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New Classification of Depression Risks More Patients Being Put on Drug Treatment from Which They Will Not Benefit

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New Classification of Depression Risks More Patients Being Put on Drug Treatment from Which They Will Not Benefit BMJ 2013;347:f7140 doi: 10.1136/bmj.f7140 (Published 9 December 2013) Page 1 of 5 Analysis ANALYSIS TOO MUCH MEDICINE Medicalising unhappiness: new classification of depression risks more patients being put on drug treatment from which they will not benefit 1 Christopher Dowrick professor of primary medical care , Allen Frances emeritus professor of psychiatry 2 1University of Liverpool, Liverpool L69 3GL, UK; 2Duke University Medical Center, Durham, North Carolina, USA doi:10.1136/bmj.f7225 studies and are so loose that, in everyday clinical practice, This article is part of a series on overdiagnosis looking at the risks and ordinary sadness can be easily confused with clinical harms to patients of expanding definitions of disease and increasing depression.5 use of new diagnostic technologies Many patients report sadness or distress during consultations Unhelpful classifications of mental with primary care doctors. Such emotions may be related to disorders grief and other life stresses, including the stress of physical illness. Sometimes sadness appears out of the blue, without Under DSM-III the term major depressive disorder combined obvious relation to external causes. Over recent decades there what had formerly been described as has been an increasing tendency, especially in primary care, to “melancholia”—characterised by severe, disabling, and diagnose depression (commonly major depressive disorder) in sometimes life threatening depression, often coming out of the patients presenting with sadness or distress and offer them blue and characterised by marked diurnal variation, suicidal antidepressant medication.1-3 thoughts, and somatic symptoms—with “reactive depression.” Reactive depression contrasted in almost every way with In this paper we offer a critical review of the diagnosis of major melancholia, with onset closely linked to a definable life event depressive disorder, show how and why this broad diagnostic and with symptoms that were milder and typically including label has resulted in overdiagnosis and overtreatment, and sadness, loss of interest, and feelings of guilt and unworthiness. suggest how the approach to diagnosis and management of Somatic changes, including difficulty sleeping and loss of depression should change to reduce stigmatising the sad and appetite, were less profound and enduring in reactive depression provide better help for those who most need vigilant care and than in melancholia. Those affected retained the capacity to feel medical treatment. pleasure. Symptoms were usually least troubling in the morning Evolving views of what constitutes and patients tended to get better over time and respond well to depression placebo and psychotherapy. Those with melancholia, by contrast, were more likely to have disturbed sleep and abnormal Descriptions of depression can be found in the Bible and dexamethasone suppression test results6 7 and to respond to drug Shakespeare, but no formal definition existed until the third treatment or electroconvulsive therapy.8 version of the American Psychiatric Association’s classification Although the DSM-III definition of major depressive disorder systems for mental disorders was published in 1980 (DSM-III). was meant to provide simplicity and increase reliability of The manual set out clear operational criteria to aid clinicians in diagnosis, from the beginning it was recognised that it would diagnosing mental disorders (see box 1) and introduced the term capture a heterogeneous population of patients. The definition major depressive disorder. therefore provided severity ratings and different subtypes (box Since then major depressive disorder has received more research 1). Unfortunately, however, the valuable distinctions offered attention than any other diagnosis in psychiatry but has created by severity and subtype ratings were generally ignored in both many problems. The criteria, which have not changed since clinical practice and research.9 Major depressive disorder became 1980, capture too heterogeneous a population for research homogenised to include “mild” major depression—arguably a Correspondence to: C Dowrick [email protected] For personal use only: See rights and reprints http://www.bmj.com/permissions Subscribe: http://www.bmj.com/subscribe BMJ 2013;347:f7140 doi: 10.1136/bmj.f7140 (Published 9 December 2013) Page 2 of 5 ANALYSIS Summary box Clinical context—Diagnoses of major depressive disorder and treatment with antidepressant drugs are increasing Diagnostic change—DSM-III homogenised the diagnosis of depression and the new DSM-5 classification broadens the definition further, allowing the diagnosis