Trends in Subthreshold Psychiatric Diagnoses for Youth in Community Treatment

Abstract

IMPORTANCE: Patterns and trends of subthreshold DSM-IV mental health diagnoses for youth within US community treatment settings merit systematic research. OBJECTIVE: To quantify and assess temporal patterns of DSM-IV diagnoses not otherwise specified (NOS) among youth during physician office visits. DESIGN, SETTING, AND PARTICIPANTS: We conducted a retrospective study using psychiatric diagnostic data from the US National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey (n = 16,295) from 1999 through 2010, combined in 4-year intervals. Using diagnoses from visits to physicians, we compared trends of the proportional distribution of the major psychiatric diagnoses with subthreshold criteria (coded as NOS) with proportions of diagnoses reaching full criteria. MAIN OUTCOMES AND MEASURES: Specific common psychiatric diagnoses NOS compared with full-criteria psychiatric diagnoses. RESULTS: Between the 1999-2002 and 2007-2010 periods, the proportion of US medical visits reporting DSM-IV NOS psychiatric diagnoses compared with the proportion reporting full psychiatric diagnostic criteria for youth aged 2 to 19 years rose prominently for major mood diagnostic subtypes. Among all visits for mood disorders, NOS visits grew proportionally 1.5-fold from 45.3% in the 1999-2002 period to 68.8% in the 2007-2010 period (P < .001). Among visits for bipolar disorder, NOS visits increased more than 18-fold, from 3.6% in the 1999-2002 period to 72.6% in the 2007-2010 period (P < .001). In addition, anxiety disorder NOS increased from 44.6% in the 1999-2002 period to 58.1% in the 2007-2010 period. Overall, NOS visits constituted 35.0% of the total psychiatric visits in 2007-2010 but represented 55.9% when attention-deficit/hyperactivity disorder codes were excluded. CONCLUSIONS AND RELEVANCE: The expansion of subthreshold (NOS) DSM-IV diagnoses of mood disorder, bipolar disorder, and anxiety disorder in youth that has occurred since 1999 in all likelihood will continue in the DSM-5 era unless administrative efforts are made to alter this practice. Unspecified diagnoses lack research reliability and potentially increase the likelihood of off-label prescribing of psychotropic medication.

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