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Influence of comorbid depression and diagnostic workup on diagnosis of physical illness: a randomized experiment

  • Linda M. Isbell EMAIL logo , Mark L. Graber , Daniel R. Rovenpor and Guanyu Liu
Published/Copyright: April 27, 2023
Diagnosis
From the journal Diagnosis Volume 10 Issue 3

Abstract

Objectives

Patients with mental illness are less likely to receive the same physical healthcare as those without mental illness and are less likely to be treated in accordance with established guidelines. This study employed a randomized experiment to investigate the influence of comorbid depression on diagnostic accuracy.

Methods

Physicians were presented with an interactive vignette describing a patient with a complex presentation of pernicious anemia. They were randomized to diagnose either a patient with or without (control) comorbid depression and related behaviors. All other clinical information was identical. Physicians recorded a differential diagnosis, ordered tests, and rated patient likeability.

Results

Fifty-nine physicians completed the study. The patient with comorbid depression was less likeable than the control patient (p=0.03, 95 % CI [0.09, 1.53]). Diagnostic accuracy was lower in the depression compared to control condition (59.4 % vs. 40.7 %), however this difference was not statistically significant χ2(1)=2.035, p=0.15. Exploratory analyses revealed that patient condition (depression vs. control) interacted with the number of diagnostic tests ordered to predict diagnostic accuracy (OR=2.401, p=0.038). Accuracy was lower in the depression condition (vs. control) when physicians ordered fewer tests (1 SD below mean; OR=0.103, p=0.028), but there was no difference for physicians who ordered more tests (1 SD above mean; OR=2.042, p=0.396).

Conclusions

Comorbid depression and related behaviors lowered diagnostic accuracy when physicians ordered fewer tests – a time when more possibilities should have been considered. These findings underscore the critical need to develop interventions to reduce diagnostic error when treating vulnerable populations such as those with depression.

Keywords: affective and cognitive biases; clinical reasoning; comorbid depression; diagnostic error; randomized experiment
Corresponding author: Linda M. Isbell, PhD, Department of Psychological and Brain Sciences, University of Massachusetts, 135 Hicks Way, Amherst, MA 01003, USA, E-mail:

Funding source: Agency for Healthcare Research and Quality

Award Identifier / Grant number: R01HS025752

Acknowledgments

We thank Charles P. Friedman, PhD for providing us with the clinical case used in the current study. In accordance with an agreement with Dr. Friedman to use his cases for research purposes, we are unable to distribute or share the clinical case used in this study.

  1. Research funding: This project was partially funded by a grant from the Agency for Healthcare Research and Quality (AHRQ; grant number R01HS025752), US Department of Health and Human Services (HHS) awarded to LMI. The authors are solely responsible for this document’s contents, findings and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of HHS.

  2. Author contributions: All authors have accepted responsibility for the entire content of this manuscript and approved its submission.

  3. Competing interests: Authors state no conflict of interest.

  4. Informed consent: Informed consent was obtained from all individuals included in this study.

  5. Ethical approval: Research involving human subjects complied with all relevant national regulations, institutional policies and is in accordance with the tenets of the Helsinki Declaration (as revised in 2013) and has been approved by the authors’ Institutional Review Board (Protocol #: 2016-3291).

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Supplementary Material

This article contains supplementary material (https://doi.org/10.1515/dx-2020-0106).

