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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: (Published 09 December 2013) Cite this as: BMJ 2013;347:f7140

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Re: Medicalising unhappiness: new classification of depression risks more patients being put on drug treatment from which they will not benefit

The assessment, possible diagnosis, and appropriate support of mental distress is a complex process. The diagnosis of major depressive disorder may be complicated by the presence of anxiety symptoms or the influence of affective instability, arising from previous adverse experience.[1] Efforts to assess and simultaneously contain the distress of another are difficult and the effects on clinical professionals are well recognised.[2] Doctors, and other health professionals, are trained in a positivist environment where illness and distress respond well to the progress of science. When suffering proves refractory to treatment the anxiety experienced by the clinician may well, understandably, rise and this loss of confidence may be mirrored by the patient. Medication as a symbol is rich in meaning and has the capacity to act as a containing object for the anxieties of both the clinician and patient, the pressure to continue prescribing varied medications, at increasing doses, is therefore great.[3]

Antidepressants are not the only psychotropic medications increasingly used in the treatment of depressive disorders - antipsychotic prescriptions have increased markedly in the 21st century and are commonly prescribed for individuals with a diagnosis of major depressive disorder.[4,5] This non-specific prescribing of psychotropic medication has led to calls for a shift of focus from disorder to drug centred prescribing - in this scenario psychotropic prescription is a negotiated individual trial of treatment where the desired effects of treatment are explicitly negotiated between clinician and patient.[6] This approach parallels the call for, careful, shared decision making made by Dowrick and Frances in their conclusion.[7]

As Dowrick and Frances describe adequate understanding of mental distress requires an idiographic approach to clinical assessment taking full account of psychological and social factors leading to the current presentation.[8,9] It is only with this depth of understanding that an adequate treatment decision can be reached as psychotropic medications and inadequately formulated, superficial, psychotherapy are not without risk of side-effects.[10] This requirement places significant demand on the average primary care consultation time frame; however serial consultation with sensitive provision of support and marshalling of social support can be beneficial at times of individual crisis.

1  Gask L, Evans M, Kessler D. Personality disorder. BMJ 2013;347:f5276–6. doi:10.1136/bmj.f5276

2  Adshead G. Psychiatric staff as attachment figures. Understanding management problems in psychiatric services in the light of attachment theory. The British Journal of Psychiatry 1998;172:64–9. doi:10.1192/bjp.172.1.64

3  Tutter A. Medication as object. Journal of the American Psychoanalytic Association 2006;54:781–804. doi:10.1177/00030651060540031401

4  Verdoux H, Tournier M, Bégaud B. Antipsychotic prescribing trends: a review of pharmaco-epidemiological studies. Acta Psychiatr Scand 2010;121:4–10. doi:10.1111/j.1600-0447.2009.01425.x

5  Citrome L, Kalsekar I, Guo Z, et al. Diagnoses Associated With Use of Atypical Antipsychotics in a Commercial Health Plan: A Claims Database Analysis. Clinical Therapeutics 2013;35:1867–75. doi:10.1016/j.clinthera.2013.09.006

6  Moncrieff J, Cohen D. Rethinking Models of Psychotropic Drug Action. Psychother Psychosom 2005;74:145–53. doi:10.1159/000083999

7  Dowrick C, Frances A. Medicalising unhappiness: new classification of depression risks more patients being put on drug treatment from which they will not benefit. BMJ 2013;347:f7140–0. doi:10.1136/bmj.f7140

8  IGDA Workgroup, Idiographic (personalised) diagnostic formulation. The British Journal of Psychiatry 2003;182:55s–57. doi:10.1192/bjp.182.45.s55

9  Phillips J. Idiographic formulations, symbols, narratives, context and meaning. Psychopathology 2005;38:180–4. doi:10.1159/000086087

10  Nutt DJ, Sharpe M. Uncritical positive regard? Issues in the efficacy and safety of psychotherapy. Journal of Psychopharmacology 2007;22:3–6. doi:10.1177/0269881107086283

Competing interests: No competing interests

13 December 2013
Andrew Shepherd
NIHR Doctoral Research Fellow, Forensic Psychiatry
GMW Mental Health NHS Foundation Trust
Prestwich Hospital, Bury New Road, Manchester, M25 3BL