Is depression overdiagnosed? Yes
BMJ 2007; 335 doi: https://doi.org/10.1136/bmj.39268.475799.AD (Published 16 August 2007) Cite this as: BMJ 2007;335:328
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The prevalence of depression in our modern-day society is becoming a more recognizable occurrence and this serves to substantiate the fact that more and more individuals are being diagnosed. While this awarness can be viewed by some proponents as a movement in the right direction towards providing improved mental health care, others may argue that this may lead to overdiagnosis and the unnecessary prescribing of antidepressants and other psychotropic agents that can be used in the management or treatment of depression. Mental health professionals must be cognizant of the clear criteria that serve to distinguish clinical from non-clinical depression which ultimately determines whether pharmacological intervention may be warranted.
Competing interests: No competing interests
I totally agree with Gordon Parker Head to head study (Is depression
overdiagnosed)? Yes.
But my view is that People are starting to think that any sort of
negative emotion is unnatural, that they can take medication and feel
better. What that can also do is . . . make it less likely for people to
make real changes in their lives that might be better than medications."
We live in a society that is perfectionistic in its expectations and
intolerant of what were previously considered to be normal and expectable
distress and individual difference. What was once accepted as the aches
and pains of everyday life is now frequently labelled a mental disorder
and treated with a pill.
Fads in psychiatric diagnosis come and go and have been with us as long as
there has been a psychiatry. The fads meet a deeply felt need to explain,
or at least to label, what would otherwise be unexplainable human
suffering and deviance.
As we all know that the mental disorders all have unclear boundaries among
themselves and with normality. Clinical experience and caution are
necessary in distinguishing at the boundary who does and who does not meet
the criteria for the diagnosis. Well informed self diagnosis or family
diagnosis can play a screening role and is part of being a wise consumer.
But self diagnosis is usually far too inclusive and needs trimming and
validation by a cautious clinician.
There are no objective tests in psychiatry--no X-ray, laboratory, or exam
finding that says definitively that someone does or does not have a mental
disorder. What is diagnosed as mental disorder is very sensitive to
professional and social contextual forces. Rates of disorder rise easily
because mental disorder has such fluid boundaries with normality.
The media feeds off and feeds the public interest in mental disorders. The
new generation of advocates is succeeding at working with the press and on
the Internet to bring mental health/illness issues both into the
mainstream of the disability movement and to the attention of the public.
On the international level, advocates are effectively combining three
straightforward messages to attract media coverage: redefining the bottom
line as a universal human rights issue, subjecting residential
institutions to worldwide exposure, and building support for community-
based services.
Depression is a diagnosis that will remain a non-specific "catch all"
until common sense brings current confusion to order." The condition, which
leads to intense feelings of sadness and despair, affects one in five
people at some point in their lives.
It is a tragedy that whilst depression is on the increase in the world
many people do not seek treatment or support for fear of the stigma
associated with both depression and mental health in general. The message
is simple - depression is in most cases treatable and sufferers can
greatly improve their quality of life. The supports are available to those
with depression, their families and friends.
References
Healy D. The anti-depressant era. Cambridge, MA: Harvard University Press,
1997.
Parker G. Beyond major depression. Psychol Med 2005;35:467-74.
Competing interests: No competing interests
Much concern has been raised regarding the diagnostic criteria for
mild depression and whether they are overused. In fact, the main problem
with diagnosing depression is not necessarily the criteria themselves, but
the time available at primary care level to understand patient’s problems
and decide what the illness is compared to normal.
Clearly the most important tool for appropriate identification of
depression is the doctor- patient relationship. It is important that
primary care doctors should feel that they have appropriate time to assess
their patients. It is only then that the depression can be properly
identified with proper application of the criteria.
Competing interests:
None declared
Competing interests: No competing interests
Sir, If it is a fact that human emotions are increasingly being
'medicalised', one has to ponder on the ethical implications of this
trend. We have already read reports in the American Press of children as
young as five being diagnosed with Bipolar Disorder and started on
psychotropic medication.
'Medicalising' normal human distress as an illness leads to an
adoption of a coping mechanism by the individual that is quite different
to what it would otherwise have been. There is an increasing reliance on
medication and outside 'professionals', associated in many instances with
an erosion of personal responsibility. There are concomitant responses
that are elicited from the 'professionals' for fear of a medico legal
backlash, that is often unhelpful.
The pressures on a treating clinician to intervene when a condition
meets criteria for a certain disorder, according to some guideline or the
other is enormous. Though a clinician is allowed discretion nominally,
he/she is expected to explain himself/herself if an accepted management
plan recommended by a guideline like the one issued by NICE is not
followed.
