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FEATURE: Ian Hickie Is depression overdiagnosed? No BMJ 2007; 335: 329 [Full text]

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Over-diagnosis of depression from global and epidemiological perspectives

Sing Lee, The Chinese University of Hong Kong, HKSAR   (17 August 2007)

Diagnosis in psychiatry

Keith E Dudleston   (20 August 2007)

Skepticism about antidepressants for under 18s

David B Menkes, Jon N Jureidini, Peter R Mansfield   (22 August 2007)

Validation of loss and grief issues

Susan P Selby   (25 August 2007)

Over-diagnosis of depression from global and epidemiological perspectives 17 August 2007
Sing Lee, Professor Department of Psychiatry, The Chinese University of Hong Kong, HKSAR Send response to journal: Re: Over-diagnosis of depression from global and epidemiological perspectives	The lively debate between Parker and Hickie may be further considered by taking accoount of the following global and epidemiological perspectives. 1. Although individual clinical instances of over-diagnosis and possible over-treatment of depression are likely to be a universal phenomenon nowadays, recent trans-national epidemiological surveys using DSM-IV diagnostic criteria and encompassing measures of received treatment have not confirmed that medicalization of sadness is a general phenomenon in the community. Rather, a substantial proportion of individuals with depression, even if the latter is of severe degree, do not receive drug or other professional treatments. This is especially so in developing countries (including Beijing and Shanghai in China) where typically less than 10% of people with mood disorders will ever receive any form of professional treatment. 2. Unlike many clinicians' mode of thinking, the epidemiological meaning of a "case" of depression (such as mild major depressive episode) may have little to do with whether the affected person needs psychiatric evaluation and/or drug treatment. This is not unlike increasingly lenient public health definitions of physical conditions such as obesity or serum cholesterol levels in the general population. In the spirit of early intervention, psychosocial intervention or a change in life style may work better than drugs in alleviating such mild metabolic disturbances. This comparison raises a deeper issue relating to individualised moral attitudes toward how normal sadness is to be demarcated from its pathological variants, and how different ways of demarcation may affect what is at stake to different individuals connected with the entity of depression one way or another. 3. The real problem for the rising diagnosis of depression is not merely medicalization and over-treatment with drugs but rather the poor access to quality psychosocial interventions such as cognitive therapy not only in developing countries but in much of the developed West as well. This is despite a strong base of evidence showing that such interventions are at least as effective as drugs in the treatment and prevention of depression. In many parts of the world, the discipline of clinical psychology has not even evolved. Sing Lee References Demyttenaere, K., Bruffaerts, R., Posada-Villa, J., Gasquet, I., Kovess, V., Lepine, J. P., Angermeyer, M. C., Bernert, S., Girolamo, G., Morosini, P., Polidori, G., Kikkawa, T., Kawakami, N., Ono, Y., Takeshima, T., Uda, H., Karam, E. G., Fayyad, J. A., Karam, A. N., Mneimneh, Z. N., Medina-Mora, M. E., Borges, G., Lara, G., Graaf, R., Ormel, J., Gureje, O., Shen, Y., Huang, Y., Zhang, M., Alonso, J., Haro, J. M., Vilagut, G., Bromet, E. J., Gluzman, S., Webb, C., Kessler, R. C., Merikangas, K. R., Anthony, J. C., Korff, M. R. V., Wang, P. S., Alonso, J., Brugha, T. S., Aguilar-Gaxiola, S., Lee, S., Heeringa, S., Pennell, B. E., Zaslavsky, A. M., Ustun, T. B. & Chatterji, S. (2004). Prevalence, severity and unmet need for treatment of mental disorders in the World Health Organization World Mental Health Surveys. Journal of the American Medical Association 291, 2581-2590. Lee S, Fung SC, Tsang A, Zhang MY, Huang YQ, He YL, Liu ZR, Shen YC, Kessler RC. (2007) Delay in initial treatment contact after first onset of mental disorders in metropolitan China. Acta Psychiatr Scand. 116, 10-16. Competing interests: None declared
Diagnosis in psychiatry 20 August 2007
Keith E Dudleston, Consultant General Psychiatrist 8 Fore Street, Ivybridge, Devon. PL219AB Send response to journal: Re: Diagnosis in psychiatry	The interested educated observer of this controversy will be surprised that despite fifty years of intensive research, and the publication of at least two well used diagnostic manuals, two senior academic psychiatrists appear unable to agree upon the criteria for the diagnosis of one of the most common psychiatric conditions. This observer should consider if this disagreement is evidence of a serious problem with the paradigm that underlies this debate. Opinions about diagnosis are valued by patients and careers and will improve patient understanding about their condition and their adherence to treatment. They are also regarded as important by lawyers and sometimes accountants. However experienced psychiatrists know that a psychiatric diagnosis does not provide significant information about aetiology, risk, capacity, prognosis or even treatment. In real life clinical practice a good patient life history and mental state examination provide the information from which we form separate opinions about aetiology, risk, capacity, prognosis and treatment. The diagnosis is not central to this process but is a tool to support communication about, and with, the patient. Advances in our understanding of genetic or environmental aetiological factors may change this state of affairs but until then please don’t exaggerate the importance of diagnosis in psychiatry. Competing interests: None declared
Skepticism about antidepressants for under 18s 22 August 2007
