Diagnostic error in mental health: a review

Diagnostic errors are associated with patient harm and suboptimal outcomes. Despite national scientific efforts to advance definition, measurement and interventions for diagnostic error, diagnosis in mental health is not well represented in this ongoing work. We aimed to summarise the current state of research on diagnostic errors in mental health and identify opportunities to align future research with the emerging science of diagnostic safety. We review conceptual considerations for defining and measuring diagnostic error, the application of these concepts to mental health settings, and the methods and subject matter focus of recent studies of diagnostic error in mental health. We found that diagnostic error is well understood to be a problem in mental healthcare. Although few studies used clear definitions or frameworks for understanding diagnostic error in mental health, several studies of missed, wrong, delayed and disparate diagnosis of common mental disorders have identified various avenues for future research and development. Nevertheless, a lack of clear consensus on how to conceptualise, define and measure errors in diagnosis will pose a barrier to advancement. Further research should focus on identifying preventable missed opportunities in the diagnosis of mental disorders, which may uncover generalisable opportunities for improvement.

The ethics of coercion in mental healthcare: the role of structural racism

In mental health ethics, it is generally assumed that coercive measures are sometimes justified when persons with mental illness endanger themselves or others. Coercive measures are regarded as ethically justified only when certain criteria are fulfilled: for example, the intervention must be proportional in relation to the potential harm. In this paper, we demonstrate shortcomings of this established ethical framework in cases where people with mental illness experience structural racism. By drawing on a case example from mental healthcare, we first demonstrate that biases in assessing whether the coercive intervention is proportional are likely, for example, due to an overestimation of dangerousness. We then show that even if proportionality is assessed correctly, and the specific coercive intervention would thus be regarded as ethically justified according to the standard framework, coercion may still be ethically problematic. This is because the standard framework does not consider how situations in which coercive measures are applied arise. If structural racism causally contributes to such situations, the use of coercion can compound the prior injustice of racist discrimination. We conclude that the ethical analysis of coercion in mental healthcare should consider the possibility of discriminatory biases and practices and systematically take the influence of structural discrimination into account.

Personality disorder type only sometimes matters: An exploration of patient's personality disorder as a source of variance in early therapeutic alliance

OBJECTIVE

The study aimed to analyse personality disorders among patients in the early phase of psychotherapy as a source of variance in the quality of the emerging alliance.

METHODS

The sample consisted of 131 individual psychotherapy patients with borderline (BPD), narcissistic (NPD), dependent (DPD) and obsessive-compulsive (OCPD) personality disorders and 131 psychotherapists. Different sources of alliance estimation were included. Therapeutic alliance was operationalized on several dimensions. The hypothesis was tested using an independent samples one-way analysis of variance.

RESULTS

The study revealed a significant effect of personality disorder type on early therapeutic alliance quality. BPD patients rated their early alliance the lowest compared to NPD, DPD and OCPD patients. This trend was dominant and replicated regardless of who rated the alliance and which dimension of alliance was estimated.

CONCLUSIONS

NPD, DPD and OCPD patients have better initial therapeutic alliances than BPD patients, and their alliances do not differ significantly. BPD patients build weaker alliances, and what poses a challenge for them is not only developing a strong and close bond but also conceptualizing goals and reaching agreement on tasks.

A network approach can improve eating disorder conceptualization and treatment

Eating disorders are severe mental illnesses with the second highest mortality rate of all psychiatric illnesses. Eating disorders are exceedingly deadly because of their complexity. Specifically, eating disorders are highly comorbid with other psychiatric illnesses (up to 95% of individuals with an eating disorder have at least one additional psychiatric illness), have extremely heterogeneous presentations, and individuals often migrate from one specific eating disorder diagnosis to another. In this Perspective, we propose that understanding eating disorder comorbidity and heterogeneity via a network theory approach offers substantial benefits for both conceptualization and treatment. Such a conceptualization, strongly based on theory, can identify specific pathways that maintain psychiatric comorbidity, how diagnoses vary across individuals, and how specific symptoms and comorbidities maintain illness for one individual, thereby paving the way for personalized treatment.

