Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Depression and anxiety are poor concepts full stop
- Sami Timimi (18 July 2003)
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Get Real
- Andrew J Smith (19 July 2003)
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Anxiety and Depression - beyond Cothymia and drugs
- Dr Peter G Harvey, Pat Harvey (19 July 2003)
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No new drugs for mood and anxiety disorders ...
- L S Lewis (19 July 2003)
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The "Depression Gene"
- Samuel A. Feldman, Ph.D. (20 July 2003)
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Neuroses are not "very real" diseases
- GH Hall (21 July 2003)
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Blind alley or poor reasoning
- Roger L Weeks (22 July 2003)
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Depession and Anxiety
- Graeme Mackenzie (23 July 2003)
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Has pharmaceutical failure created the niche diagnosis culture?
- Michael Joffe (24 July 2003)
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Classifications in psychiatry,comorbidity of depression and anxiety
- Detlef Degner, Stefan Bleich (25 July 2003)
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Ghostwriting
- Adam Jacobs (31 July 2003)
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On classifications
- Paul M Verheecke (7 August 2003)
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Don't shoot the messenger--lack of understanding about pathophysiology is the problem.
- Michael B. First, Darrel A. Regier (8 August 2003)
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Declaration of Interests
- susanne stevens, NONE (12 August 2003)
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We are responsible too.
- Tanuj Sidhartha (7 August 2005)
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Sami Timimi, Consultant Child and Adolescent Psychiatrist Ash Villa, Willoughby Road, Sleaford NG34 8QA
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Shorter and Tyrer do a an excellent a bit of sociological analysis illustrating how current practice in treating depression and anxiety has been developed to suit the economic and political interests of drug companies. Then they go and spoil it all with some sloppy thinking of their own (that we should view anxiety and depression as a single disease category) apparently without realising that their conceptualization simply replicates the same sociocultural dynamic but under a different label. The central problem is that of medicalization of interpersonal, emotional and social problems. This is what has opened the door to the drug industry. It is psychiatrists who are giving the drug industry the conceptual tools which drug companies then use to manipulate populations. As they mention in their article, psychiatric diagnosis are formed by a small committee of powerful 'experts' through their consensus. In the absence of objective knowledge, tests and other ways of establishing physical pathology underlying these consensus diagnosis, the categories used will never be based on 'good scientific evidence', they will always represent the subjective belief of those in the most powerful position and so long as psychiatrists cling on to outdated uni-dimensional medical models (as Shorter and Tyrer do), mental health will continue to bring rich (literally) rewards for drug companies. Competing interests: None declared |
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Andrew J Smith, Consultant in Common Sense Psychiatry BS1 6SY
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It is interesting that your illustration contains a young mother with at least two children at the top of some tower block. To suggest there are problems distinguishing anxiety and depression as diseases does of course assume that they both are diseases. I often feel anxious, but would never consider it a disease. One of my colleagues maintains that all we do in depression is give modified cocaine anyway, and so no wonder that we might feel nom better. All I can reasonable do as a practising psychiatrist is tell the difference between psychosis and non-psychosis. Everything else is very difficult to determine, and although this is frustrating, it also makes it so interesting. Competing interests: None declared |
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Dr Peter G Harvey, Consultant Clinical Psychologist for Oncology Department of Clinical & Health Psychology, St James's University Hopsital, Leeds, LS9 7TF, Pat Harvey
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This article, whilst justifiably questioning the effects of “the inter-penetration of industry and academe” in relation to psychopharmacology, is redolent with non sequiturs and fails to grapple with the fundamental problem of seeking to construe human distress within a framework of disease diagnosis and classification. Drugs, where useful to help distressed people, must offer appropriate symptom relief. Many desperately anxious patients are not depressed and many people with very low mood are not at all anxious. The search for the blockbuster to deal with a range of negative emotional states can only make worse a frequent clinical situation where the patient on antidepressants, having struggled to continue medication despite initial side-effects notes that panic symptoms and unpleasant agitation are made worse, or the patient whose anxiety was