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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:f7140

Rapid Response:

Overprescribing of psychotropic drugs: re-awakening of old concerns

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

19 January 2014
J Guy Edwards
Emeritus Consultant Psychiatrist
Royal South Hants Hospital
Southampton, SO14 OYG