The deliberate misdiagnosis of major depression in primary care.
OBJECTIVE
Because the correct diagnosis of a psychiatric condition can jeopardize reimbursement and other benefits, physicians deliberately substitute alternative diagnoses. We estimated the prevalence of alternative coding for major depression by primary care physicians and the reasons for its occurrence.


METHODS
Cross-sectional mail survey with telephone follow-up of nonresponders.


METHODS
Primary care practices in communities across the nation.


METHODS
Physicians were eligible to participate if they were randomly selected from membership lists of two professional organizations of primary care clinicians. Four hundred forty-four physicians (70.0% of eligible physicians and 89.5% of eligible physicians we could locate) completed the survey by mail or telephone.


METHODS
Substitution of an alternative code for major depression within a 2-week period.


RESULTS
Of our respondents, 50.3% (SE, +/- 2.5%) reported that they had substituted another diagnostic code during a 2-week period for one or more patients whom they recognized met the criteria for major depression in the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition. Thirty-one percent of depressed patients received alternative codes. The most common reasons for these substitutions involved physician uncertainty about the diagnosis and problems with reimbursement for services if a diagnosis of major depression was coded.


CONCLUSIONS
The practice of deliberately substituting another diagnostic code for major depression is widespread among primary care providers. Physicians who employ deliberate misdiagnosis circumvent inequitable policies for particular patients, but the impact of substitution on the health care system as a whole deserves more careful consideration.
Department of Veterans Affairs Health Services Research, University of Arkansas for Medical Sciences, Little Rock.
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Rost
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Smith
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Matthews
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Guise
D000328:Adult; D003430:Cross-Sectional Studies; D003866:Depressive Disorder / Q000145:classification* / Q000175:diagnosis; D003953:Diagnosis-Related Groups; D005194:Family Practice; D006801:Humans; D007344:Insurance Claim Reporting; D011795:Surveys and Questionnaires; D035501:Uncertainty