controlled by benzodiazepines became increasingly flat and depressed. Conflating the variety of human experiences already reduced by using the labels ‘anxiety’ and ‘depression’ into the pseudo disease category ‘cothymia’ is a further departure from clinical reality and is not a reflection of a “natural disease category” Explanations for the fact that “the increase in the diagnosis of anxiety and depression has occurred at the same time as an equivalent slow down in the production of new drugs” do not lie within the very evident failings of the world of DSM. Increased presentation is a complex interaction of social changes, personal lifestyles and expectations and public awareness. Further, clinicians and patients have other increasingly favoured options which are equally, if not more, effective than pharmacology in the form of modern psychological interventions (e.g. cognitive behavioural treatments). Not only do these work, they are more speedy, effective and accessible that traditional psychotherapies. They have the added advantage of helping patients make enduring changes as well as encouraging them to develop long-term strategies for dealing with emotional distress rather than contemplating a lifetime of medication with potentially serious and unwanted side effects. Competing interests: None declared |
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L S Lewis, GP Surgery, Newport, Pembrokeshire UK SA42 0TJ
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It is interesting how the psychiatrists respond.. questioning sociological dis-ease versus medical disease, revisiting the old chestnuts re: 'mental illness' and disease classification ( inducing a depressing effect in me ). Could it be that response of 'depression' to modern drugs is evidence enough of the validity of 'medical model diagnosis' ? Many 'patients' with 'depression' feel much better after SSRIs - and some very interesting, complex and usually predictable cases do not .. And many 'deprived people' with 'hopelessness' feel much better after Crack Cocaine.. ( though not for long ). Would the illicit-drug industry be more or less motivated to develop non-addictive and harmful substitutes ? Maybe the fact that 'No new drugs for mood and anxiety disorders have reached the market for over a decade' is a cause for celebration - I have plenty of effective psychotropic drugs too choose from in general practice. As I see it, my main problem is to address the needs of those 'depressed' people who do not ( can never or will not ? ) respond to drugs. If I fail to identify them at the outset, then 'trial by SSRI' is a useful further investigation. Competing interests: None declared |
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Samuel A. Feldman, Ph.D., Pres. PPR 33179
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The newly discovered "Depression Gene," seems to compete with the author's article(s) joining anxiety and depression as a constant "co- diagnosis catagory." Please email or communicate responses to this new finding. Thanks, Samuel A. Feldman, Ph.D. Competing interests: The newly discovered "Depression Gene," seems to compete with the author's article joining anxiety and depression as a "co-diagnosis." Please email or communicate responses to this notion. Thanks, |
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GH Hall, Retired physician EX1 2HW
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The question of the validity of postulated disease entities was dealt with by Kendell in an unsurpassed critique in Psychological Medicine,1989,19,45-55. This contribution and suggestions for further work have been studiously ignored because, one can only assume, the deeply sceptical message was unwelcome to professionals, patients, and drug peddlers. This group covers most of those concerned with mental wellbeing. There certainly is a need for a new paradigm, and the rumblings of discontent with current classification systems may indicate an impending Kuhnian shift. The rigid self preserving parasites of the present arrangements will however, hold things back as long as possible. This is the "social" aspect which needs exposing. Competing interests: None declared |
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Roger L Weeks, GP 2 Deanhill Road London SW14 7DF
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Shorter and Tyrer's case (1) for their conclusion that failure to advance (drug) treatment of anxiety and depression is related to wrong (disease) classification, appears to be based on several false premises: 1. Precise diagnosis is possible in mental disorders;
Diagnosis is not the only goal of clinicians who must also consider the whole patient and their complaints in the context of their environment, beliefs, disease causation, ingestion of food and medicines, mental state, family, friends and social situation. Labelling of patients with diagnoses is, at best, a short-cut categorization to guide investigation and treatment; at worst, a device to shoe-horn the patient into a (diagnostic) group for which the clinician and his treatment agency happens to provide a service. The 'Specification of Product Characteristics' (2) for the anxiolytic benzodiazepine 'Librium' (chlordiazepoxide) lists the following licensed indications: • Short-term (2-4 weeks) symptomatic treatment of anxiety that is severe,
disabling or subjecting the individual to unacceptable distress, occurring
alone or in association with insomnia or short-term psychosomatic, organic
or psychotic illness.
