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Poor Practice, Managed Care, and Magic Pills: Have We Created a Mental Health Monster?

Anyone working in the mental health field will recognize that in patients with extreme irritability, explosive behavior, or quick mood changes, bipolar disorder (BD) is often unquestionably diagnosed. Thus, it is no surprise that a recent US study indicated a 10-year 40-fold increase in BD diagnosis in pediatric patients.¹

A mental health monster

Three factors are largely responsible for the phenomenon: poor practice, managed care, and a pill-pushing society.

• Poor practice. Even though the standard of care in psychiatry is structured around standardized assessments and measurement-based practice, this may not be adhered to in community clinics, private practices, and even academic centers. In addition, residents and fellows in training may not have been exposed to structured interviewing. Clearly, this perpetuates unstructured interviewing and impressionistic diagnostic assessments in clinical settings.
• Managed care. Many managed care companies do not allow those patients who are clearly a danger to self or others to be admitted to acute psychiatric units with diagnoses such as substance use disorders, conduct disorders, and intermittent explosive disorders. Combined with impressionistic diagnostic practices, this phenomenon makes BD the diagnosis of choice to get reimbursement for evaluation and treatment.
• Pharmacotherapy. Rather than taking responsibility for interpersonal and family dynamics, or going through labor-intensive psychotherapeutic interventions, many parents opt for the quick fix of a BD diagnosis. A diagnosis of BD not only justifies psychopharmacological interventions, but it also arguably absolves the family of personal responsibility. The fact that managed care has led to pharmacotherapy being less expensive than intensive psychotherapy has enhanced the “McDonaldization” of mental health care.

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