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-effective6, 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
References
- Parker G. Is depression overdiagnosed? Yes. BMJ 2007;335:328
- Hickie I. Is depression overdiagnosed? No. BMJ 2007;335:329
- Kirk SA, Kutchins H. The selling of DSM. The rhetoric of science in psychiatry.
- Parker G. Beyond major depression. Psychol Med 2005;35:467-74
- Ludwig J, Marcotte D. Anti-depressants, suicide, and drug regulation. J Policy Analysis Manage 2005;24:249-72
- 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
- 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
- Pirkis J, Hickie I, Young L, Burns J, Highet N,
- Lee S,
Posts
No comments:
Post a Comment