The Cost of Checklists in Psychiatry

"When the DSM-III appeared in 1980, it broke with earlier editions that reflected rivalries among psychodynamic, behavioral, and biological schools. Its architects sought to resolve diagnostic muddle by introducing field-guide-style checklists of signs and symptoms. By bracketing causation, psychiatry gained diagnostic consistency, uniform regimens, and greater research confidence."

"The unintended consequence has been a drift toward top-down diagnosis by checklist, with little attention to biography, detailed mental status, or corroborative history. Although efficient, this method flattens complexity. Patients with bereavement, job loss, academic difficulty, or demoralization may all be assigned the same DSM category. Such blurring undermines nuance, dilutes research findings, and broadens prescribing beyond evidence-based boundaries. Psychiatric disorders cannot be understood without biography, context, and causation."

DSM-III introduced field-guide-style checklists in 1980, producing diagnostic consistency, uniform treatment regimens, and stronger research confidence by bracketing causation. The checklist model narrowed psychiatric assessment, prioritizing symptom counts over biography, causation, and detailed mental-status examination. That narrowing enabled efficient, top-down diagnoses that flatten patient complexity and group diverse experiences under identical categories. The alignment with insurance structures and pharmaceutical marketing encouraged widespread prescribing of benzodiazepines, SSRIs, and stimulants beyond guideline indications. Resultant polypharmacy increases adverse effects with limited additional benefit. Reimbursement models favor medication over psychotherapy, reinforcing profit-driven overprescribing.

Read at Psychology Today