David B Menkes, Associate Professor Waikato Clinical School, Hamilton 3240, New Zealand, Jon N Jureidini, Peter R Mansfield Send response to journal: Re: Skepticism about antidepressants for under 18s	Hickie asserts that antidepressant drugs can benefit those under 18 (1). The best evidence supporting this assertion comes from a meta-analysis by Bridge et al (2) concluding that the benefits of newer antidepressants outweigh the harms posed by treatment-induced suicidality. This conclusion warrants skepticism for several reasons. First, Bridge et al treat responder status and suicidality (ideation or attempts) as though they were opposite but equal. For depression, 10% more responded to antidepressants than to placebo, whilst 1% more subjects had at least one episode of suicidality. This numerical difference is taken as showing that benefit outweighs harm. However, the difference between responders and non-responders is often no more than a few points on a continuous rating scale; difference scores between antidepressant and placebo groups are often of little or no clinical significance (3). By contrast, there is a categorical and life-threatening difference between children who do and don’t have suicidal ideation or attempts. Second, the authors calculated suicidality per individual rather than per act. More children on antidepressants exhibited multiple acts, and more serious acts, than those on placebo. Similarly, the authors chose to use the more conservative of the two datasets considered by the US Food and Drug Administration in its analysis of antidepressant-induced suicidality (4). This dataset is likely to underestimate the problem; for example, the category ‘self injury with intent unknown’ is excluded. Third, the claim that there were no suicides in the trials is uncertain because some were lost to follow up. Fourth, suicidality was the only harm considered by Bridge et al. They did not mention other common adverse effects including hostility and drug withdrawal. Nor did they consider the possibility of long-term adverse effects of antidepressants on young peoples’ physical and/or psychological development. Whilst antidepressants can be beneficial, recent trial (5) and case- control data show excess suicidality and completed suicide in young people (6). Together with concerns about the quality of paediatric antidepressant trials (7), such findings bedevil clinician guidance. On the basis of available evidence, we believe routine use of these drugs is unjustified. There may be merit in exploiting the 32-50% ‘placebo’ response (NNT = 2-3) (2) and proceeding to antidepressants, cautiously, if this fails. 1. Hickie I. Is depression overdiagnosed? No. BMJ 2007;335:329 2. Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, Ren L, Brent DA. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment: a meta-analysis of randomized controlled trials. JAMA 2007;297:1683-96. 3. Moncrieff J, Kirsch I. Efficacy of antidepressants in adults. BMJ 2005;331:155-7. 4. Hammad TA, Laughren T, Racoosin J. Suicidality in pediatric patients treated with antidepressant drugs. Arch Gen Psychiatry 2006;63:332-9. 5. Apter A, Lipschitz A, Fong R, Carpenter DJ, Krulewicz S, Davies JT, Wilkinson C, Perera P, Metz A. Evaluation of suicidal thoughts and behaviors in children and adolescents taking paroxetine. J Child Adolesc Psychopharmacol 2006;16:77-90. 6. Olfson M, Marcus SC, Shaffer D. Antidepressant drug therapy and suicide in severely depressed children and adults: A case-control study. Arch Gen Psychiatry 2006;63:865-72. 7. Jureidini JN, Doecke CJ, Mansfield PR, Haby MM, Menkes DB, Tonkin AL. Efficacy and safety of antidepressants for children and adolescents. BMJ 2004;328:879-83. Competing interests: JNJ and PRM have no competing financial interests to declare. DBM has been a paid expert witness on behalf of plaintiffs in civil cases defended by antidepressant manufacturers Eli Lilly and Pfizer.
Validation of loss and grief issues 25 August 2007
Susan P Selby, Associate Clinical Lecturer,The Discipline of General Practice The University of Adelaide, Adelaide, Australia, 5005 Send response to journal: Re: Validation of loss and grief issues	The debate between Parker and Hickie about the overdiagnosis of depression emphasises the importance of the recognition of normal human emotional states and sadness. However, the state of grief(1) which includes alterations in six domains of the individual, including the emotional was not mentioned. The importance of loss and grief as a paradigm for clinical practice as suggested by Parkes(2) and Clark(1)is not addressed. Recognition of loss and grief is now facilitated by a validated clinical tool in primary care, The Grief Diagnostic Instrument.(1) Widespread use of this instrument in primary care will facilitate the diagnosis and management of grief states and aid in the recognition of those at risk of complicated grief which may be associated with depression(3),(4),(5). Until the area of loss and grief is validated by psychiatrists, the diagnosis and management of depression will continue to be problematic. Susan Selby susan.selby@adelaide.edu.au References 1. Clark S, Marley J, Hiller JE, Leahy C, Pratt N. A grief diagnostic instrument for general practice. Omega 2005-2006;52(2):169-195. 2. Parkes CM. Facing loss. BMJ 1998;316:1521-4. 3. Boelen PA, van den Bout J, van den Hout MA. The role of negative interpretations of grief reactions in emotional problems after bereavement. J Behav Ther Exp Psychiatry 2003;34(3-4):225-38. 4. Sanders S, Adams KB. Grief reactions and depression in caregivers of individuals with Alzheimer's disease: results from a pilot study in an urban setting. Health Soc Work 2005;30(4):287-95. 5. Simon NM, Shear KM, Thompson EH, Zalta AK, Perlman C, Reynolds CF, Frank E, Melhem NM, Silowash R. The prevalence and correlates of psychiatric comorbidity in individuals with complicated grief. Compr Psychiatry 2007;48(5):395-9. Competing interests: None declared