Race bias and gender bias in the diagnosis of psychological disorders

Bias is said to occur when validity is better for one group than another (e.g., when diagnoses are more valid for male or female clients). This article provides (a) a methodological critique of studies on race bias and gender bias in diagnosis and (b) a narrative review of results from studies with good internal validity. The results suggest that race bias occurs for the diagnosis of conduct disorder, antisocial personality disorder, comorbid substance abuse and mood disorders, eating disorders, posttraumatic stress disorder, and the differential diagnosis of schizophrenia and psychotic affective disorders. Other results suggest that gender bias occurs for the diagnosis of autism spectrum disorder, attention deficit hyperactivity disorder, conduct disorder, and antisocial and histrionic personality disorders. The way that symptoms are expressed (e.g., Black cultural expressions of depression) appears to have a significant effect on diagnoses. It may be possible to decrease bias by expanding the use of (a) mental health screening, (b) self-report measures including some psychological tests, (c) structured interviews, and (d) statistical prediction rules. Finally, evidence exists that (a) the diagnosis of personality disorders should be made using dimensional ratings and (b) training in cultural diversity and debiasing strategies should be provided to mental health professionals.

Clients in context: Environment, class, race, and therapists' perceptions of generalized anxiety disorder

Evidence-based practice necessitates the inclusion of client identity and contextual information when conceptualizing diagnosis.

OBJECTIVE

To examine how therapists' perceptions of Generalized Anxiety Disorder is influenced by client environmental contextual and identity factors, like class and race.

METHOD

Therapists (n = 138; 76% women; M_age  = 38.3) were randomly assigned three of six client vignettes and asked to provide diagnostic recommendations, confidence in diagnosis, and perception of client's concerns. Vignettes differed in their description of client class, race, and contextual factors. A linear mixed-model was used to test confidence in diagnosis and generalized linear mixed-models were conducted to predict diagnosis and client concerns.

RESULTS

Therapists altered diagnosis, confidence, and client concerns based on client contextual factors-but not identity factors.

CONCLUSIONS

Therapists consider contextual factors in making clinical decisions, with overall tendency towards diagnosis regardless of if symptoms met the diagnostic criteria of being "excessive" given the environmental context.

Similarities in client-clinician perceptions of subjective social status and its association to similarities in the quality of working alliance and client anxiety symptoms

Subjective social status (SSS) has largely been ignored within psychotherapy literature. We investigated the association between similarities in client-clinician perceptions of SSS, similarities in their report of the quality of working alliance, and resultant anxiety symptoms.

Participants represented a primarily low-income, culturally diverse sample of 312 clients receiving care from 68 clinicians at 13 outpatient mental health clinics in the Northeastern United States between September 2013 and August 2016. As part of a larger randomized controlled trial, clients and clinicians completed the MacArthur Scale of subjective social status and the Working Alliance Inventory (WAI), and clients completed the Generalized Anxiety Disorder 7-item Scale (GAD-7).

At the within-clinician level, client-clinician dyads with less similar perceptions of the client's SSS were characterized by less similar perceptions of their alliance, which in turn resulted in worsening anxiety symptoms.

Clinicians' correct perception of their clients' social status might be important for sharing a similar view of the client-clinician level of alliance, which can, in turn, contribute to lowering the client's anxiety symptoms.

The Role of Culture/Ethnicity in Communicating with Cancer Patients About Mental Health Distress and Suicidality

To explore the role of culture in communicating with cancer patients about mental health distress and suicidality. The Grounded Theory method of data collection and analysis was used. Healthcare professionals (HCPs) reported that language competency was a facilitator while being unable to speak the language or understand the nuances of their patient's communication could be a barrier. HCPs noted that being culturally matched with their patients helped them communicate effectively. HCPs also spoke about religious taboos on suicide as being a barrier to having conversations, either because patients did not feel comfortable discussing these issues, or because they perceived that this was not a topic they could bring up. Some HCPs reported that the culture/ethnicity of their patients had no effect on their ability to communicate effectively with them about mental health distress or suicidality. Advancing effective cross-cultural communication is a challenge faced by HCPs. Raising awareness about communication styles is an important step in addressing communication gaps about mental health and suicide with cancer patients. Training should facilitate skill development to engage in a culturally humble approach to cross-cultural communication including diversity training which encourages asking and actively listening to patients' needs and preferences.

It takes two to self-disclose: Incremental theorists facilitate others' self-disclosure more than do entity theorists

OBJECTIVE

We tested the prediction that incremental theorists are more likely to facilitate others' self-disclosure than are entity theorists.

