What should the standard of care for psychiatric diagnostic evaluations be?

Recent research has raised concerns about the adequacy of psychiatric diagnostic evaluations conducted in routine clinical practice. Semistructured diagnostic interviews have been considered the diagnostic gold standard. Judged against this standard, studies comparing unstructured clinical evaluations with semistructured interviews have found that there is a high rate of missed diagnoses and misdiagnosis using the usual clinical assessment. Whether this is clinically significant is uncertain because there are no studies that have examined whether the use of standardized research interviews improves clinical outcome. Based on common sense, however, it seems reasonable that greater diagnostic precision will improve outcome. More complete and accurate diagnostic evaluations may impact on patients' satisfaction with the diagnostic assessment, alliance with the treating clinician, selection of medication, or recommendation for psychotherapy. Additionally, improved diagnostic practice may be a better predictor of course and outcome, another important function of diagnosis. In the meantime, until studies are conducted to determine whether standardized research-like evaluations improve outcome or the prediction of outcome, clinicians may want to consider whether one of the recently developed broad-based self-administered diagnostic screening questionnaires could be a useful adjunct to their unstructured diagnostic interview. The results of recent work on the Psychiatric Diagnostic Screening Questionnaire (PDSQ) are summarized.