Over Diagnosis: Blame the DSM-5

Don’t get me wrong: I use and appreciate the DSM-5. I also remember the controversy over ten years about some of the consequences of the update. Placing disorders on a continuum is something that still makes sense to me, and is an basic part of the Evolution of mental health treatment in general. However, like most things in life, it does carry some undesirable or even unintentional consequences, like over-diagnosis.

One of complaints about the DSM-5 was that it could lead to “over-diagnosis.” I’ve been aware of this for years. I came across an article from the Johns Hopkins Bloomberg School of Public Health. It reports that only 38.4% of adults with depression actually had depression according to the established criteria. You can read the article here.

Anecdotal Evidence for Over-Diagnosis

Now, this article is 10 years old, and it’s not a comprehensive review of the DSM-5. But it still raised my awareness, and certainly affected my clinical assessments since it came out. Just because someone has the symptoms, doesn’t mean they meet criteria for the diagnosis.

Overdiagnosis is not confined to depression. I once worked at a world class facility that had an interesting anomaly. According to the National Alliance on Mental Health, roughly 1.4% of the United States population meets criteria for Borderline Personality Disorder. Yet 74% of the women on my caseload had that diagnosis. At the time, I was a certified counselor, working on my masters degree in addiction psychology. I was helpless to affect those diagnosis rates, since that was outside of my scope of practice. (It didn’t prevent me from having energetic debates about it, though).

Insurance- the Last Straw

Lastly is my experience with insurance, which is the last straw. I do need to be clear: expanding insurance coverage for mental health and substance use treatment is essential. Both fields have worked tirelessly to get parity with physical health, and this will benefit millions of people.

At the same time, whenever you turn a light on you also cast a shadow. One of the unintended consequences of Insurance parity is that in order to qualify for insurance, one must meet criteria for a diagnosis. I can only speculate how many people are going to be over-diagnosed with a disorder in order to meet insurance payment criteria.

There’s an old saying in the field: “Whoever pays for the treatment controls the treatment plan.”

What Coaching Offers My Practice

The decision last year to begin practice Coaching was strongly influenced by what I wrote about above. I realized that as a Coach, I had flexibility and ability to minimize the prevalence of over-diagnosis in my practice. It opens up a range of options from Prevention work (which I wrote about here) to the unexplored frontier of coaching people in long-term recovery who no longer meet a diagnosis.

Building our practices been a slow and steady process. The majority of our income is still derived from substance-abuse treatment (via insurance and the wonderful people at Headway) and Clinical Supervision. But coaching has offered a myriad of opportunities I never would have encountered through traditional therapy.

I also enjoy the process and focus of coaching. Instead of being diagnosis-driven, I have an opportunity to work with clients on behaviors and situations that counseling generally does not address. The work I do is based on the here and now, as well as plans for the immediate future, rather than a history of dysfunction.

That Shadow Thing…

Still, coaching by itself is not a perfect solution. I remain aware the turning on the light casts a shadow, and there are some serious problems with the coaching industry in general. I can only promise that we do our best to avoid as many of those problems as possible. I will definitely be covering that in the future post.

In the meantime, thank you very much for reading this! If you have any questions or comments, please leave them in the comment section below. Or, better yet, contact us if you need more information.