METHOD

We conducted three studies: (a) a field study that examined client's self-disclosure (N = 122; M_age  = 41.9, 67.8% woman; Israelis) during an intake interview with a professional therapist (N = 38; M_age  = 46.2, 84.20% woman; Israelis), (b) a survey of adults (N = 120; M_age  = 37.14, 57.6% female) who reported self-perceptions and behaviors during conversations and their perceptions of others' self-disclosure. In both studies participants reported their implicit theories, and (c) an experiment (N = 250; M_age  = 28.27, 56.6% female) in which participants whose implicit theories were manipulated reported their opening behaviors during a conversation and their perceptions of others' self-disclosure.

RESULTS

Ones' incremental theory of personality was positively related to another's self-disclosure, to one's opening and disclosure-encouraging behaviors, and was negatively related to one's perceptions of others' self-protection tendency. Furthermore, one's opening behaviors and perceptions of others' self-protection tendencies mediated the effect of one's incremental theory on others' self-disclosure.

CONCLUSION

Those who believe people can grow and change, can influence others to trust their personal information with them, even when the information is negative.

"Why Come for Treatment?" Clients' and Therapists' Accounts of the Presenting Problems When Seeking Mental Health Care

Although identification of main problems is the foundation for treatment planning, limited research has examined reasons for seeking mental health care. We identified reasons for seeking mental health care as reported by clients and therapists upon initial contact with mental health services. We conducted in-depth interviews with clients and their therapists immediately following the intake. We analyzed 117 therapist and 112 client interviews using thematic analysis. Overall interrater reliability among three raters who coded the interviews was high (kappa = 0.72). Our findings suggest that, overall, clients and therapists report similar main area problems that bring clients to care. Emotional distress and other psychiatric symptoms as well as interpersonal problems were most prevalent. Therapists tended to ignore some problem areas that clients highlighted, including physical problems and socioeconomic strains. Raising awareness to potential gaps in perception of main problems that bring clients to care will promote a shared understanding and improve quality of care.

Oncologists' identification of mental health distress in cancer patients: Strategies and barriers

The purpose of this research was to examine oncologists' perspectives on indicators of mental health distress in patients: what strategies they use to identify these indicators, and what barriers they face in this task. Twenty-three oncologists were interviewed, and the grounded theory method of data collection and analysis was used. Oncologists perceived distress to be a normative part of having cancer and looked for affective, physical, verbal and behavioural indicators using a number of strategies. Barriers to identification of mental health distress included difficulty in differentiating between mental health distress and symptoms of the disease, and lack of training. A systematic, time-efficient assessment of symptoms of emotional distress is critical for identification of psychiatric disorders among patients and differentiating normative emotional responses from psychopathology. Clinical bias and misdiagnosis can be a consequence of an ad hoc, intuitive approach to assessment, which can have consequences for patients and their families. Once elevated risk is identified for mental health distress, the patient can be referred to specialised care that can offer evidence-based treatments.

Racial and Ethnic Variation in Perceptions of VA Mental Health Providers are Associated With Treatment Retention Among Veterans With PTSD

BACKGROUND

Veterans with posttraumatic stress disorder (PTSD) who seek mental health care in the Veterans Health Administration frequently discontinue treatment prematurely. Early discontinuation of mental health treatment is more common among Veterans with PTSD who are of minority race or ethnicity.

OBJECTIVES

To determine whether retention in individual therapy or pharmacotherapy among Veterans with PTSD are associated with patients' ratings of their mental health providers, and if those associations differ depending on Veteran race or ethnicity.

RESEARCH DESIGN

Latino, African American, and white Veterans (n=2452) who participated in a prospective national cohort study of Veterans with PTSD at the beginning of an episode of care were surveyed immediately following Veterans' PTSD diagnoses and 6 months later. Pharmacy and mental health service utilization were abstracted from Veterans Health Administration administrative databases for 6 months postdiagnosis. Retention in treatments were modeled using logistic regression among Veterans who initiated individual therapy or pharmacotherapy. Demographics, treatment need, treatment-related beliefs, treatment process measures, and ratings of mental health providers were considered as predictors.

RESULTS

Ratings of mental health providers, more than treatment beliefs, were associated with treatment retention. Among African American Veterans, retention in pharmacotherapy was reduced if the provider was perceived as not having helped manage medication side-effects (odds ratio, 0.36; confidence interval, 0.16-0.80). All Latino Veterans but one (99% or n=64) who rated their therapist as not caring discontinued individual psychotherapy.

CONCLUSIONS

Ratings of mental health providers were associated with treatment retention. The salience of specific provider behaviors to treatment retention varied by Veteran race or ethnicity.