Potential benefits of diagnosis

Stories from doctors and the press, which detail serious disease potentially cured or ameliorated as a result of intervention by hawk-eyed doctors, reveal the most important function provided by an unsolicited diagnosis: it is a formulation which opens up a route to formal diagnosis and treatment through contact with health professionals. In the case of a colleague showing behavioural disturbance, the doctor standing by and doing nothing out of concern for offending his colleague or for his own sense of professionalism may be making the greater error. Concern for psychiatric colleagues might take into account the fact that psychiatrists have one of the highest suicide rates among medical specialties. ^{Reference Hawton, Clements, Sakarovitch, Simkin and Deeks7} Encouragement to seek help does not require a diagnosis; a humane concern for the suffering of others and a sympathetic ear is more appropriate, even if that offer turns out to be unappreciated. Indeed, should we suspect a colleague’s behaviour or judgement to be sufficiently disturbed that it may impair their fitness to practise, licensing bodies such as the General Medical Council require us to address the issue with the person or appropriate manager.

Facilitation of such contact is of particular importance in the case of mental health problems. Even though the lifetime prevalence of mental disorder is estimated to be 50% of individuals, only a small proportion receive professional treatment in any year, even among those reporting substantial distress and role impairment. ^{Reference Katz, Kessler, Frank, Leaf, Lin and Edlund8} Indeed, only about a half of individuals with addictive disorders or phobias ever receive treatment during their lifetime, and there is a median delay from symptom development to treatment of 6 years for major depression and 14 years for generalised anxiety disorder. ^{Reference Kessler, Olfson and Berglund9} This is especially worrying considering that for some disorders such as schizophrenia delay in treatment is associated with a poorer outcome. ^{Reference Harrigan, McGorry and Krstev10} People are frequently reluctant to disclose psychological symptoms in general practice consultations, ^{Reference Prior, Wood, Lewis and Pill11} either on account of stigma or believing that such symptoms are ‘part of life’ rather than representing a potential health problem. Furthermore, the public deems self-help to be the most efficacious intervention for psychiatric disorder; ^{Reference Jorm12} even when people do enlist the help of others, they do not necessarily see health professionals as their first port of call. In the USA, a quarter of those who seek help turn to clergy, whereas psychiatrists and medical doctors are contacted by only 17%. ^{Reference Wang, Berglund and Kessler13} The public may regard psychiatry with suspicion and its methods as harmful ^{Reference Jorm12} and, as a consequence, they are reluctant to seek help or adhere to treatment. ^{Reference Fischer, Goerg, Zbinden, Guimón, Guimón, Fischer and Sartorius14} However, they are more likely to seek help when told to do so by another person. ^{Reference Vogel, Wade, Wester, Larson and Hackler15}

Psychiatric conditions have a particularly poor prognosis, increasing the potential benefits of (and thereby lowering the threshold for) unsolicited diagnosis. For example, approximately 1 in every 20 people with depression, alcoholism or schizophrenia kills themselves (with the greatest risk being soon after symptom onset). ^{Reference Inskip, Harris and Barraclough16} The possibility of risk of harm to others (albeit highly unlikely in most cases of mental disorder) presents a particular diagnostic exigency which is not shared with physical conditions (save for certain infectious diseases and conditions impairing ability to drive). ^{Reference Mitchell17} Mental disorder also carries a high social burden to friends, family and others.

In summary, the benefits to the recipient of an unsolicited diagnosis may include a substantial decrease in both morbidity and mortality. There may also be benefits to society through decreased social burden. Other significant primary and secondary gains may emerge, most notably the sense of relief and removal of responsibility for ‘bad’ behaviour which are a function of gaining a medical ‘label’ for what might otherwise be seen by the self and others as ‘deviant’ behaviour. ^{Reference Chadwick18}

Risk of harm

Unsolicited diagnosis also carries a risk of harm. Type I errors (false-positive diagnoses, which hold the potential to cause their recipient grave psychological and physical harm) are a risk of any diagnosis, no matter whether of physical or mental disorder, and whether solicited or not. However, psychiatric diagnosis, due to its reliance upon a process of extensive clinical history and mental state examination (which is likely impractical or inappropriate in an informal setting) may be particularly liable to type I error; even in formal settings, the majority of positives generated by brief psychiatric screening instruments are false positives (although, in fact, the positive predictive value of such instruments is no worse than for physical screening tests such as faecal occult blood testing or mammography). ^{Reference Leon, Portera, Olfson, Weissman, Kathol and Farber19} Two types of false positive errors may be made by the diagnostician: (1) wrongly attributing psychiatric disorder to a person; and (2) correctly attributing psychiatric disorder, but being mistaken as to the actual diagnosis.

