The epidemiology of depressive disorders

Recently, the issue of whether depression is overdiagnosed has been discussed, by two leading Australian authorities, in the British Medical Journal ^1,2,. This timely debate has reignited the controversy about how depressive disorders are diagnosed, and whether the diagnostic criteria are sufficiently accurate, robust and reliable. Few reading this article have not suffered unhappiness at some time. Often such emotional discomfort can be a normal "physiological response" to major stresses and life events. The invisible line, beyond which such sadness becomes pathological, is notoriously difficult to identify. This article considers the arguments for and against the proposition that depression is over diagnosed.

Diagnostic precision may be possible in other branches of medicine; however defining mental ill health continues to pose challenges. Sophisticated investigations, relying on imaging or assays, do not have a role in diagnosing depressive illnesses. The diagnostic and statistical manual (DSM-III)^, published by the American Psychiatric Association, provides the basis for diagnosis in modern clinical psychiatry. DSM-III lists inclusion and exclusion criteria for the diagnosis of mental health disorders. Such a checklist approach, familiar to readers of "pop medical" questionnaires, may be based upon assumptions, and the reliability of DSM-III has been challenged ^{3, 4।}

Over diagnosis risks exposing those who are unhappy to potentially harmful effects of antidepressants, psychotherapy and electroconvulsive therapy¹.

Hickie argues that depression is not over diagnosed and that evidence suggests that prompt intervention can reduce the incidence of suicide ⁵, whilst proving cost-effective^{6, 7}. Therapeutic intervention relies on diagnostic tools with high degrees of specificity and sensitivity. "Tightening" diagnostic criteria, may appeal to epidemiologists and clinical scientists, however it risks denying treatment to the marginalised, who's suffering does not fulfil rigid tick box diagnostic criteria. Hickie cites evidence that increased diagnosis has improved treatment outcomes, leading to improved physical health, social functioning and employability with reduced levels of substance misuse). More widespread recognition of depressive illness may improve understanding about depression, helping to destigmatising mental illness⁸.

Summary

There can be no doubt that depression can be incorrectly diagnosed; conversely, there are many in whom depressive disorders continue to elude health professionals. The pharmaceutical industry will seek to promote new therapeutic agents in their quest to maximise profits. Meanwhile, governments struggle to contain the rising costs of healthcare, and rationing decisions are becoming more explicit. In many nations, as few as 10% of those suffering from depression ever receive treatment⁹. It is critical that we remember that this debate is about real people who are suffering. The government have identified mental health a key priority; mental health has been a Cinderella service for too long. It is essential that the NHS continues to fund treatment for those who may benefit from treatment.

Web resources

www.mind.org.uk

www.rcpsych.ac.uk

References

1. Parker G. Is depression overdiagnosed? Yes. BMJ 2007;335:328



2. Hickie I. Is depression overdiagnosed? No. BMJ 2007;335:329



3. Kirk SA, Kutchins H. The selling of DSM. The rhetoric of science in psychiatry. New York: Aldine De Gruyter, 1992.



4. Parker G. Beyond major depression. Psychol Med 2005;35:467-74



5. Ludwig J, Marcotte D. Anti-depressants, suicide, and drug regulation. J Policy Analysis Manage 2005;24:249-72



6. Simon G, Revicki D, Heiligenstein M, Grothaus L, Von Korff M, Katon, et al. Recovery from depression, work productivity and health care costs among primary care patients. Gen Hosp Psychiatry 2000;22:153-62



7. Sanderson K, Andrews G, Corry J, Lapsley H. Reducing the burden of affective disorders: is evidence-based health care affordable? J Affect Disord 2003;77:109-25



8. Pirkis J, Hickie I, Young L, Burns J, Highet N, Davenport T. An evaluation of beyondblue Int J Mental Health Promotion, Australia's national depression initiative



9. Lee S, Fung SC, Tsang A, Zhang MY, Huang YQ, He YL, et al. Delay in initial treatment contact after first onset of mental disorders in metropolitan China. Acta Psychiatr Scand 2007;116:10-6

Australian has 'world-first' conscious brain surgery

Mon Sep 24, 5:20 AM ET

 

An Australian man was conscious and spoke to his medical team during life-saving brain surgery in what doctors are claiming as a world-first procedure with cutting-edge technology.

