Patterns of psychiatric diagnosis in a county mental health system

This article examines concordance in psychiatric diagnoses received by 280 clients of a county mental health system throughout their history with the system. Automated Information System records from all episodes of care since the first admission to the county system were analyzed, and diagnoses for each client for the first 5, first 10, last 5, and last 10 episodes were compared with generalized kappa. Sequential patterns of diagnosis were also examined. Overall concordance for diagnoses for the last 5 episodes was fair (kappa = .46), and concordance for major depression, bipolar disorder, and paranoid schizophrenia was good. Sequential patterning showed some tendency for more of the clients with a given modal diagnosis to be assigned that diagnosis in the middle of the sequence, and then fewer toward the end of the sequence, possibly because of effects of homelessness. Overall, the degree of concordance was quite high for some of the major disorders and compared favorably with concordance in more rigorous research settings. However, clinicians need to be more aware of the potential for assigning diagnosis based on stereotypical views of clients, as well as the effects of substance abuse and homelessness, in arriving at their diagnoses.