Many Docs Not Using Established Criteria to Diagnose Depression

/ Author:  / Reviewed by: Joseph V. Madia, MD

A new study indicates a majority of nonpsychiatrist physicians and a substantial minority of psychiatrists often do not use the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) when diagnosing major depressive disorder (MDD) in patients.
The study, led by Mark Zimmerman, M.D., of Rhode Island Hospital, appears in the Journal of Clinical Psychiatry.

The criteria for MDD in DSM-IV have remained relatively unchanged for nearly 30 years. In a previous study, Zimmerman and colleagues questioned the clinical utility of the criteria. This latest study looks at physicians' habits in using the criteria.

The researchers asked physicians attending a continuing medical education conference to complete a brief questionnaire. A total of 291 physicians responded to the six questions, with one question asking about the use of the diagnostic criteria for depression. The question read, "When diagnosing depression, how often do you determine whether the patients meet the DSM-IV diagnostic criteria for major depressive disorder?" A multiple choice response offered the following answers: (a) Less than 25 percent of the time, (b) 26 to 50 percent of the time, (c) 51 to 75 percent of the time or (d) More than 75 percent of the time.

Nearly 25 percent of the responding psychiatrists indicated they used the DSM-IV MDD criteria to diagnose depression less than half of the time. In contrast, more than two-thirds of the nonpsychiatrist physicians indicated they used the DSM-IV criteria less than half of the time when diagnosing MDD. The difference between the psychiatrists' and the nonpsychiatrists use of the criteria was significant.

Says Zimmerman, "Our results suggest that a minority of psychiatrists and majority of nonpsychiatrist physicians do not use the DSM-IV MDD criteria the majority of the time. These findings are disconcerting. While the symptom criteria for diagnosing MDD have not been changed much over the last 30 years, psychiatrists, especially older psychiatrists, apparently have not uniformly embraced their use, and nonpsychiatrist physicians seem to have rejected the formal application of the criteria."

Zimmerman theorizes that doctors are not using the DSM-IV criteria because of their length, and some may not be able to recall all the criteria. He says that if incomplete recall of the criteria is the reason, it is not being used to diagnose MDD, then a shortened definition of MDD may help make it easier for all practitioners to use the criteria.

The researchers suggest that if physicians are not determining whether the criteria for MDD are met, then it is possible many patients diagnosed with depression do not have major depression. This overdiagnosis is of critical importance because there is little evidence that antidepressants are effective for patients who do not have major depression, thus some patients may be prescribed medications unnecessarily.

Zimmerman found older psychiatrists reported they were less likely to use the DSM-IV criteria than younger psychiatrists. He offers this possible explanation: "Perhaps older psychiatrists who were training in the pre-DSM-III era never bought into the importance of using operational criteria to make a diagnosis."

The researchers note the study has limitations in that the reasons for not following DSM-IV guidelines were not asked, and interpretation of the question about the use of diagnostic criteria for MDD may not be consistent for all respondents. The results of the present study should be interpreted with caution because they did not conduct a random survey of psychiatrists and nonpsychiatrist physicians practicing in the country, and the physicians who did respond may not be representative of all physicians.

Jill Reuter

Reviewed by: 
Review Date: 
September 16, 2010