The trouble with that of course is that there is very little room for
manouevre and it becomes 'tick box' medicine. All the guidelines do
require fairly intensive treatment/ management for 'moderate- severe
depressive illness'. One has to wonder if we are doing ourselves and our
patients a disservice or even harm by treating potentially 'non-medical'
emotions.
It is therefore imperative that criteria such as ICD10 and DSMIV are
not over inclusive or too simplistic.In the case of depression a possible
solution would be more emphasis on the old 'melancholic depression'
symptoms than there is now.
Competing interests:
None declared
Competing interests: No competing interests
It's rather depressing (used in a colloquial sense) to see in
Parker's original article and the subsequent rapid response correspondence
the implicit model that depression affects mental functioning only. There
is good evidence now that depression also fundamentally affects
physiological functioning. It is a risk factor for second myocardial
infarction; it is arrhythmogenic and exacerbates poor glycaemic control
among other effects. Given that many people will present to primary care
with existing CHD or diabetes also, the presence of depression should be
considered a serious issue. Treating depression is not just about
alleviating misery, although an important end point in itself, it is also
about treating the whole person – who probably has existing risk factors
for other conditions. Can we please abandon the separation of mind and
body? This anti –evidence position is no longer tenable.
Competing interests:
None declared
Competing interests: No competing interests
The unitary model of "depression" gives diagnostic simplicity but
creates conceptual confusion and a treatment nightmare.
The binary model of "depression" as advocated by Parker embodies
diagnostic complexity and uncertainty but that is the reality. It thus
creates conceptual clarity and allows rational treatment.
I believe Parker's model fosters earlier more accurate diagnosis and
treatment. In particular, it:
1. permits earlier diagnosis of the bipolar disorders,
2. avoids under-medication of mild to moderately severe treatment
resistant melancholia
3. and avoids over-medication and under-therapy with severe non-
melancholic depression.
May I offer the following for consideration:
"Depression" is not Diagnostic.
But don't be a Prozac Agnostic.
It's good for the right ones.
But watch for the high ones.
And you'll really improve the Prognostic.
Competing interests:
None declared
Competing interests: No competing interests
Dear Madam,
Parker is to be saluted for his brave yet common-sense approach to the medicalisation of sadness.1 He is correct in his assertion that the pharmaceutical giants are both the protagonists of, and the winners from, this gross error on the part of our profession, whilst the public - patients and taxpayers alike - are the losers.
All doctors who assess non-mentally ill sad people have a duty to sensitively inform their patients of their formulation, and give advice based on this. It is all too easy to agree with a patient that she is "depressed" and prescribe a treatment for which no sound research evidence exists. But to do so causes unrealistic expectations or, worse still, a belief that the placebo effect of the drug has actively brought about some modest improvement, resulting in long-term dependence on both the drug itself and healthcare services.
Although Parker correctly states that current diagnostic criteria lack reliability, I believe that if the research criteria set out in the tenth edition of the International Classification of Diseases (ICD-10)2 and the fourth revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV)3 were more closely adhered to in clinical practice, the problem of overdiagnosis would be far smaller. ICD-10, for instance, stipulates that not only must mood have been definitely abnormal for that individual over a period of at least two weeks, but also that the low mood is "present most of the day and almost every day, largely uninfluenced by circumstances," and coupled with anhedonia.2 My clinical experience has shown me that whilst the non-mentally ill sad person may have difficulties sleeping or concentrating, he still enjoys the company of his family or friends, or even a good film, for as long as it can take his mind off his real-life problems.
I wish I could agree with Hickie's unreferenced assertion that "most doctors can now differentiate normal sadness and distress from more severe clinical conditions."4 Sadly, I am not confident that even my fellow mental health professionals are skilled in such differentiation. In 2005, I conducted an audit of 82 referrals by general practitioners and experienced mental health practitioners to my rapid access clinic on the Isle of Wight. The vast majority of referrers had made a diagnosis of depressive disorder and had either initiated or were seeking an antidepressant prescription. At assessment, only 34 patients (41%) had a mental illness; the rest invariably had substance misuse, adjustment or personality disorders.
I am, Madam, your obedient servant,
Dr Rich Braithwaite
1. Parker G. Is depression overdiagnosed? Yes, BMJ 2007;335:328, doi:10.1136/bmj.39268.475799.AD
2. World Health Organisation. The ICD-10 Classification of Mental and Behavioural Disorders: Diagnostic Criteria for Research. WHO, 1993.
3. American Psychiatric Assocation. Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) (DSM-IV) APA, 1994.
4. Hickie I. Is depression overdiagnosed? No, BMJ 2007;335:329, doi:10.1136/bmj.39268.497350.AD
Competing interests:
None declared
Competing interests: No competing interests
Depression as a human condition is ubiquitous and depression as a
clinical condition is very common too. It is true that both over-diagnosis
and under-diagnosis of clinical depression as a disorder can pose a
problem. In essence it boils down to the validity of the clinical entity
and the reliability of the tools used to identify the condition.
