BMJ  2003;327:869 (11 October), doi:10.1136/bmj.327.7419.869-a

Letter

Separation of anxiety and depressive disorders

Normal rules of critical evaluation were presumably suspended

EDITOR—Shorter and Tyrer's conclusion that failure to advance (drug) treatment of anxiety and depression is related to wrong (disease) classification seems to be based on several false premises.¹

View larger version (21K): [in this window] [in a new window]   Inverse relation between number of new drugs patented for mood and anxiety disorders and number of anxiety and depressive diagnoses in DSM revisions

 

Firstly, precise diagnosis is possible in mental disorders.

Secondly, drug licensing authorities require disease indications in standard (coded) diagnostic terms.

Thirdly, drugs are used only to treat disease (cause) not symptoms (effect).

Fourthly, drugs are the principal treatment agent in anxiety and depression.

Diagnosis in patients, particularly in mental illness, is simply a shortcut categorisation prompting further elucidation. Full appraisal of patients in the context of their environment, beliefs, and many other factors is a more appropriate guide to therapeutic choices, of which drug treatment is only one option.

The specification of product characteristics for the benzodiazepine librium lists among its licensed indications symptomatic treatment of anxiety, anxiety with other conditions (many diseases listed here), muscle spasm, symptomatic relief of acute alcohol withdrawal.² Clearly not the language of disease classification, this example refutes the second premise above.

Most clinicians know that anxiety and depression are symptoms (alone or together) found in situations (not necessarily disease) and conditions including schizophrenia, mood disorders, and phobic disorders. Calling symptoms disease is like telling a patient with headache that they have "cephalgia."

I am amazed that, to pursue its otherwise excellent scrutiny of the pharmaceutical industry's influence on medical practice, the BMJ has suspended its normal rules of critical evaluation to publish this paper, which sees conspiracy where clearly none exists.

2 Deanhill Road, London SW14 7DF roger{at}safescript.org

---

Competing interests: RW is managing director and majority shareholder of SafeScript Limited, a company that provides an electronic thesaurus based coded drug information database for electronic patient record systems.

References

1. Shorter E, Tyrer P. Separation of anxiety and depressive disorders: blind alley in psychopharmacology and classification of disease. BMJ 2003;327: 158-60. (19 July.)[Free Full Text]
2. Medicines.org.uk. Librium capsules SPC. 4.1 Therapeutic indications. Electronic Medicines Compendium www.emc.medicines.org.uk (accessed 13 Sep 2003.)

Related Article

Separation of anxiety and depressive disorders: blind alley in psychopharmacology and classification of disease

Edward Shorter and Peter Tyrer
BMJ 2003 327: 158-160. [Extract] [Full Text] [PDF]