Medicalising unhappiness: new classification of depression risks more patients being put on drug treatment from which they will not benefit
BMJ 2013; 347 doi: https://doi.org/10.1136/bmj.f7140 (Published 09 December 2013) Cite this as: BMJ 2013;347:f7140All rapid responses
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I should like to add support to the important messages containing in the paper by Dorwick and Francis [1] on medicalising unhappiness.
Particularly in primary care and psychiatry, a wide range of heterogeneous, ill-understood, stress-related and spontaneously-occurring, normal experiences are labelled as ‘depression’. This leads to inappropriate drug treatment, avoidable adverse reactions and interactions, and an unnecessary drain on our underfinanced health service. It may also remove from individuals the will needed to try to overcome some of the problems known to have caused their symptoms [2], and contribute to over-estimates of the prevalence of true depressive disorders. Diagnostic criteria in international classifications, although useful for administrative and research purposes and as a framework for teaching, are not as helpful as often assumed and undue reliance on checklists adds to the problem.
The question of overdiagnosis first struck me forcefully when undertaking fieldwork in the Washington Heights study [3] of the prevalence of psychiatric disability in New York City as far back as the early 1970’s. I felt uncomfortable with the ratings of ‘caseness’ and disability demanded by the data elicited by the structured interviews and criteria layed down in the study, as I would not have regarded as many respondents as ‘cases’ or as disabled in clinical practice. I therefore assessed data on all the respondents I personally interviewed on both the study criteria and the criteria I would have used in psychiatric practice in the UK. I also assessed on both sets of criteria a sub-sample of 98 of the total cohort of 528 respondents. I had achieved a high level of inter-rater agreement with my US colleagues using the study criteria, but the differences between my UK and the US ratings were remarkable.
My ‘UK ratings’ were lower in a majority of respondents in each of the sub-groups of the study [4] - the community sample, community leaders, psychiatric outpatients and ex-prisoners, from each of the five main ethnic groups living in Washington Heights - white Protestants of old American ancestry, Irish, Jews, Blacks and Puerto Ricans - all rated blind to their status. These findings were consistent with the prevalent belief of the time that more American than British people underwent psychiatric treatment for problems that many UK doctors would not regard as psychiatric (although there are, of course, other possible explanations for this).
Some of the factors leading to overdiagnosis and overprescribing, such as ‘managing uncertainty’, were discussed by Dowrick and Frances [1]. I would add to these [5]:
i) Insufficient time and/or training to assess patients fully and provide alternative treatments, largely due to doctors’ having to practise conveyor-belt medicine in our overstretched National Health Service (without its coming to a standstill). This was expressed candidly by Sir Derrick Dunlop [6] 40 years ago when he wrote ‘……..we have all, I guess, overprescribed in order to get luncheon or supper - and once started the habit is apt to grow’.
ii) The demand of patients for their 21st century, culturally-familiar treatment (drugs) which many regard as the panacea for minor mood changes or other emotional symptoms considered incompatible with normal, healthy human existence. Patients ‘know’ that drugs will cure them, often because they’ve read it in that most authoritative source of all knowledge, ‘the internet’!
iii) Difficulty in diagnosis, as there are no truly objective, scientific, biological tests for psychiatric disorders that allow us to distinguish them from commonplace distress, demoralisation and unhappiness.
iv) Treating minor symptoms in the hope of preventing the later development of more serious disorders. This inevitably means prescribing for many patients who do not need drugs and for symptoms that are, in any case, likely to remit spontaneously.
v) Availability of active compounds - active, that is, in related more severe disorders. The message here was wittily put by Marinker [7]: ‘Well, Mrs. Smith, I have listened to your story and examined you and it seems to me that you are a case of diazepam. You had better have some anxiety’.
v) Faulty prescribing habits, such as rushing into treatment when ‘watchful waiting’ would have been more helpful; choosing a drug on the basis of weak evidence for its effectiveness (often promoted as being more robust than it really is by those with a vested interest); and continuing medication for excessive periods.
During recent decades the overdiagnosis/overprescribing problem has been well-recognised and possible means of decreasing it have been offered [eg 5], but as Dowrick and Francis’s paper has shown the problem has escalated. So what are needed now, in addition to continued attention focused on the problem, are more research into the causes and methods of decreasing overdiagnosis and overprescribing; sustained undergraduate and postgraduate education, with questions on the problems in examinations; more monitoring and auditing of prescribing practices locally and nationally; and greater emphasis placed on the problems in all national clinical guidelines, including General Medical Council advice to doctors [8], and appraisal for revalidation.