It could be countered that owing to their necessary foundation on less than optimal clinical information, both psychiatric and physical diagnoses will be accordingly inaccurate to greater or lesser degrees when made in informal contexts. For example, a formal diagnosis of myocardial infarction, in addition to clinical history, requires abnormal electrocardiographic activity and/or elevated serum cardiac markers, ^{Reference Gillum, Fortmann, Prineas and Kottke20} which are clearly not data that can be gleaned in an informal setting. That does not, however, mean that making an unsolicited diagnosis of a myocardial infarction upon seeing a breathless man gripping his chest is clinically presumptive, if the aim of making it is to set in train a series of events that will result in the person receiving formal diagnosis and treatment. Likewise, it does not matter when an unsolicited diagnosis of major depression in fact turns out to be bipolar disorder or schizoaffective disorder, if it spurs its recipient into getting treatment. Thus, although psychiatric diagnoses (whether solicited or not) are frequently criticised for having poor interrater reliability (and, indeed, validity), ^{Reference Spitzer and Fleiss21} this does not necessarily undermine their utility ^{Reference Kendell and Jablensky22} if they eventually result in benefit for the recipient.

Mistaking a condition for one more serious than that by which a person is actually affected can cause particular problems for the person for whom the diagnosis is made. A goitre may indicate thyroid cancer but is more likely caused by thyroiditis; flattened affect could indicate schizophrenia or mild depression. If the goal of unsolicited diagnosis is as catalyst to formal diagnosis and treatment, then the graver diagnosis comes with a correspondingly increased risk of maleficence. This suggests that circumlocutory language of a formulation would be more appropriate than a specific diagnosis in most cases, pointing out the possibility of a problem potentially amenable to treatment and encouraging contact with healthcare professionals in general terms (inaccurate diagnoses may also be subsequently presented as a ‘fait accompli’ by their recipient, prejudicing further diagnosis and treatment).

Some such risks can be offset if the diagnostician has a level of intimacy with the person for whom they make a diagnosis. Indeed, in the case of unsolicited diagnoses of both psychiatric and physical disorder, applying one’s expertise to a person with whom we are familiar is likely to be seen by doctors as more ethically palatable than doing so for a relative stranger. In the case of unsolicited psychiatric diagnosis, only in the context of such intimacy is the diagnostician likely able to obtain a reasonable history and mental state examination. Low mood and trouble sleeping would be unreliable signs of depression if confided by a casual acquaintance without context; the same symptoms will carry far greater probative value if observed over a period of time, and apparently without cause, in person whom the diagnostician knows intimately (although psychiatric examination of such persons carries its own ethical issues).

Other situations may be envisaged where harm is likely to result from unsolicited diagnosis, for example, when making an unsolicited diagnosis of a condition which the person has already presented to a health professional. It is easy to see the potential stress caused by telling a person that they show signs of mental disorder, when they had already sought help for such problems. Indeed, there might be a general presumption that behaviour abnormal enough to draw an unsolicited diagnosis might already have resulted in presentation to a health professional, on account of the public’s ability to recognise mental disorder (even if they struggle to differentiate between various disorders). ^{Reference Jorm12} If accepted, this hypothesis would considerably reduce the need for, and ethical acceptability of, unsolicited diagnosis.

An unsolicited diagnosis will not be of benefit to the person who is not likely, or not able, to follow it up, either through incapacity or inability to access suitable healthcare resources. Those who have egosyntonic psychiatric symptoms (or who derive significant primary or secondary gains from their symptoms) might be particularly unlikely to follow up an unsolicited diagnosis. For example, van Putten and colleagues ^{Reference van Putten, Crumpton and Yale23} identified a group of psychotic patients who did not adhere to pharmacotherapy because they preferred their grandiose psychotic state over a medicated but sober reality. The inability of such persons to benefit from downstream ‘formal’ diagnoses and treatment leaves potential for harm as the only consequence of unsolicited diagnosis.