of major depressive disorder just two weeks after bereavement Rationale for change—To provide more patients with access to effective treatments Leap of faith—Accurate diagnosis of mild depression is possible; treatment is necessary and leads to better outcomes Increase in disease—Although community prevalence of major depressive disorder has remained static, diagnoses doubled among Medicare recipients in the US between 1992-95 and 2002-05 Evidence of overdiagnosis—Depression is now more likely to be overdiagnosed than underdiagnosed in primary care. Rates of prescribing of antidepressant medication doubled in the UK between 1998 and 2010 and in the US 11% of the population aged over 11 now takes an antidepressant. People without evidence of major depressive disorder are being prescribed drug treatment Harms from overdiagnosis—Turning grief and other life stresses into mental disorders represents medical intrusion on personal emotions. It adds unnecessary medication and costs, and distracts attention and resources from those who really need them Limitations—We do not know whether clinicians will follow the DSM-5 proposals Conclusions—Patients with mild depression or uncomplicated grief reaction usually have a good prognosis and don’t need drug treatment. Clinicians should focus on identifying people with moderate to severe depressions and sufficient impairment to require treatment. Box 1: Diagnostic classification of mental disorders Diagnostic and Statistical Manual of Mental Disorders (DSM) III (1980) introduced a unitary diagnosis of major depressive disorder (MDD) with nine symptoms (mood, interest, activity, fatigue, weight/appetite, sleep, guilt, concentration, and suicidality). The main emphasis of DSM-III was on severity ratings: • Mild MDD was defined as five or six symptoms of mild severity, including either low mood or loss of interest • Moderate MDD was defined as seven to eight symptoms with moderate impairment • Severe MDD was defined as six or more symptoms with severe impairment or psychotic features and strong suicidal intent DSM III also included depressive subtypes: • Secondary depression arose from a clear external cause • Psychotic depression had associated psychotic symptoms • Melancholic depression involved lack of pleasure or lack of mood reactivity plus three of the following: subjective mood qualitatively different from grief or loss; severe loss of appetite or weight; psychomotor agitation or retardation; early morning waking, excessive guilt; and mood worse in the morning. DSM-IV (1994) used a similar classification system.4 DSM-5 (2013) now allows grief reaction to be classified as major depressive disorder (MDD) after two weeks. The International Statistical Classification of Diseases and Related Health Problems (ICD), produced by the World Health Organization, also includes criteria for mental disorders. This is used more widely in Europe and other parts of the world. The coding systems of DSM and ICD are designed to correspond with each other contradiction in terms for it is not major, nor really depressive symptom trajectory, very different from the experience of the or a disorder. small minority of people (n=69) with severe persistent depression, who had high levels of disadvantage, abuse, DSM-IIIR and DSM-IV carried forward the DSM-III definition, 14 and the recently published DSM-5 broadens the diagnosis of morbidity, and disability. major depressive disorder still further. It allows major depressive Including people, as the DSM- 5 classification does, who are disorder to be diagnosed just two weeks after a bereavement. experiencing grief only two weeks after the loss of a loved one The change in the diagnostic status of grief from bereavement is a mistake. Bereaved people follow a course very different (not a mental illness) to depressive episode (a mental illness) from those with recurrent major depressive disorder. A study introduced by DSM-5 was designed to provide more patients of over 30 000 US citizens found that single bereavement related with access to effective treatments.10 This is particularly relevant brief depressive episodes have distinct demographic and in insurance based health systems such as the US, where a symptom profiles that differ from those of other types of specific diagnosis is needed before funders will agree to pay depressive episodes and are not associated with increased risk the costs of treatment. It has, however, provoked both of future depression.15 Uncomplicated bereavement is not controversy and concern focused on the medicalisation of the associated with an increase in suicidality.16 normal human experiences of loss.5 11 12 Increase in diagnosis of depression and Homogenisation of depression has been antidepressant drug prescriptions a mistake The prevalence of depressive disorders in the community is People with uncomplicated episodes of major depressive stable. In the United States
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