References
1. Dowrick C, Frances A. Medicalising unhappiness: new classification of depression risks more patients being put on a drug treatment from which they will not benefit. BMJ 2013; 347: f 7140.
2. Trethowan WH. Pills for personal problems. BMJ 1975; 4: 749-751.
3. Dohrewend BP, Egri G, Mendelsohn FS. Psychiatric disorder in general populations: a study of the problem of clinical judgement. Am J Psychiat 1971; 127: 1304-1312.
4. Edwards JG. Cross-national differences in measures of psychiatric morbidity. Ment. Hlth. Soc 1977; 4: 126-135.
5. Edwards JG. Overprescribing of psychotropic drugs. In Current Themes in Psychiatry, eds Raghu N Gaind and Barbara L Hudson. London: Macmillan 1979; 97-115.
6. Dunlop D. Medicines, governments, doctors and pharmacists. Chemistry and Industry 1973; Feb 3: 127-131.
7. Marinker M. The doctors’ role in prescribing. J Royal Coll¬ Gen Pract 1973; 23 supp. 2:26-29.
8. General Medical Council. Good practice in prescribing and managing medicines and devices. 31 Jan 2013.
Competing interests: No competing interests
As a GP for the last 35 years I think that the criticism of GPs drug scripting for unhappiness is absolutely correct, however understandable this actions is. And as a lifelong socialist who is currently a very grateful recipient of NHS care (I am now in hospital with a fractured femur) I know that NHS does many things superbly, but not this. I lost a much loved father two weeks ago and the idea that my feelings at this point should be of professional interest to my doctor is ludicrous to the extent of making me profoundly concerned as to what is happening to society and why. It was not SO long ago that the medical profession worked together with the local church, each having an awareness and an appreciation of the wisdom of the other. It is revealing that to date there has not been a single mention of this aspect in all the responses so far - this despite the fact that it has been an intrinsic feature of most cultures in the world since, probably, the dawn of humankind. Society has changed, but the medical profession is not helping itself or society by accepting the priestly role that is being offered to it. It is not something that we are trained for, nor should we be. It may enhance our status as a guild but smacks of an arrogance that goes along with that, and is doomed to failure.
My father had a good death as was possible under the circumstances and the surgeon contributed to this by his openness and honesty with regard to the prognosis, based on his knowledge and experience. GPs have knowledge and experience of unhappiness and I have no doubt that their cumulative wisdom, best assessed by qualitative rather than the quantitative studies, would not include the prescription of any drug.
On another point, the patient response. It is right and proper that patients should have their say, but presumably these are not peer reviewed so wouldn't it be more appropriate if they were in the quick responses rather than the print edition? The authors do not at all dismiss the placebo effect, quite the reverse, but continuing to knowingly prescribe a potentially toxic drug purely for this reason is not ethical. Discussion on this issue continues in the journals but on balance I am on the side of honesty. There is also a rather depressing lack of knowledge or insight into the realities of modern doctoring and potential GMC interest in the active recommendation of herbal medicines - although I do accept that St. John's wort is an exception in that it does have some evidence base. Blame the pharmaceutical companies (again) for not taking that up! Bearing in mind the article itself and all the discussion that has subsequently taken place how can a consistency of response be possibly expected on this subject? And the view that the GP role includes keeping the patient happy by sending them away with a placebo prescription is something we have been trying to get away from for a long time. I am really not making any sort of personal attack, more questioning BMJ policy
Competing interests: No competing interests
I did appreciate this article. A key line for me, & an echo from my teens of my late Ghandian Indian father was: "there is a trend in Western society to expect the right to happiness & a need to restrict the range of negative emotions that are considered 'acceptable & normal'."
I have more sympathy with Stuart Jessup's commentary, as he is a patient. However for "GPs to bear in mind placebo & psychological effects when making prescription decisions"..is not the game medicine should be playing. What is needed is what is recognised to be effective, for: GPs to spend more time with (patients)...Inappropriate prescribing is a wasteful distraction.
Competing interests: No competing interests
With interest we read the article by Dowrick and Frances. In the article the authors state that “overdiagnosis is now more common than underdiagnosis” in reference to the diagnosis of depressive illness.
From our own practise we find that this is unlikely. The year prevalence of depression is estimated to be 0.9% for the 5 to 16 year old population (1) and 5.6% for the 13-18 year old population (2) . Currently in Newcastle there are 49, 000 young people between the ages of 5-19 (3), 28500 of whom are aged between 5-14 (4). A conservative extrapolation of the above data would suggest that there are 944 young people with depression in Newcastle. As the total number of young people currently within specialist mental health services in Newcastle for any mental health condition is 1, 387, it is highly likely that a substantial number of depressed young people are not in receipt of mental health services.