Received: 2020-07-28
Accepted: 2023-03-22
Published Online: 2023-04-27

© 2023 Walter de Gruyter GmbH, Berlin/Boston

Articles in the same Issue

  1. Frontmatter
  2. Review
  3. Cognitive biases in internal medicine: a scoping review
  4. Opinion Papers
  5. “Pivot and Cluster Strategy” in the light of Kahneman’s “Decision Hygiene” template
  6. Developing a European longitudinal and interprofessional curriculum for clinical reasoning
  7. Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic error (SPADE): comparison groups to maximize SPADE validity
  8. Reframing context specificity in team diagnosis using the theory of distributed cognition
  9. Original Articles
  10. Promoting clinical reasoning with meta-memory techniques to teach broad differential diagnosis generation in a pediatric core clerkship
  11. Semantic competence and prototypical verbalizations are associated with higher OSCE and global medical degree scores: a multi-theory pilot study on year 6 medical student verbalizations
  12. Influence of comorbid depression and diagnostic workup on diagnosis of physical illness: a randomized experiment
  13. Recognition, diagnostic practices, and cancer outcomes among patients with unintentional weight loss (UWL) in primary care
  14. Quantitation of neurofilament light chain protein in serum and cerebrospinal fluid from patients with multiple sclerosis using the MSD R-PLEX NfL assay
  15. Analysis of common biomarkers in capillary blood in routine clinical laboratory. Preanalytical and analytical comparison with venous blood
  16. Comparison between cerebrospinal fluid biomarkers for differential diagnosis of acute meningitis
  17. Short Communications
  18. Exploring relationships between physician stress, burnout, and diagnostic elements in clinician notes
  19. Development of a student-created internal medicine frameworks website for healthcare trainees
  20. Case Report - Lessons in Clinical Reasoning
  21. Lessons in clinical reasoning – pitfalls, myths, and pearls: a case of crushing, substernal chest pain
  22. Letters to the Editor
  23. Ample room for cognitive bias in diagnosing accidental hypothermia
  24. Auscultation order of lung and heart sounds and autonomous noise cancellation
  25. Reliability of a single-nostril nasopharyngeal swab for diagnosing SARS-CoV-2 infection
https://doi.org/10.1515/dx-2020-0106
Keywords for this article
affective and cognitive biases; clinical reasoning; comorbid depression; diagnostic error; randomized experiment

Articles in the same Issue

  1. Frontmatter
  2. Review
  3. Cognitive biases in internal medicine: a scoping review
  4. Opinion Papers
  5. “Pivot and Cluster Strategy” in the light of Kahneman’s “Decision Hygiene” template
  6. Developing a European longitudinal and interprofessional curriculum for clinical reasoning
  7. Optimizing measurement of misdiagnosis-related harms using symptom-disease pair analysis of diagnostic error (SPADE): comparison groups to maximize SPADE validity
  8. Reframing context specificity in team diagnosis using the theory of distributed cognition
  9. Original Articles
  10. Promoting clinical reasoning with meta-memory techniques to teach broad differential diagnosis generation in a pediatric core clerkship
  11. Semantic competence and prototypical verbalizations are associated with higher OSCE and global medical degree scores: a multi-theory pilot study on year 6 medical student verbalizations
  12. Influence of comorbid depression and diagnostic workup on diagnosis of physical illness: a randomized experiment
  13. Recognition, diagnostic practices, and cancer outcomes among patients with unintentional weight loss (UWL) in primary care
  14. Quantitation of neurofilament light chain protein in serum and cerebrospinal fluid from patients with multiple sclerosis using the MSD R-PLEX NfL assay
  15. Analysis of common biomarkers in capillary blood in routine clinical laboratory. Preanalytical and analytical comparison with venous blood
  16. Comparison between cerebrospinal fluid biomarkers for differential diagnosis of acute meningitis
  17. Short Communications
  18. Exploring relationships between physician stress, burnout, and diagnostic elements in clinician notes
  19. Development of a student-created internal medicine frameworks website for healthcare trainees
  20. Case Report - Lessons in Clinical Reasoning
  21. Lessons in clinical reasoning – pitfalls, myths, and pearls: a case of crushing, substernal chest pain
  22. Letters to the Editor
  23. Ample room for cognitive bias in diagnosing accidental hypothermia
  24. Auscultation order of lung and heart sounds and autonomous noise cancellation
  25. Reliability of a single-nostril nasopharyngeal swab for diagnosing SARS-CoV-2 infection
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