed by the DSM vary widely, but the treatment options for varying degrees of depression are very similar. This can be highly detrimental to the patient because the treatment is not specialized enough (Szalavitz, 2013).  Additionally, a lot of the symptoms for depression can be indicators for symptoms of other mental illnesses such as anxiety. This leads to false positives and diagnostic inflation, which is when a patient is over diagnosed with a multitude of mental illnesses, and perceived comorbidity, which is when two chronic illnesses are present simultaneously.

For a lot of patients, diagnostic inflation and false positives can lead to feelings of hopelessness and despair, as in the case of Maia Szalavitz. In her 2013 article for TIME magazine, Szalavitz states that she has been diagnosed with no fewer than six mental illnesses over the course of her lifetime. Szalavitz goes on to say:

My multiple diagnoses are the rule, not the exception, and one criticism of the DSM structure is that if you qualify for one diagnosis, you typically also qualify for others. Which one should be treated? Or do they all require interventions? And what if the therapies conflict with each other? You see the problem” (Szalavitz, 2013).

Although diagnostic labels are sometimes needed for treatment, over diagnosing patients can lead to risky medication combinations and incorrect labeling (Szalavitz, 2013). An increased number of diagnoses can understandably lead to more despair in the patient without providing a concrete solution to the patient’s problems (Batstra et. al., 2012).

Diagnoses are not at all an exact science, and the DSM tries to treat them as such. Overall, not enough is known about mental illnesses such as depression to narrow symptoms down to a precise list of categories. Labels for mental illnesses are far from perfect, and over labeling adds to stigma and only increases patient distress. To some extent, we do need labels, but mental health professionals should realize that these labels are not set in stone.

References:

Special thanks to Dr. Nicholas Eaton for providing information for this article

Batstra, L., & Frances, A. (2012). Holding the Line against Diagnostic Inflation in Psychiatry. Psychotherapy and Psychosomatics, 81(1), 5-10. doi:10.1159/000331565

Hunt, C., Slade, T., & Andrews, G. (2004). Generalized Anxiety Disorder and Major Depressive Disorder comorbidity in the National Survey of Mental Health and Well-Being. Depression and Anxiety, 20(1), 23-31. doi:10.1002/da.20019

Nemeroff, C. B., Weinberger, D., Rutter, M., MacMillan, H. L., Bryant, R. A., Wessely, S., … Lysaker, P. (2013). DSM-5: a collection of psychiatrist views on the changes, controversies, and future directions. BMC Medicine, 11(1). doi:10.1186/1741-7015-11-202

Pearson Clinical. (2013). Major Depressive Disorder. Retrieved from http://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_MajorDepressiveDisorder.pdf

TIME. (2013, May 17). Viewpoint: My Case Shows What’s Right — and Wrong — With Psychiatric Diagnoses. TIME Magazine.

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