Indeed, national data suggest that only 27% of children and young people with mental disorders gain access to specialist mental health services (1). Further, according to the same study, only 5 (8%) of the 64 children with depression were prescribed antidepressant medication. Among young people the evidence indicates gross under-recognition and under-diagnosis; this is the real crisis.
Works Cited
1. Green, Hazel, et al. Mental health of children and young people in Great Britain, 2004. 2005.
2. Costello E., Erkanli A. and Angold A. (2006) Is there an epidemic of child andadolescent depression. Journal of Child Psychology and Psychiatry 47: 1263-1271
3. Child health Profile. [Online] March 2013. http://www.chimat.org.uk/resource/view.aspx?RID=152541.
4. 2011, Census. 2011 census: KS101EW Age structure, local authorities in England and Wales. 2011.
Competing interests: No competing interests
The elephant in the room of British primary care is time. Forty years ago the booked length of a GP consultation was 10 minutes, and that has not changed. However, it takes very little time to prescribe antidepressants, but 20 to discuss a patient's issues, identify some elements of self-help that might be useful, and signpost him or her to the local psychological service. At a time when society is becoming harsher towards the most vulnerable, GPs need to be given the time to help properly patients with stress and distress, or more doctors will be tempted to prescribe antidepressants because that feels better than doing nothing.
Competing interests: No competing interests
I want to offer some hope here and invite you to be courageous.
I'm at the other end of all this. I'm a personal development coach in private practice, working in the field of Therapeutic Coaching and Auto Response Psychology. Many of my clients (we deliberately avoid the use of the word 'patient' because of its subservient associations) have already been to their GP and been offered some form of medication or CBT to alleviate their sadness and it hasn't worked. I also have GPs as clients, coming to see me because of the challenges they are facing, both personal and professional.
My contribution to this discussion is to say that there are now all sorts of very effective interventions available that sort out the causes of emotional damage due to life experiences. Some of the issues mentioned in the article can be addressed directly, have simple, clean and direct solutions, that literally 'rewire' the patient's thinking - and it can take as little as a few hours, perhaps just two 2-hour appointments to do that. (Typically a maximum of 4 sessions.)
Could it be that the main problem is that doctors are frightened to step beyond the current perceived options recommended by NICE? It takes courage to risk being regarded as lacking in judgement by their peers, and being reported by their patients for NOT prescribing, even though the GP knows they don't need that medication.
GPs who I deal with often cite their ethical problems in this field: Do they prescribe unnecessary medication 'on demand' when they know the side effects may be significant and potentially increase the life experience damage the patient has experienced? How can they do more within the minimal timeframe of the average consultation?
Hope? Yes, those of us putting the work in at this end can reassure our primary care colleagues that effective alternatives (and training) are available, but it needs your courage to explore them and use them in the face of sometimes overwhelming pressure not to.
Competing interests: Professional coach with GPs and their patients as clients.
I read the article with great interest as this is a fairly common experience for Community Psychiatrists to see people being prescribed antidepressants fairly soon after stressful life events often within days. There is evidence from from antidepressant trials that a number of patients improve during the single-blind placebo period or "washout" (Rabkin et al)of 10 days. This is particularly true for mild depression. This suggests that holding off prescribing antidepressants at the first consultation following a stressful life event allows for the full clinical picture to develop.As the authors suggest watchful waiting should be the first intervention in many mild cases.
The other concern is that it is not for depression alone that antidepressant get prescribed but for anxiety disorders as well where the placebo response tends to be even higher. This may also add to the increase in antidepressant prescribing. Overdiagnois is not restricted to depression alone as more recently there is a rise as well in the diagnosis of Bipolar II and Adult ADHD where the criteria have similarly been made looser.
I think the BMJ should be commended for highlighting this issue.
Rabkin, J. G.,Stewart, J.W., McGrath, P. J., Markowitz, j. S.,Harrison, W.,and Quitkin, F. M. (1987)
Baseline characteristics of 10-day placebo washout responders in antidepressant trials.
Psychiatry Research,Vol. 21, Issue 1, 9-22.
Competing interests: No competing interests
I agree with the authors that we are medicalising unhappiness and over-prescribing anti-depressants.(1)
I would be very happy to withhold pharmacotherapy if quick access to talking therapies became a reality.