The ability to make a good diagnosis is central to a reliable and
valid classificatory system, and helps understand the cause(s), prognosis
and outcome of a certain condition (like depression, hypertension or
carcinoma), even if the presentation does vary significantly between
individual patients (with depression, hypertension or carcinoma). However
valid a diagnostic entity or reliable the assessment tools be, the correct
clinical application of the tools is vital in translating this validity
and reliability to the clinical situation.
Depression as a symptom, sub-syndromal depression, mild depression
and severe depression seem to appear on a continuum (or spectrum) and it
is essential to focus on the threshold of diagnosis in clinical situations
or, similarly, ‘caseness’ in similar epidemiological work.
As Matthews has so correctly alluded to (1), the presence of distress
and/or impairment (disability) due to sustained mood change (present for
most of the day, nearly everyday) for a sufficient period (at least two
weeks) appears to be a useful threshold of diagnosing clinical depression,
if applied correctly in routine clinical care. The criterion of distress
and/or disability has been used by both DSM-IV-TR and ICD-10 a definition
point for mental illness as a broad concept as well.
Parallels to a clinical staging model in cancer care, as referenced
to by Hickie (2), have been adopted by DSM-IV-TR, ICD-10 as well as the
NICE guidance on Depression (3). Although there are exceptions to the
rule, generally the milder forms of the illness often need less vigorous
(and/or different) treatment. For example, the Quality and Outcomes
Framework (QoF) Guidelines 2006/07 (4) provide useful guidance regarding
use of PHQ-9 (Patient Health Questionnaire - 9) with helpful cut-offs for
minimal symptoms, mild depression, moderate depression and severe
depression, with suggestions for treatment options in primary care.
There are differences in epidemiological and clinical definitions of
depression, just as there are differences in definitions of schizophrenia
or metabolic syndrome. There have been arguments for early detection of
cases of early psychosis just like for early cancer. Is it likely that
milder forms of depression, including dysthymia, predispose these patients
to more severe depression with worsened prognosis and outcome, and an
early detection would prevent a worsening of eventual outcome? There is
some data to suggest that chronicity of depression may correlate with
worse outcome and increased chances of refractoriness, at least to
pharmacological treatment.
Similar to treatment of medical illnesses, it is needless to say that
treatment needs to be individualised depending on several factors
including a correct diagnosis, ‘staging’ of severity and, not least of
all, an informed patient choice.
I agree with Lee (5) that one of the major issues is non-availability
of psychological treatments like cognitive behaviour therapy (CBT)
throughout the world. We often moan about long delays in accessing CBT
(and other psychotherapies) till recent availability of online CBT
resources (e.g. the excellent Chris Williams resource
www.livinglifetothefull.com) made self-help easier to get for patients
with depression. However in most of the developing world, clinical
psychology has generally not kept pace with clinical psychiatry and
psychotherapy resources (including CBT ones) are usually much harder to
access. It is almost cliché to say that antidepressants are just one
method in the armamentarium of depression treatment. The focus should be
on the correct (evidence-based) use of antidepressants (and/or
psychotherapy) rather than deriding an attempt towards more awareness of,
and attempts to consider (or rule out), a diagnosis of clinical
depression. Clearly an overenthusiastic over-diagnosis of depression (just
like any other medical condition) can be just as harmful as an under-
diagnosis of depression.
It would then seem that the focus should be on further improving the
skills of physicians, GPs and psychiatry trainees to correctly recognise
symptoms of depression, confirm (or exclude) a diagnosis of clinical
depression, assess the severity of depression and help choose the patient
an appropriate (and available) treatment choice in an individualised
manner. The imparting of this skill should begin at the trainee level
(e.g. medical students), in both the developed and developing world. In
addition, there is need for generation of stronger evidence base for
improving the sensitivity and specificity of assessment and severity tools
for making a correct diagnosis of clinical depression.
It is not difficult to see that a senior researcher and educator like
Professor Parker is clearly well-meaning in his article (6). However,
sometimes alarmist, ‘newsy’ and eye-catching articles can unwittingly
detract much-needed support from the very important public health focus of
improving recognition of clinical depression in clinical practice.
