Rethinking Intake for Complex Psychiatric Diagnoses

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Your Health Magazine Contributor

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Rethinking Intake for Complex Psychiatric Diagnoses

A 2021 study of specialized psychiatric centers in Ethiopia found that more than a third of patients with severe psychiatric disorders had previously received a misdiagnosis [1]. In a separate Canadian primary-care study, nondetection rates were 92.7% for bipolar disorder, 85.8% for panic disorder, 71% for generalized anxiety disorder, and 65.9% for major depressive disorder [2].

Incorrect diagnoses prevent or delay people from receiving life-changing treatment, as well as waste medical time and resources. They additionally increase the risk of relapse and hospitalizations, lead to unnecessary care, and slow health developments among a particularly vulnerable group of people.

Intake for mental health conditions is typically the first place where incorrect or missed diagnoses occur. By reviewing what isn’t working during this step, we can improve the number of accurate diagnoses and improve outcomes for people who receive aligned, effective care.

Drawing on my experience from working in psychiatry in Colorado, these are my observations and recommendations to rethink intake for complex psychiatric diagnoses.

Overlapping & Comorbid Symptoms Across Disorders

One of the biggest challenges at intake is distinguishing mental health symptoms that manifest in multiple different conditions. For example, sleep disturbances show up in anxiety, depression, and post-traumatic stress disorder (PTSD). Mood shifts appear in bipolar disorder and early psychosis. Hallucinations can happen with schizophrenia, bipolar disorder, and depression.

In fact, up to 82% of people with schizophrenia have symptoms that overlap with other mental health conditions [3].

There’s also a reality that many mental health disorders occur alongside other disorders. Around 60% of people with depression also have anxiety [4], while two-thirds of patients with bipolar disorder have a comorbid psychiatric illness, such as panic disorder [5].

The crossover of symptoms, plus the increased likelihood of experiencing more than one mental health condition at the same time, makes intake more complicated. Even highly qualified physicians struggle to identify conditions with confidence, separate them, and understand how they interact with one another.

Misdiagnoses not only hinder a patient’s potential to recover, they can also worsen symptoms. In the case of bipolar disorder and panic disorder, prescribing a selective serotonin reuptake inhibitor (SSRI) antidepressant can trigger a manic or mixed episode [5].

Moving Away from Symptom-Based Psychiatry

Symptom-based psychiatry is when doctors rely on patients to describe their mental health symptoms at intake, such as:

• Mood
• Sleeping and eating patterns
• Physical discomfort
• Intrusive thoughts
• Energy levels
• Quality of relationships

Patients usually describe their symptoms in one session with a doctor, in their own words, which leaves a lot of room for subjectivity. How one person describes general anxiety may be another person’s interpretation of depression. People may also not have the vocabulary or be able to articulate their symptoms well. This limitation can make symptoms less visible at intake and easier to miss or misdiagnose.

Communicating symptoms also doesn’t account for the causes or influences that act on them. Stress at work, grief, or traumatic experiences may trigger mental health symptoms but aren’t always highlighted during symptom-based intake. Not being aware of these can severely limit treatment that follows.

Another possible drawback with a symptom-based focus at intake is if a person doesn’t describe a particular symptom, a corresponding diagnosis may be ruled out. For instance, a lack of hypersexuality might exclude someone from a bipolar disorder diagnosis. Complex psychiatric disorders manifest differently in different people, and only following rigid symptom categories can increase the risk of inaccurate conclusions.

Bridging the Diagnostic Gap

One of the most powerful ways to rethink intake for complex psychiatric diagnoses is to extend the process over multiple sessions, not just one. Rather than one hour of intense information sharing (which can put pressure on patients and lead to greater misrepresentation of symptoms and experiences), multiple, shorter sessions give people time to consider their presentation, clarify explanations, and build a relationship of trust with the physician.

Pre-screening is also valuable. Before patients see a doctor, a Comprehensive Intake Assessment (CIA), such as a digital questionnaire, can be used in tandem with intake interviews or to prepare for them. In one study of children and adolescents in mental health clinics, this approach increased diagnostic accuracy and shortened intake time by almost 15%. [6].

As a complementary or alternative approach to symptom-based psychiatry, the Power Threat Meaning framework and Perspectives approach can help. The former links mental distress to a broader context of life, including power dynamics, trauma, and poverty. It encourages doctors to ask questions such as ‘What happened to you?’ and ‘What did you have to do to survive?’ to understand patients’ threat responses (known as symptoms in symptom-based psychiatry) and if those are automatic, habits, or chosen.

The Perspectives approach considers psychiatric responses from four angles: disease, dimensional, behavior, and life story. Similar to the Power Threat Meaning framework, it provides a deeper way to understand the origins of patients’ mental health.

Psychiatric intake must be more than purely extracting data. From the beginning of treatment patients should be offered psychoeducation, regulation skills training, and safety planning. The person needs support to feel stable, and early action can facilitate clearer diagnosis by stripping away diagnostic “noise.”

For example, people in severe crises may display paranoia due to insufficient sleep, not because it’s a real symptom of their mental health. A short-acting sedative can help them rest and return to intake with a less distorted presentation of their condition (if one is present).

Looking Beyond Static Strategies

Rethinking how we conduct complex psychiatric diagnoses in a mental health facility in Colorado and beyond can create more space to accommodate their complexity. Integrating the Power Threat Meaning framework and Perspectives approach, plus multi-session intake, pre-screening, and care from the first point of contact, provides more dynamic strategies to comprehend mental health and form personalized treatment plans.

By reviewing our attitude and action around diagnosing, we can both deepen our knowledge of disorders and how they surface, and deliver essential care to people who need it now and in the future.

Sources

[1] Ayano, G. et al. 2021. Misdiagnosis, detection rate, and associated factors of severe psychiatric disorders in specialized psychiatry centers in Ethiopia. Annals of General Psychiatry.

[2] Vermani, M. et al. 2011. Rates of Detection of Mood and Anxiety Disorders in Primary Care: A Descriptive, Cross-Sectional Study. The Primary Care Companion for CNS Disorders.

[3] Dybdahl Krebs, M. et al. 2021. Associations between patterns in comorbid diagnostic trajectories of individuals with schizophrenia and etiological factors. Nature.

[4] National Alliance on Mental Illness. 2018. The Comorbidity of Anxiety and Depression. nami.org.

[5] Parker, G. 2010. Comorbidities in bipolar disorder: models and management. The Medical Journal of Australia.

[6] Plishty, S. et al. 2023. Revisiting the intake policy at the mental child and adolescent clinics. Journal of Psychiatric Research.