Clinicians, particularly GPs, will not recognise the 'problem' raised by the authors. Most view both anxiety and depression as symptoms (alone or together) found in a number of conditions including schizophrenia, bipolar affective disorder (and other so-called mood disorders), phobic disorders and not as distinct precise disease entities. Indeed, to classify these symptoms as diagnoses has no practical value and is a gross oversimplification. Such classification is akin to the situation of telling a patient complaining of headache that they have 'Cephalgia'! For years clinicians have been urged not to reach for their prescription pads to prescribe for anxiety or depressed mood but to talk to their patients and use other therapies - and not simply to avoid creating benzodiazepine addiction. Anxiolytic agents are useful for relaxing patients in the short term and we should be glad that the Pharmaceutical industry is more focussed on producing safer antidepressant and antipsychotic agents rather than agents to treat the mythical disease of 'anxiety and depression' which sounds to me like the sound bite "for Colds and 'Flu" much used by advertisers of such remedies. I am surprised that the editors of the BMJ saw fit to publish Shorter and Tyrer's paper which, in my view, adds nothing to medical education. Debate will no doubt rage over the extent of the depths of inferior intellectual rigour to which your publication has descended in order to pursue your (otherwise justified) campaign of scrutiny of the enormous influence of the Pharmaceutical industry on medical practice and publications. Obviously you have suspended normal rules of critical evaluation to allow publication of this ill thought through paper which raises problems where none exist. Competing interests: RW is Managing Director and majority shareholder of SafeScript Ltd - a company which provides a thesaurus based coded drug information electronic database for computerised clinical patient management systems |
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Graeme Mackenzie, GP WHITEHAVEN CUMBRIA UK CA28 7RG
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So depression and anxiety can co-exist. Well knock me down with a feather..... Competing interests: None declared |
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Michael Joffe, Reader in Epidemiology Dept of Epidemiology, Imperial College, St Mary's Campus, Norfolk Place, London W2 1PG
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Dear Sir Shorter and Tyrer provide an important case study in the way that medicine and science can become subverted by commercial pressures. On one hand, new patents for drugs for mood and anxiety disorders have dwindled to almost nothing from a high point in the 1960s and 1970s. On the other, niche diagnoses have proliferated – apparently as a result of collusion between experts and the pharmaceutical industry. In the absence of new drugs for existing conditions, it seems, a good commercial alternative is to market the existing drugs as being effective for new diagnoses. However, if we accept the existence of this association, the direction of causation is unclear. The authors “believe that the failure to advance the treatment of anxiety and depression is related to the wrong classification” – with the implication that use of a superior categorisation that no longer separates the two diagnoses would stimulate pharmaceutical innovation. But it could equally well be true that the proliferation of niche diagnoses is a commercial strategy that is a response to the absence of good new drug discoveries. After all, other sections of the industry have also experienced a falling off of new patents, e.g. antibiotics. Perhaps we will not have any new therapeutic agents for anxiety and/or depression, as we may have reached the limits of this pharmacological approach. The fact that these two symptoms tend to occur together in real life should not obscure that they are just that: symptoms not diagnoses. A diagnosis provides an explanation of symptoms (and other manifestations of a disease process) that goes beyond their mere description, even if that does include “a dimensional approach to illness definition”. It is unclear that there is a diagnosis to find here, beyond the attempt to understand why some people – and some cultures – tend to respond in this way to adverse life situations. Competing interests: None declared |
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Detlef Degner, MD Department of Psychiatry.University of Göttingen,Germany, Stefan Bleich
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The classification of psychiatric disorders and the differentation in psychopathology has a long tradition.There are many good reasons for this,but there are also some problems and dangers in rigid systems and operational diagnostic manuals.Shorter,E is against a separation of depression and anxiety disorders.These diseases are different entities,the argument that antidepressant drugs are used in all cases is weak.The treatment strategies are divergent and more complex,than the simple administration of SSRI.Insurance companies and the adminstration has special interest in classification systems,not pharmaceutical companies,as the authors believe. SSRIs are no lifestyle drugs,they are drugs for different pychiatric diorders with different aetiology and nosology.There is a high interest in innovation of new antidepressants,for example with an early onset and less adverse drug reactions. The developments in novel atypical antipsychotics show such an innovation and a new approach in an individual therapy.New genetic and neuroimaging findings will stimulate this process. Competing interests: None declared |
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Adam Jacobs, Director Dianthus Medical Limited, London SW19 3TZ