There is also great potential for ‘downside’ and little ‘upside’ to making unsolicited diagnoses, if the condition being diagnosed has a particularly poor prognosis, or little exists by way of treatment or palliation.

Types of harm particular to unsolicited psychiatric diagnosis

Aside from the usual negative effects of receiving a diagnosis of illness (a potentially significant source of stress and worry), differences in the social consequences of being diagnosed with psychiatric and physical disorder entail different ethical considerations for the diagnostician in formal and informal settings.

The first issue to be considered is stigma. People with mental disorder may face negative attitudes and discrimination from other members of society. ^{Reference Crisp, Gelder, Rix, Meltzer and Rowlands24} That the diagnostician may not him- or herself attach stigma to the person’s diagnosis is of no consequence (although it is a worrying finding that health professionals may themselves perpetuate stigma towards people with mental disorder). ^{Reference Corker25} If the person holds negative beliefs about individuals with mental disorder, and as a result of unsolicited diagnosis believes that they might be one of those people, they are liable to hold (or believe that others hold) negative beliefs towards themselves. This ‘self-stigma’ results in loss of self-esteem and self-efficacy, and is associated with poorer clinical outcomes. ^{Reference Watson, Corrigan, Larson and Sells26,Reference Corrigan and Watson27}

Concern about confidentiality is another source of specific potential harm. Mental health (along with sexual/reproductive health and drug use) is a category of health information with which people have particular confidentiality concerns. ^{Reference Sankar and Jones28} By having an unsolicited diagnosis made in an informal setting, the person might presume that the diagnostician could be equally as informal in respect of confidentiality with regard to that diagnosis, especially as some patients believe (sometimes correctly) that doctors and nurses share confidential medical information with family and friends. ^{Reference Sankar, Mora, Merz and Jones29}

Finally, it might be argued that an unsolicited psychiatric diagnosis presents the opportunity for the health professional to commit a particularly grave transgression of the limits of his or her profession that an unsolicited physical diagnosis does not.

Limits of practice

The transgression of the limits of practice is a function of differing views about treatment for physical and psychiatric conditions in the mind of the public and many professionals. Harm may of course occur to persons with solicited or unsolicited physical diagnoses (particularly through adverse effects of pharmaceutical or surgical intervention), but the public holds more positive attitudes towards treatment for physical conditions than for psychiatric conditions. ^{Reference Angermeyer, Daumer and Matschinger30} Popular images of psychiatric treatment focus on negative and paternalistic issues such as involuntary detention and electroconvulsive therapy. ^{Reference Jorm12}

In the same way, members of society, researchers, and mental health professionals of a critical or anti-psychiatry persuasion, ^{Reference Double31} who concentrate on the adverse effects of diagnosis and treatment, might regard the labelling of the individual through unsolicited psychiatric diagnosis as particularly unpalatable and paternalistic; that the diagnosis carries a high risk of being incorrect or a false positive is likely to prove doubly so. The situation differs from that in which a person voluntarily seeks a diagnosis on account of distress from symptoms of mental disorder (although those critical of the consequences of psychiatric diagnosis would argue that both situations result in an unnecessary medicalisation of ‘problems of living’). ^{Reference Szasz32}

Such notions echo the downstream consequences of receiving a ‘dangerous and severe personality disorder’ label in the UK, an unsought ‘diagnosis’ which can result in potential harm through deprivation of liberty, and one which has resulted in considerable introspection by the psychiatric profession as to their limits of practice. ^{Reference Sarkar33}

As diagnoses can harm their recipients, so can they be of harm to those who award them. Delivering unsolicited diagnoses to strangers fits with a popular conception of psychiatrists constantly analysing everyone they encounter, and is thus hardly compatible with attempts by psychiatrists to portray themselves as professionals whose special training does not cause them to somehow judge or monitor the behaviour and utterances of others. Indeed, the American Psychiatric Association deems that ‘it is unethical for a psychiatrist to offer a professional opinion unless he or she has conducted an examination and has been granted proper authorization’. ³⁴ This so-called ‘Goldwater rule’ was designed to apply to psychiatric analysis of public figures following publication of a damning survey of psychiatrists into the psychological characteristics of the US presidential candidate, Barry Goldwater. ^{Reference Post35} It does highlight, however, the profession’s rightful concern with causing negative effects upon an individual through flippant commentary or without in-depth knowledge of an individual case.