Experts say sadness is wrongly being medicalised

Two experts have warned that antidepressants are being “doled out as cure for simple sadness,” reports The Daily Telegraph.

The news is based on an opinion piece written by two professors in the British Medical Journal. It is one of an ongoing series of articles looking at the potential harms of overdiagnosing different conditions.

The authors argue the current criteria for diagnosing depression includes wide groups of people with mixed severities of the condition, and are therefore too broad.

They are concerned that diagnostic criteria are “medicalising” normal human experiences such as grief, and other life stresses. They highlight the importance of providing appropriate support – not antidepressants – for these individuals. The authors also note the importance of GPs identifying people with severe depression and providing them with better access to adequate evidence-based care.

They are also concerned that despite studies suggesting the number of people with depression in the general population has stayed roughly the same in recent years, the number of diagnoses of the condition in general practice and prescriptions of antidepressants are increasing. They say this is not due to better diagnosis, but rather to overdiagnosis.

This article represents the expert authors’ viewpoints based on various studies and observations. This was not a systematic review and therefore it is possible that not all evidence relevant to depression diagnosis and prevalence has been considered. Other professionals may have differing views.

Where did the story come from?

The article was written by two professors of primary medical care and psychiatry from the University of Liverpool and Duke University Medical Center in the US. It was a discussion piece, which did not receive any specific funding.

One of the authors had worked on previous versions of the US diagnostic criteria for depression – the fourth version of the American Psychiatric Association's “Diagnostic and Statistical Manual of Mental Disorders” or DSM-IV.

The piece was published in the peer-reviewed British Medical Journal (BMJ) as part of a series of articles about over-diagnosis – which is when a person is diagnosed as having a condition that would not have gone on to cause them harm had it not been diagnosed. This means that when these people are treated for the condition they don’t stand to benefit, but they are at risk of the treatment’s side effects.

What kind of article was this?

This was a discussion article, commissioned as part of a series of similar articles discussing the potential risks to patients of expanding definitions of different diseases and use of new methods of diagnosis.

The article specifically looked at the potential for overdiagnosis and overtreatment of depression resulting from the new classification system. The authors discuss issues such as the changing views of the definition of depression, changes in how common diagnoses of depression are and the use of antidepressants, potential harms of over-diagnosis, and how the situation can be improved.

The article did not aim to be a systematic review, so does not carry out a systematic search to identify all relevant evidence on this issue. The authors cite information from various research papers including systematic reviews, as well as academic books and other sources to show the basis for their views. However, it is possible that not all evidence relevant to depression diagnosis and prevalence has been considered.

What did the article say is the problem?

The authors start out by saying that in the past few decades, there has been an increasing tendency to diagnose patients with sadness and distress as having depression, and to offer them antidepressant drugs.

Definitions of depression

They report that:

• The first formal criteria for the diagnosis of depression (“major depressive disorder” or MDD) were published in 1980 (as part of the DSM-III classification system)
• These criteria identify a mixed group of patients and are “so loose that, in everyday clinical practice, ordinary sadness can be easily confused with clinical depression”.
• The most recent version of these criteria (DSM-5) has broadened the definition of depression further, as it now allows grief from bereavement to be classified as MDD if it has persisted for longer than two weeks.
• They say that this change in DSM-5 was designed to provide more patients with access to effective treatments, but has provoked controversy and concern about “medicalisation” of a normal human experience. They believe this change was a mistake, as those with bereavement have different symptom profiles to those with MDD.

Number of diagnoses of depression and antidepressant prescriptions

The authors report that:

• Surveys have found that the proportion of people with depression in the general population in the US and UK has remained stable in recent decades.

However:

• The number of people diagnosed with depression among recipients of the US medical insurance Medicare doubled between 1992-5 and 2002-5.
• Prescribing of antidepressant medication increased by over 10% each year in England between 1998 and 2010, mainly due to increases in long term prescriptions.
• They say that these increases are not because doctors are getting better at diagnosing the condition, instead it is due to over-diagnosis.

A pooling (meta-analysis) of 41 studies suggested that for every 100 cases seen in primary care there were more cases of people incorrectly diagnosed with depression (15 cases), than those who had depression that had been missed (10 cases) or who had been correctly diagnosed with depression (10 cases). Another study in the US found that more than 60% of adults diagnosed by their doctor as having depression did not currently meet criteria for a diagnosis of depression, but many were still taking medication for the condition.

What do the authors think has been causing this problem?

The authors suggest that the broad criteria for diagnosing depression are in part a result of “heavy drug company marketing” and a focus among many psychiatrists on the biology of psychiatric symptoms rather than their psychological, social, and cultural aspects. They say that patients “often request treatment for symptoms of sadness”, and that doctors “can feel obliged to offer… a diagnosis of major depressive disorder” and patients may also feel obliged to accept this diagnosis.

What are the potential harms of over-diagnosis?

The authors note that meta-analyses have suggested that antidepressants have little or no effect in mild depression. They say that there is no evidence that people with uncomplicated bereavement benefit from antidepressants, and little evidence from trials about their effects in people with complicated grief.

They say that turning grief and other life stresses into psychiatric disorders “represents medical intrusion on personal emotions”. They also say that it adds unnecessary drug treatment and costs, and takes resources away from those with severe mental health problems who really need them.

How did the article say the situation could be improved?

The authors call for diagnostic criteria for depression to be tightened. They suggest that:

• Milder symptoms should be persistent throughout the day, present for at least a month or two, and cause significant distress or impairment for a diagnosis of mild major depression to be made.
• Existing diagnostic criteria should be accurately applied in diagnosing moderate to severe depression, with diagnoses made only when there are substantial symptoms and clear associated impairment.
• People presenting with milder or loss-related symptoms should not be dismissed, but the focus should be on time, support, advice, social networks, and psychological interventions.

They say that the problems with DSM-5 – a US based diagnostic classification system – could be avoided in ICD-11 – the update to the UK-based diagnostic classification system that is currently being prepared.

The authors also say that:

• GPs should focus on identifying people with severe depression and provide them with better access to adequate evidence based care.
• Drug companies should be stopped from marketing antidepressant medication to physicians and the public (the latter is already not allowed in the UK), and from supporting professional organisations and consumer groups.
• People with mild depression or uncomplicated grief reaction usually have a good outlook and don’t need drug treatment
• Doctors should sensitively discuss with patients the potential for the placebo effect with antidepressant medication, as well as the side effects and costs associated with these drugs.
• Doctors should listen carefully to patients, and promote the effects of time, exercise, support, and changing circumstances where possible to help deal with life problems, as well as patients sharing their experiences with each other.

What does UK guidance say about treating mild depression?

Notably, the UK guidance from the National Institute for Care Excellence for the management of depression in adults, currently says that the “first-line” treatment approach for mild depression is with psychological interventions such as cognitive behavioural therapy (CBT) or physical activity programmes.

Therefore the authors’ suggestions about the treatment of mild depression are generally consistent with current recommended practice in the UK.