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Shorter and Tyrer state ‘Sometimes the relation between academic psychiatrists and industry veers over the line of acceptability in the form of ghost writing—academics lending their names to articles drafted by industry hacks.’ To describe ghostwriting as ‘over the line of acceptability’ suggests that Shorter and Tyrer don’t really understand what ghostwriting is. To describe medical writers as ‘industry hacks’ is just offensive. Ghostwriting is in fact a perfectly acceptable and common practice, by no means unique to psychiatry. When an article is ghostwritten, a professional medical writer assists the named author with writing the article. The medical writer would normally agree an outline of the article with the named author before drafting the article. The named author is then given a chance to amend the draft before the final version is produced. The ghostwritten paper is thus very much the intellectual property of the named author. Reporting research is a specialist skill, and it therefore makes sense for this final stage of the research process to be done by specialists in medical communication. This can improve not only the quality of publications, but also the speed with which they appear. Medical researchers can more productively spend their time doing research and treating patients than writing papers. For anyone who is unconvinced by this argument, would you expect all medical researchers to analyse their own data, or is it OK for that task to be delegated to a statistician? Delegating statistical analysis to a statistician is conceptually no different to delegating writing a paper to a medical writer. If Shorter and Tyrer had had the benefit of a professional medical writer to assist them with their paper, they might have been told at an earlier stage that their entire article was based on a false premise. The main argument of the paper, that the number of new drugs for mood disorders is decreasing, seems to be based on the finding that few psychiatric drugs currently in clinical use have been patented since 1990. After a drug is patented, it has to go through many years of laboratory testing and clinical trials before it can be licensed. The lack of drugs in clinical use that were patented in the last decade is simply a reflection of that long lag time, not necessarily of any slowing of drug development. Competing interests: I have ghostwritten many papers in psychiatry and other medical disciplines. I am also vice president of the European Medical Writers Association, which represents the interests of professional medical writers. The views expressed in this response are my own, and do not necessarily reflect the position of EMWA. |
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Paul M Verheecke, Chemical Pathologist 62, rue des Champs-Elysées, B-1050 Brussels
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This happens quite frequently. A child with Tourette's syndrome and very aggressive bouts, for example, is prescribed risperidone by his pedopsychiatrist. Reaction at the pharmacy when the mother presents the prescription : "What! Your child is given a drug for schizophrenics!". Isn't it time that we stop labelling drugs with names of disorders and symptoms at a period when drugs are designed to reach specific receptors? Competing interests: None declared |
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Michael B. First, Associate Professor of Clinical Psychiatry, Columbia University New York State Psychiatric Institute, New York, NY 10032, USA, Darrel A. Regier
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To the Editor:
Edward Shorter and Peter Tyrer (1) make a number of astonishing claims about the implications of the decision to separate depressive and anxiety disorders in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM). The authors’ suggestion that the paucity of new antidepressant development is due to the separation of mood and anxiety disorders is simply perplexing. The only “evidence” the authors provide is the graph showing an inverse relationship between the number of patented new drugs and the number of DSM categories. Although the authors note that “this association may not be causal,” they fail to offer any hypothesis on how they might be connected. That pharmaceutical companies can obtain FDA approval for multiple indications reflects their broad spectrum of efficacy. Why should this hinder new drug development? The authors’ solution is for the pharmaceutical companies to develop drugs that target the broad heterogeneous category of “mixed anxiety-depression.” Such a move would make new drug development even more costly than it already is, since huge samples of patients would be needed even to see small drug effects. Furthermore, defining a drug indication for such a broadly defined category may encourage overprescribing of medication since this it will be quite difficult to define a diagnostic threshold that separates “normal” depression and anxiety from pathological states. Furthermore, the authors’ claim that the pharmaceutical industry has had a significant influence on the diagnostic revision process is simply untrue. DSM-IV revisions were based on a comprehensive and critical review of the psychiatric literature which examined the quality of the research evidence. The industry-sponsored papers referred to in the article invariably focused on treatment issues (e.g., better purported efficacy or superior side effect profile) that were irrelevant to the DSM-IV revision process. Furthermore, to insure independence from industry influence, the DSM-IV revision process was conducted without any pharmaceutical company support whatsoever. Certainly the biggest hindrance to both successful new drug development and the utility of the DSM classification is our current lack of understanding regarding the underlying pathophysiology of psychiatric disorders. We expect that the availability of new tools such as neuroimaging, genotyping and phenotyping, functional genomics and pre-clinical animal models will elucidate the pathophysiology of mood and anxiety disorders and ultimately lead to both a more valid classification system as well as more effective programs for the development of new psychopharmacological agents. Michael B. First, M.D.