 

John James said it was a strange experience to hear the doctors and nurses talking to each other as he lay on the operating table with a 1.5-centimetre (half-an-inch) hole in his head.

But he said he was confident throughout the April surgery to remove an aneurysm from his brain, which threatened to burst and kill him.

 

"The nurses looking after me, they were talking to me," the retired bus driver told a press conference in Canberra. "I could only see bits because I couldn't move my head at all."

"I wasn't worried whatsoever.... I was quite confident all the way through."

 

Doctors asked James to read the words and numbers on flashcards shown to him during the surgery so they knew they were not affecting his vision.

 

The team believes the combination of the technology and the small size of the hole in James's head, as well as the fact he was conscious throughout the operation, makes it a world first.

 

"As far as I'm aware reading the literature, this kind of thing done as a package has never been done before," Canberra Hospital neurosurgeon Vini Khurana said.

"So we were pleased. The result was obviously very good."

 

Virtual reality software, which created a three-dimensional image of James's brain, was used to allow the team to rehearse the operation to drain the blood from the aneurysm.

 

During the surgery, Khurana had a 3-D image of the brain projected onto one side of his eyepiece. On the other side he could see a close-up view of the brain through a microscope.

 

An ultrasound probe was also used to ensure that no more blood was flowing through the aneurysm after the drainage was completed.

 

"The technology we used was quite extraordinary," Khurana said.

 

"It's like GPS navigation that you use in the car being injected into your sunglasses as you drive."

 

James, who has since turned 78, initially went to the doctor because of problems with his vision and dizzy spells and scans revealed the potentially deadly aneurysm.

 

Surgery was required but because the aneurysm was behind his right eye the operation could have blinded him, which is why the doctors wanted him awake during the procedure.

 

The great-grandfather, who was sent home two days after the operation, said he felt fine after the surgery.

 

"I had to sit for an hour to make sure everything was alright," he said. "I just came back to normal after that."

PM in pledge to beat hospital bugs

 

Press Assoc. - Sunday, September 23 06:02 am

 

Gordon Brown has set the stage for his first Labour Party conference as leader with a pledge that every hospital in the country will undergo a ward-by-ward "deep clean" in a bid to drive out superbugs from the NHS.

A buoyant Prime Minister arrived in Bournemouth on Saturday amid a swirl of speculation that he will capitalise on his opinion poll lead to call a snap general election this autumn.

 

That speculation was intensified by an ICM poll for the Sunday Mirror which put Labour on 39%, six points ahead of the Tories on 33%, with the Liberal Democrats on 19%.

 

The findings suggest that Labour has emerged from the Northern Rock crisis with its reputation for economic competence intact.

 

Chancellor Alistair Darling will tell the conference that through its "strength of purpose" the Government has built "one of the strongest economies in the world".

 

The confidence coursing through the party was graphically illustrated by Foreign Secretary David Miliband, who suggested that it was now looking forward to a second decade in power.

 

"We didn't solve all the problems of the world in 10 years in government. Well, this is a party that is planning how it is going to use the next 10 years to go further towards solving them," he told The Observer.

 

The Prime Minister refused to be drawn on whether he intended to go to the country this autumn, telling The Sunday Times: "My focus is and will remain on the work that needs to be done".

 

He was, however, swift to launch his first policy initiative, promising that over the next 12 months all hospitals would be restored to a pristine state of cleanliness to rid them of MRSA and C-difficile.

 

Officials said that it would be up to individual NHS trusts to decide how the cleaning programme was implemented. However, it is thought wards could be closed for a week at a time while they are systematically cleansed.

MEDICAL MATRIX readers can you assist with TV documentary?

Tiger Aspect productions are one of the UK's leading independent television production companies, responsible for respected and varied factual output (the Monastery, Seaside Parish, Diet Doctors and more).

We are currently focusing on a feature dealing with people who suffer from excess sweating (hyperhidrosis). We are looking for case studies who would be willing to discuss with us the issues they have faced and the treatments they have used to combat the problem. We are looking for a variety of experiences. If you suffer from the problem or have a story relating to excess sweating we would love to hear from you.

