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