Darrel A. Regier MD, MPH
References 1. Shorter E, Tyrer P. Separation of anxiety and depressive disorders: blind alley in psychopharmacology and classification of disease. BMJ 2003;327 (July 19, 2003):158-160. Competing interests: Dr. First was editor of text and criteria for DSM-IV and DSM-IV-TR. Dr. Regier is Director of APA Division of Research, which oversees the development of the DSM. |
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susanne stevens, retired n/a, NONE
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Surely Peter Tyrer is the Editor of the British Journal of Psychiatry? Perhaps when he and his colleague submitted this article he was still just on the Editorial Board. I would have thought that this position should be declared though especially as the Journal accepts money from drugs companies' advertisements. (One of his predecessors (Editor of the Journal) was mentioned in the press a few years ago for not declaring his ownership of shares in a drugs company whilst also sitting on a committee for DoH which considered the use of drugs in the NHS). Peter Tyrer who describes himself in the Journal as a consultant to the N.W. and Central H.A. is in a position to influence the promotion of certain treatments and it is therefore important that a proposal which is seen to be as flawed as this one has some check on it being promoted either in that locality or the wider community. The Journal of Psychiatry still includes a loophole in it's guidance to authors which allows the use of persons' information if they refuse consent.(See guidance to contributors).Unfortunately this disallows an important check on what is printed by researchers and practitioners and encourages breach of the DPA; GMCguidelines; Human Rights and Common Law Rights and other relevant guidelines.The group whose members have been found guilty of several cases referred to the GMC and Information Commissioner have practiced in the N.W.Central London area. It seems that one of those involved is flagging up the need for a Code of Ethics for the College of Psychiatrists. Who will draw it up? Who will control it? Who will enforce it? See next edition of the J o Psychiatry perhaps. Competing interests: None declared |
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Tanuj Sidhartha, Resident Physiscian, Psychiatry UT Southestern, Dallas, TX, USA
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The author's suggestion of having a diagnostic category of "cothymia" is not a new one. What is quite remarkable is their suggestion of doing away with the current diagnostic categories in the mood and anxiety disorders section of DSM IV. The DSM manual has become everyone's favorite whipping boy. We tend to blame it's categorical system and sharp diagnostic categories for most if not all of our frustrations related to our inability to understand and treat our patients. The manual in its introduction clearly states the limitations of the categorical system, but defends it saying that at the time of its development the approach served best its purpose. Further it says,"Our highest priority has been to provide a helpful guide to clinical practice. We hoped to make DSM-IV practical and useful for clinicians by striving for brevity of criteria sets, clarity of language, and explicit statements of the constructs embodied in the diagnostic criteria. An additional goal was to facilitate research and improve communication among clinicians and researchers. We were also mindful of the use of DSM-IV for improving the collection of clinical information and as an educational tool for teaching psychopathology." The manual provides for many categories for classifying the varied presentations of mood..depressed, elevated or anxious, including subthreshold presentations.Lack of time or initiative to do a thorough phenomenological evaluation contributes more to to the confusion regarding the best DSM diagnosis rather than the criteria themselves.Inability to obtain a good collatereal history for various reasons has led to the disregard for many categories like the "adjustment disorders" which could provide for a label for many of the presentations. The ICD has a category called "mixed anxiety and depressive disorder" F41.2 for presentations with both anxiety and depressive features but not severe enough to meet independent diagnosis. The DSM does not have such a category and that is a limitation. When the criteria for both depression and anxiety disorder are met, using a comorbid diagnosis is acceptable for purpose of clarity, communication and generation of data for further revision of diagnostic categories in future revisions. If as a community we could pay more attention to making the right diagnosis according to the DSM we could , as the author's suggest end up having the evidence for the need of "cothymia" as another category. Finally the evidence presented to support the drug-diagnosis link is quite inadequate to say the least. And yes, the DSM was not dveloped by a group of people sitting in a room. The intoduction to the manual describes at length the process and its limitations. Competing interests: None declared |
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