Shrink's Views

ramblings of an unknown psychiatrist

‘Agreement’ among Psychiatrists and Legal proffessionals:Towards better Mental Healthcare and Justice

Posted by Dheeraj Kattula on October 12, 2009

Consider a psychiatrist who diagnoses ‘severe depressive disorder with psychotic features’ in a patient. He makes diagnoses like this everyday. How can we be sure that he is making a right diagnosis? How do we judge? Usually this would be based on his qualifications and training. Isn’t it? What is training? How does training help?

A psychiatrist learns a set of criteria based on which he makes the diagnosis. He learns this process by observing senior psychiatrists till he begins to identify signs and symptoms just like them. This happens to every student of psychiatry. So at the end of a long period of training every student would probably make same diagnosis on seeing the same patient. Practically this does not happen in all cases. It would be in ‘typical’ cases but not all cases. When two doctors see a patient separately and diagnose a patient to have an illness or clear him as not having an illness, we can say they are in ‘agreement’. When one diagnoses a illness and another clears the same patient as not having an illness, we can say they are in ‘disagreement’.

The criteria for diagnosis are formulated in such a way that agreement of responses is made possible to the maximum extent. For example, we can study two psychiatrists by making them assess 100 patients among whom there are few patients with depressed mood. Each psychiatrist is asked to evaluate for depressive symptoms. At the end of the study usually psychiatrist A and psychiatrist B would have agreed on certain people to have depressive symptoms and certain to not have depressive symptoms. There would be certain people whom A would have said to have depressive symptoms which B would have cleared them off as not having depressive symptoms. There would be another set of people whom B would have said to have depressive symptoms which A would have cleared them off as not having depressive symptoms.

If B was a 10 year old boy who would toss a coin and call all ‘heads’ as ‘depressive symptoms’ and all ‘tails’ as ‘no depressive symptoms’, there would still be some agreement between A and B. This is because of chance. Isn’t it? We can adjust for chance ‘agreement’ and find ‘true agreement’ by calculating a statistic called Kappa. If Kappa is high, it means that level of agreement is high.

Lately, I have found many lawyer friends. I discuss legal issues with them. I have been learning much from them. I also bore them with theoretical questions like this one- what is the level of agreement among judges while sentencing convicts?

For example there are 100 convicts. How would Judges A and B sentence them? There would be few to who both might give strict punishment. There would be few for who both would give liberal punishment (not so strict). There would be few, for whom one would give a strict punishment and another would give a liberal one.

Judge A

Punishment strict

Punishment liberal

Judge B

Punishment strict

🙂

😦

Punishment liberal

😦

🙂

Intuitively the level of agreement ought to be high, if one were to have faith in the legal system. The smiley in the table indicates that there is no problem when there is agreement.The sad face reflects feelings when a person could possibly be getting the wrong sentence.

To my surprise, many of my lawyer friends felt that agreement would probably be less. I was also shocked to see that they were comfortable with this lack of ‘clarity’. I sensed how other doctors perceived the low agreement levels in few of the psychiatric diagnosis. But ‘psychiatric diagnosis’ is of less significance than a ‘sentence’ in court. A disagreement in psychiatry might mean a patient might take a medicine for few extra months. Whereas a disagreement in a court of law might mean a death sentence for someone!!! How can lawyers be comfortable with this sort of system?

There is another principle which operates in the legal system. That principle allows a party to ‘appeal’ to a higher court. Just in case a party feels justice was not delivered in a court of law, then the party could appeal to a higher court. The higher court would look at evidence again and pass a fresh judgement. Courts are organized in such a way that there are 3-4 levels till which a case can be taken up. How on earth does this help? Let us see it- statistically!

Let us assume an average Judge has 90% accuracy in making his judgements. If he were to sentence 1000 people, he would have 900 correct decisions and 100 errors. If these 100 go to a higher court, 90 sentences would be corrected and only 10 errors would remain. If these 10 go to an even higher court 9 would be corrected and only 1 would end up getting a wrong sentence. This model assumes that every judge has 10 % error in judgements. The truth is that as we move to the higher courts there would be judges with less error rates. This is because higher courts have judges with more experience and better track records. This ensures that justice does get served.

Hmmm… Now I know realize why they were comfortable. It reminds me of what I do when I have a diagnostic dilemma in an atypical case. I would ask my peers to see the patient. If we ‘agree’ I assume that we are right. Something like this happens when courts use a ‘jury’. What do I do when my peer and I ‘disagree’? We ask a senior’s opinion. It would be usually someone with more experience and knowledge. Hey…That is like an ‘appeal’ to a higher court in the legal system. What can be done if the agreement among judges at higher courts is low? Make the law more comprehensive and clear! This is similar to what psychiatric researchers do, while revising the diagnostic criteria.

Wow! Is it not amazing to see commonalities in approach of lawyers and psychiatrists? We also share a common desire for our clients. That is the client’s well being. But, it is funny that we don’t seem to understand each other in our arguements. We would…soon 🙂

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