interviews with patients or their caregivers regarding the patient’s symptoms and a clinician’s application of expert, but still subjective, judgment. Moreover, different types of clinicians vary in the breadth, depth, and theoretical basis of their training (see Chapter 7). As a result, individuals with the same symptoms presenting to different mental health clinicians can receive very different diagnoses (Eaton et al., 2000; Kramer et al., 2000; Lefever et al., 2003; Lewczyk et al., 2003; McClellan, 2005; Mojtabai, 2002). In children, diagnoses may have an even greater range of variability because clinicians are greatly dependent upon parents’ perceptions of the nature of the presenting problem. Subjectivity in diagnosis is also manifest in the different diagnoses received by individuals who are members of ethnic minorities (Bell and Mehta, 1980, 1981; Mukherjee et al., 1983). Criteria for accurately diagnosing M/SU problems and illnesses are found in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, now in its revised fourth edition (DSM-IV-TR). However, adherence to these guidelines is not uniform (Rushton et al., 2004), nor is training on the appropriate use of this manual required for professional credentialing.

Mode of Clinician Practice

A substantial proportion of mental health clinicians report that “individual practice” is either their primary or secondary2 employment setting (Duffy et al., 2004) (see Table 2-2).

Among primary care and specialist physicians who are self-employed or employees of physician-owned medical groups,3 psychiatrists are most likely to work in solo practices or small groups. Fully 85 percent practice in groups of one to three clinicians, compared with 53 percent of physicians overall, 54.9 percent of pediatricians, and 62.7 percent of internists (Cunningham, 2004).

Individual practice may be an impediment to the delivery of high-quality M/SU health care for multiple reasons. As described in Chapter 6, the size of health care provider organizations is related to the uptake of information technologies. Use of electronic health records, for example, is typically found in larger health care organizations (Brailer and Terasawa, 2003). Moreover, as articulated in Crossing the Quality Chasm, “Today,


Many mental health practitioners work in multiple settings. For example, 60 percent of full-time psychiatrists reported working in two or more settings in 1998, as did 50 percent of psychologists in 2002, 20 percent of full-time counselors, and 29 percent of marriage/family therapists. Rates were higher for part-time counselors (Duffy et al., 2004).


Residents and employees of hospitals, universities, medical schools, government, and health maintenance organizations (HMOs) are excluded.

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