Clinical use of the DSM categorical diagnostic system during the mental health intake session.

OBJECTIVE: The primary purpose of diagnostic systems is to improve the care of individuals suffering from mental disorders. Yet, few studies have explored the clinical use of the DSM. Here, we investigated clinicians' methods of obtaining and using diagnostic information during the mental health intake session. We examined the specific diagnostic information collected in usual care using unstructured interviews and the way this information was applied to make diagnostic decisions within naturalistic settings. We compared these decisions to diagnoses made using independent structured diagnostic interviews that served as the gold standard for psychiatric diagnosis. Finally, we examined ways to improve diagnostic efficiency by identifying the best probes for the diagnosis of major depressive disorder (MDD) in naturalistic settings.

METHOD: A total of 122 intake sessions in 4 community mental health clinics in Israel were audiotaped. Data were collected from October 2012 to April 2013. Immediately following the intake, clinicians listed the service user's diagnoses according to the DSM-IV while the service user completed a structured diagnostic interview with an independent interviewer. Recorded intake sessions were coded by independent clinicians using an information checklist.

RESULTS: Overall, clinicians tended to underuse the DSM, not collecting sufficient information to establish a correct diagnosis for most disorders. Accuracy of diagnostic decisions for MDD improved when only 2 screener items (depressed mood and diminished interest or pleasure) were assessed, compared to assessing 5 or more criteria as required by DSM-IV (diagnostic odds ratios = 9.44 and 3.85, respectively).

CONCLUSION: The problem of missing diagnostic information may underlie the poor reliability of the clinical diagnostic decision process. Systematically evaluating clinicians' assessment process in regular care can help identify the best probes to use in clinical practice to increase diagnostic efficiency.