However, when local mental health services are almost full to capacity managing the serious end of the case-load, what else can we as GPs offer apart from empathy, kindness and time to do the healing?
Until then I shall continue to feel helpless and guilty of prescribing antidepressants or hypnotics as options to ease my patients' distress.
1 Dowrick C, Frances A. Medicalising and medicating unhappiness. BMJ 2013; 347:f7140
Competing interests: No competing interests
Re: my response to: “It is interesting that medical ethicists are staying silent in these debates”
The quote at the end of my rapid response is taken from page 7 of reference 2, not page 2.
Competing interests: No competing interests
Re: Medicalising unhappiness: new classification of depression risks more patients being put on drug treatment from which they will not benefit
We support the broad thrust of Professor Dowrick’s paper on trends in antidepressant prescribing(1), but add the qualification that UK data since the millennium do not support an unvarying increase in antidepressant prescribing and use.
The National Psychiatric Morbidity Surveys (NPMS)(2)(3)(4) provide population-based nationally representative information on trends both in the prevalence of depression, as assessed by the Revised Clinical Interview Schedule, and in anti-depressant use. We have previously reported that there was no change in the prevalence of depression, between 2000 and 2007, apart from an increase in women aged 44-50 years(5). While the use of common antidepressants increased markedly between the 1993 and 2000 surveys(6), unpublished data from the NPMS do not support a further rapid increase in use between 2000 and 2007. Point prevalence of antidepressant use in those aged 16 to 64 years remained at 2.8% in both 2000 and 2007 in men (95% confidence interval for difference -1.0% to 0.9%), and increased by a percentage point in women, from 5.9% in 2000 to 6.9% in 2007 (95% confidence interval for increase -0.3% to 2.3%).
These results are broadly consistent with routine database(7) and prescription data(8)(9) that also show a slowing of the increase in prescribing in the UK in the early 2000s, after the rapid increases of the 1980s and 1990s, which were in part due to a move away from the use of benzodiazepines. This evidence suggests that pressure on Primary Care Physicians to medicalise and prescribe may not be the only driver of trends in antidepressant use.
Prescribing data show a resumed increase since 2006(8), despite the Improving Access to Psychological Therapies initiative, but the impact of the economic recession is unquantified. English population-based data from NPMS 2014, currently underway, will enable examination of the extent to which the more recent increase in prescribing is due to these or other factors.
References
1. Dowrick C, Frances A. Medicalising unhappiness: new classification of depression risks more patients being put on a drug treatment from which they will not benefit. BMJ 2013; 347: f 7140.
2. Meltzer H, Gill B, Petticrew M, Hinds K. OPCS surveys of psychiatric morbidity in Great Britain, report 1: The prevalence of psychiatric morbidity among adults living in private households. Her Majesty’s Stationary Office, 1995.
3. Singleton N, Bumpstead R, O'Brien M, Lee A, Meltzer H. Psychiatric morbidity among adults living in private households. Her Majesty’s Stationery Office, 2000.
4. McManus S, Meltzer H, Brugha T, Bebbington P, Jenkins R. Adult psychiatric morbidity in England, 2007 results of a household survey. The NHS Information Centre for Health and Social Care, 2009.
5 .Spiers, N., Brugha, T. S., Bebbington, P., McManus, S., Jenkins, R., & Meltzer, H. Age and birth cohort differences in depression in repeated cross-sectional surveys in England: the National Psychiatric Morbidity Surveys, 1993 to 2007. Psychol Med 2012; 42(10):2047-2055. doi:10.1017/S003329171200013X
6. Brugha TS, Bebbington PE, Singleton N, Melzer D, Jenkins R, Lewis G, Farrell M, Bhugra D, Lee A, Meltzer H. Trends in service use and treatment for mental disorders in adults throughout Great Britain. Br J Psychiatry 2004;185:378-384.
7. Moore M, Yuen HM, Dunn N, Mullee MA, Maskell J, Kendrick T. Explaining the rise in antidepressant prescribing: A descriptive study using the general practice research database. BMJ 2009;339:b3999.
8. Ilyas S & Moncrieff J. Trends in prescriptions and costs of drugs for mental disorders in England, 1998 to 2010. Br J Psychiatry 2012;200:393-398.
9. Lockhart P, Guthrie B. Trends in primary care antidepressant prescribing 1995-2007: a longitudinal population database analysis. Br J Gen Pract 2011;61(590):e565-72. doi: 0.3399/bjgp11X593848.
Competing interests: No competing interests