Of course we understand that this is a delicate subject and we can confirm that any contact with ourselves is in strict confidence, there is no obligation to be part of the program and no information will be shared or broadcast without permission from the case study.

Please email - duncanthompson@tigeraspect.co.uk

Alternativly please call Duncan Tompson on: 0207 434 6909

Knife crime-an emerging public health issue

Report by Dr. Tom Fitzgerald - for Medical Matrix

 

According to a recent study, published by the Centre for Crime and Justice Studies, recorded muggings, involving the use of knives, have increased from 25,500 in 2004-5 to 64,000 in the year to April 2007. This reflects 175 victims every day, compared to just 69 in 2004-5.

 

Every day, between 1997 and 2005, 13 people required hospital admission for treatment following stab injuries ¹. Knife-related injuries are a major public health issue and treating victims of knife crime places a massive strain on our already overstretched NHS.

 

Injuries caused by knives can have a devastating effect on victims and their loved ones. According to Home Office figures, between 1995-200, 37.9% of homicide victims were the victims of stabbings-the commonest cause of death. A similar study in Scotland revealed an even more alarming picture, with the homicide rate for stabbing-related assaults increasing 164% between 1981 and 2003². An audit of forensic knife injuries at one East London hospital revealed 309 injuries over a 2 year period, of which 259 victims required admission, 184 required surgery and 8 died of their injuries ³. This audit suggested that the injuries were becoming more serious. In an editorial in the BMJ in 2005, a team of emergency physicians called for a ban on pointed-tip kitchen knives of the dagger variety, which anecdotally are thought tobe used in a significant proportion of forensic knife injuries ⁴.

 

There are no reliable statistics on the incidence of knife carrying. With the rise in gang culture, many young people carry knives because of peer pressure or for protection against assailants. This creates a vicious cycle and evidence suggests that young people carrying knives are themselves more likely to be victims of knife-inflicted injuries. Evidence from the British Crime Survey 2005-6 suggests that young men, those from minority ethnic communities and the poor are most likely to be victims of violent crime ⁵.

 

Tackling the rise in knife crime will require an integrated approach, involving a number of government departments and other agencies. This must include action to address the root causes of violent crime as well as robust measures to deter young people from carrying knives. Further research will be required to evaluate various interventions to reduce knife-inflicted injuries. Steps need to be taken to reduce poverty, unemployment and social deprivation-all factors known to predispose young people to commit violent acts. Young people need positive role models, together with training opportunities if they are to turn their backs on the sub-culture of violence and knife carrying. Educational strategies will be required to provide young people with information about the consequences of knife injuries. High profile knife amnesties, such as the 2006 amnesty which saw 90,000 knives surrendered, are only part of the solution. The Violent Crime Reduction Act 2006 gave teachers tough powers to search pupils, suspected of  carrying weapons. The Act also raises the age at which young people are allowed to purchase knives from 16 to 18. Currently, those prosecuted for carrying knives illegally may be imprisoned for up to 2 years, yet custodial sentences are rarely handed down. This is an ineffective deterrent and tougher penalties, together with robust enforcement have a vital role in preventing the increase in knife crime.

 

Web resources:

 

http://www.kcl.ac.uk/depsta/rel/ccjs/knife-crime-2006.pdf

 

http://www.publications.parliament.uk/pa/cm200607/cmselect/cmhaff/433/433we03.htm

 

 

References:

1.      Maxwell, R., Trotter, C., Verne, J., Brown, P., Gunnell, D. (2007). Trends in admissions to hospital involving an assault using a knife or other sharp instrument, England, 1997-2005. J Public Health (Oxf) 29: 186-190

2.      Leyland, A. H. (2006). Homicides involving knives and other sharp objects in Scotland, 1981-2003. J Public Health (Oxf) 28: 145-147

3.      Konig, T., Knowles, C. H, West, A., Wilson, A., Cross, F. (2006). Stabbing: data support public perception. BMJ 333: 652-652

4.      Hern E, Glazebrook W, Beckett M. Reducing knife crime. BMJ 2005;330: 1221-2

5.      British Crime survey 2005/06 Home Office