Diagnosis, screening, and 'demoralization': epidemiologic implications.

The Dohrenwends have associated psychiatric screening instruments with Frank's concept of 'demoralization' through negative evidence of the criterion validity of the instruments for identifying 'diagnosable mental disorders'. New evidence from the Stirling County Study is given to suggest that absence of validity stems from symptom-enumerative scoring procedures and that concordance with clinical judgment is improved by employing diagnostic algorithms. The concepts of diagnosis and 'demoralization' are discussed, and the history of screening instruments is reviewed. It is suggested that, while 'demoralization' may be a useful concept for clinicians, it poses serious drawbacks for epidemiological research because of the assumptions it involves about etiology and outcome.