In 1959, Dr. Julian Lasky decided to conduct an experiment: How well could psychiatrists and hospital staff at a V.A. general-medicine and surgical hospital use individual patient interviews to predict post-hospital adjustments among their psychiatric patients? Once a month over a period of six months, Lasky gathered predictions on factors such as rehospitalization, work, family, and health adjustment. He then correlated those predictions, along with a number of other possible predictive factors, with actual readjustment success. He discovered something striking: the single strongest predictor of a patient’s adjustment success was the weight of his case file. The heftier the file, the less likely a patient was to successfully readjust to life outside of the hospital. File weight significantly predicted every single outcome criterion—from the patient’s ability to hold a job to his capacity for carrying on a successful, long-term romantic relationship—more accurately than monthly interviews, as well as other behavioral and self-report measures. And in the case of some factors, such as the chances of rehospitalization, the correlation was remarkably high. The natural conclusion was that the best predictor of future behavior is past behavior.
In some ways, not much has changed since those early days of clinical diagnosis. The director of the National Institute of Mental Health, Thomas Insel, announced last week that the institute would be officially reorienting its research agenda away from the categories in the soon-to-be-published fifth edition of the Diagnostic and Statistical Manual of Mental Disorders and toward a new set, the Research Domain Criteria (R.D.O.C.): “Unlike our definitions of ischemic heart disease, lymphoma, or AIDS, the DSM diagnoses are based on a consensus about clusters of clinical symptoms, not any objective laboratory measure. In the rest of medicine, this would be equivalent to creating diagnostic systems based on the nature of chest pain or the quality of fever.” In other words, we are still relying on the subjective assessments that lost out to the weight of the case file over half a century ago.
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