Diagnosis and the Need for Treatment Are Not Linked

Kermit Cole

A longitudinal study of 34,653 non-institutionalized U.S. adults (age ≥20 years) who were interviewed at two time points, 3 years apart, found that those with a diagnosis of depression, anxiety or substance abuse (DAS) use who have not been treated prior to or after the diagnosis had levels of functioning similar to those without a DAS disorder. The authors conclude that “individuals with an untreated DAS disorder at baseline have a substantial likelihood of remission without any subsequent intervention.”

Article →

Sareen, J., Henriksen, C., Stein, M, Afifi, T., Lix, L., Enns, M.; Common mental disorder diagnosis and need for treatment are not the same: findings from a population-based longitudinal survey. Psychological Medicine. 43(09) September 2013, pp 1941-1951

From the abstract:

“Controversy exists regarding whether people in the community who meet criteria for a non-psychotic mental disorder diagnosis are necessarily in need of treatment. Some have argued that these individuals require treatment and that policy makers need to develop outreach programs for them, whereas others have argued that the current epidemiologic studies may be diagnosing symptoms of distress that in many cases are self-limiting and likely to remit without treatment. All prior studies that have addressed this issue have been cross-sectional. We examined the longitudinal outcomes of individuals with depressive, anxiety and substance use (DAS) disorder(s) who had not previously received any treatment.”

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Kermit Cole
Kermit Cole, MFT, founding editor of Mad in America, works in Santa Fe, New Mexico as a couples and family therapist. Inspired by Open Dialogue, he works as part of a team and consults with couples and families that have members identified as patients. His work in residential treatment — largely with severely traumatized and/or "psychotic" clients — led to an appreciation of the power and beauty of systemic philosophy and practice, as the alternative to the prevailing focus on individual pathology. A former film-maker, he has undergraduate and master's degrees in psychology from Harvard University, as well as an MFT degree from the Council for Relationships in Philadelphia. He is a doctoral candidate with the Taos Institute and the Free University of Brussels. You can reach him at [email protected]


  1. This is a very important finding! It really calls the entire DSM enterprise into question – if a diagnosis doesn’t predict need for treatment, and if receiving treatment doesn’t impact the outcome, what is the point of diagnosing someone in the first place???

    —– Steve

  2. Thanks for posting this incredible study! This one is a BIG DEAL. It deserves its own blog post from Bob Whitaker, and plenty of national media attention. In my opinion, it is at least as significant to public health as Martin Harrow’s research.

    The title of this post, “Diagnosis and the Need for Treatment Are Not Linked,” is actually misleading. The study shows quite clearly that diagnosis and treatment are indeed linked, but in the opposite direction treatment advocates would predict. In a sample of 34,653 community adults, those who met DSM criteria for depression, anxiety, and substance use disorders had better mental health outcomes 3 later when no treatment was received. MUCH BETTER. Table 3 in the article shows this quite clearly: http://journals.cambridge.org/download.php?file=%2F12455_09A835953334010212C802E513EB9DB7_journals__PSM_PSM43_09_S003329171200284Xa.pdf&cover=Y&code=cb882683ec086476d36eebf438633b36. From the article (p. 1945): “The data show that the vast majority of people with persistence, co-morbidity or suicidal behavior during the follow-up had incident mental health service use in comparison to a minority of people with remission of the disorder. X2 analyses showed a significant difference across all types of disorders.” Translation: all outcomes examined were significantly worse among those who had received treatment for their mental health problems.

    The authors interpreted their findings quite conservatively, in a manner reminiscent of Martin Harrow’s interpretation of his schizophrenia treatment research. My reading of this study yields two primary conclusions: (a) adults with the most common, “bread and butter” DSM diagnoses experience worse outcomes with treatment than without, and (b) this is especially true for those with a prior history of treatment. The huge size of the sample and the robustness of the results suggest these findings are legitimate and replicable. This study raises a serious challenge to the mental health treatment industry, particularly those who advocate for screening and primary prevention (e.g., “National Depression Screening Day”), and further suggests that for many people, mental health problems often described as “chronic brain diseases” self-correct over time even without (actually, especially without) treatment.

    For me, the key to understanding these findings is to ascertain what is meant by “treatment.” The authors had access to four treatment questions (including inpatient hospitalization and medication prescription) but did not specify how they measured “treatment.” Presumably, participants received “treatment” if they answered “Yes” to the following question: “Did you EVER go to any kind of counselor, therapist, doctor, psychologist or any person like that to get help for your fear/low mood/panic/etc.?” I’m left with the burning question, “how did the effects of treatment differ among those who received medication vs. those who did not?” I’ll contact the authors and see what I can find out.

  3. Diagnosis is a double-edge sword, but an “atomic” approach is good …

    Diagnosis can be reassuring – to know that others have been through similar problems. In our “blame game” society, some people take comfort in the medical model that says “it’s a brain disease and not your fault”.

    However, the DSM approach to diagnosis is dangerous as it can turn a temporary problem into a chronic illness!

    The biggest problem are the assumptions that lead on from a diagnosis:

    1) You have these symptoms

    2) It’s called something, e.g. Bipolar.

    3) You may also have these symptoms (increases anxiety & is self fulfilling)

    4) It’s a physical illness – a brain disease (despite no evidence or clinical tests)

    5) It’s a permanent disability and your life will never be the same again.

    6) You need to take a whole bunch of meds to fix the problem.

    7) Let us distract you with different meds until you acquiesce

    8) Trust us, and don’t ask questions!

    Step (1) is valid but everything else is guesswork! The criminal thing is that a story is fabricated despite evidence to the contrary.

    I prefer a “phenomenological” approach to diagnosis:

    1) You have these symptoms

    2) It could be temporary

    3) Clinical tests haven’t revealed a physical problem.

    4) The brain is the most complex thing in the universe, so instead of guessing we’ll ask you some questions:

    a) What are your current life stresses at the moment?

    b) How are you sleeping?

    The only thing I don’t like about the phenomenological approach is the name. I myself have come up with the term “atomic” diagnosis.

    This is an interesting article, which can be used to argue the same point for psychotic disorders.