References
1. Matthews PR. Unpublished data.
http://www.bmj.com/cgi/eletters/335/7615/328#174856
2. Hickie I. Is depression overdiagnosed? No.
http://www.bmj.com/cgi/content/full/335/7615/329
3. NICE guidance on depression http://www.nice.org.uk/CG023
4. QoF. Quality and Outcomes Framework. Revisions to the GMS contract
2006/07. http://www.nhsemployers.org/primary/primary-890.cfm
5. Lee S. Over-diagnosis of depression from global and
epidemiological perspectives.
http://www.bmj.com/cgi/eletters/335/7615/329#174757
6. Parker G. Is depression overdiagnosed? Yes. BMJ 2007; 335: 328.
http://www.bmj.com/cgi/content/full/335/7615/328
Competing interests:
Actively involved in teaching GPs, primary care nurses and community mental health teams about mood disorders and their management (including lectures sponsored by pharmaceutical industry, e.g. Astra Zeneca, Boehringer-Ingelheim, Bristol-Meyer-Squibb, Eli Lilly, Janssen-Cilag, and Wyeth).
Competing interests: No competing interests
Gorden Parker’s paper raises interesting questions.1 Psychiatrists
and general practioners are often met with people presenting their
personal and social difficulties as causing low moods trying to convince
themselves and others that their problems are resulting from an underlying
mental illness thereby avoiding the personal responsibility of their
decisions and actions. Sometimes depressive feelings are mistaken for
depressive illness but it does not respond to antidepressant medication
and can get worse if they are used.2 A sad person though experinces
lowering of mood is capable of enjoying the pleasures of life whereas a
genuinly depressed patient suffers from anhedonia.One of the reasons for
the uncertainty involved in the detection and management of depression is
due to the fact that depression
carries different meaning to different professionals even though
international
criteria have been set out for its assessment. General practoners
perceive
depression differently from hospital psychiatrists. Because there are no
objective
indicators, depression is interpreted differently and the concept of
depression
has been so much stretched that it has nearly lost it’s meaning.
If depression can be considered as a psycho-bio-social condition,
while antidepressants correct the neurotransmitter disease involved
in this illness, cognitive depression is demystified by psychotherapeutic
methods. The controversy whether biological depression precipitates
cognitive depression or vice versa, still remains unresolved.3 But,
cognitive and behavioural factors are relevant to all human experiences.4
A few other reasons that have also contributed to the prevailing
uncertainty in distinguishing and treating mental illness in the primary
care remains unclarified. The belief that anxiety or panic attack could
sometimes be a heralding symptom of depressive illness is thought to
justify premature introduction of antidepressant medication. The recent
media propaganda against minor tranquillisers has also contributed to the
excessive usage of antidepressants in primary care so as to take advantage
of the anxiolytic properties of such drugs. Many general practioners
prescribe anti depressants for cognitive depression along with counselling
hoping it has some prophylactic value against biological depression and
this has not been proved. When antidepressants are used as anti-stress
agents patients are running the risk of getting over diagnosed as
suffering from depressive illness, which can lead to disabling abnormal
illness behaviour as time goes by. The same view can be held against
psychotherapeutic techniques when applied in the medical setting of
primary care. Ideally antidepressants are indicated only when there are
biological symptoms.
Neutralising it with positive life events can heal depression, but
positive life experiences are not always easily available, and people look
for synthetic happiness in antidepressants convincing themselves as
mentally ill.
In many cases, depression could be considered as “a common cold of
mind” but when active suicidal ideas are present, it can be as fatal as
malignancy. This situation puts the psychiatrist into a diagnostic dilemma
when patients express self-harm thoughts. Verbal expression of suicidal
thoughts is more socially acceptable now than years ago. Probably the
higher expression of suicidal thoughts in recent years has also
contributed to the over diagnosis of clinical depression.The rising
incidence of completed suicides is disturbing for the mental health
professionals, but without realising that it is not the sole duty of the
mental health profession to prevent all suicides, clinicians who practice
defensive medicine tend to overdiagnose all such cases as depression.
References,
[1] Parker Gorden. Is Depression Over diagnosed? yes.BMJ.2007;335:328
[2] Cookson. J, Crammer J. Heine B. The use of drugs in psychiatry
1993 p133 Gaskell. London.
[3] Teasdle JD. Cognitive vulnerability to persistent depression.
Cogn. Emotion 1988; 2; 247.7
[4] Simon Jenright Cognitive behavioural therapy—clinical
applications. BMJ 1997; V314, P, 1811-1813.
Competing interests:
None declared
Competing interests: No competing interests
Re: Is depression overdiagnosed? Yes
Consumption of antipsychotic drugs in Greece has leapt by 3,500% in just a few years!
Consumption of antidepressants from Greeks, during the same period, increased by 1,900%.
There exists no prior globally for such an acute increase of all mental diseases, in such a short period of time.
Greek Psychiatrists probably overdiagnose and overmedicate patients.
Reference
https://www.thetimes.co.uk/article/greece-hit-by-1-100-rise-in-depressio...
Competing interests: No competing interests