Psych diagnosis inflation, thriving drug industry

 
Post new topic   Reply to topic    msspeaks Forum Index -> GENERAL
View previous topic :: View next topic  
Author Message
agate
Site Admin


Joined: 17 May 2006
Posts: 5694
Location: Oregon

PostPosted: Sat Jul 21, 2012 8:57 am    Post subject: Psych diagnosis inflation, thriving drug industry Reply with quote

Persons with MS are all too often misdiagnosed as having a mental illness. This trend might worsen if the new psychiatric guidelines for defining a mental illness go into effect.

The June 2012 issue of Journal of Nervous and Mental Disease (pp. 474-479) has an interesting article on the upcoming revised edition of the Bible of the psychiatric profession, known as DSM-5(the Diagnostic and Statistical Manual of Mental Disorders). Reference notes have been omitted.

Quote:
Diagnostic Inflation: Causes and a Suggested Cure

Batstra, Laura PhD*; Frances, Allen MD†


Author Information

*Department of Special Needs Education and Child Care, University of Groningen, Groningen, the Netherlands; and †Department of Psychiatry, Duke University Medical Center, Durham, NC.

Editor’s note:
Proposed DSM-5 criteria sets do not represent the final DSM-5 criteria for the disorders.

Send reprint requests to Laura Batstra, PhD, Department of Special Needs Education and Child Care, Faculty of Behavioral and Social Sciences, University of Groningen, Grote Rozenstraat 38, 9712 TJ Groningen, the Netherlands. E-mail: l.batstra@rug.nl.

Abstract

There have been a striking diagnostic inflation and a corresponding increase in the use of psychotropic drugs during the past 30 years. DSM-5, scheduled to appear in May 2013, proposes another grand expansion of mental illness. In this article, we will review the causes of diagnostic exuberance and associated medical treatment. We will then suggest a method of stepped care combined with stepped diagnosis, which may reduce overdiagnosis without risking undertreatment of those who really need help. The goal is to control diagnostic inflation, to reduce the harms and costs of unnecessary treatment, and to save psychiatry from overdiagnosis and ridicule.

The major achievement of DSM-III was its provision of a criteria-based system that brought greater uniformity and reliability to psychiatric diagnosis. Unfortunately, however, the DSM criteria sets have an inherent weakness when applied to milder disorders. They are unable to draw a bright line to demarcate the fuzzy (and heavily populated) boundary separating mental disorder from normality.

The mislabeling of expectable, everyday life problems as psychiatric disorder is a setup for false-positive overdiagnosis and unnecessary overtreatment. Acutely mindful of this risk of diagnostic inflation, DSM-IV requires not only that the symptom cluster be present but also that it causes a clinically significant level of distress or impairment. This is an attempt to discriminate those who require clinical attention from those who do not. To emphasize the crucial importance of this judgment, a criterion requiring attention to clinical significance was written into almost all of the definitions in DSM-IV-TR.
However, there is an inherent paradox built into this method of protecting against false-positives—there is no way of making operational the definition of whether any given presentation is causing clinically significant impairments. Thus, especially at the unclear boundary with normality where it is most needed, the assessment of clinical significance is not likely to be at all reliable. DSM-IV leaves this important call in psychiatric diagnosis to the idiosyncratic judgment of the individual clinician. Without any external guidelines, he/she gets to decide what is to be diagnosed a clinically significant mental disorder, what is best considered to be part of normality.

Clearly, the DSM-IV clinical significance requirement is no more than tautological fudge introduced because there is no other and better defining marker of mental disorder (Wakefield et al., 2010). This is better than nothing, but admittedly not by much. Seemingly small shifts in the definition of specific mental disorders, or differences in how they are diagnosed, can lead to the relabeling of the many millions of people who occupy the elastic boundary between mental illness and mental health. And most unfortunately, the requirement for clinical significance is often ignored when the rates of mental disorders are determined in epidemiological studies (Frances, 1998).

There has been a striking diagnostic inflation and a corresponding increase in the use of psychotropic drugs during the past 30 years. In this article, we will review the causes of diagnostic exuberance and of treatment creep and their costs. We will then suggest a method of stepped diagnosis intended to ensure that psychiatric diagnosis and treatment are targeted more specifically to those who really need it. The goal is to control diagnostic inflation, reduce the harms and costs of unnecessary treatment, and help to redirect scarce resources away from those with mild symptoms (who may not need them) back to those with moderate/severe symptoms who almost always do.

Excerpts from the article, which includes an indictment of the drug industry:

THE CAUSES OF DIAGNOSTIC INFLATION

In recent decades, two interacting pressures have expanded the reach of psychiatric diagnosis into the realm of what was previously regarded as normal variation: a) the publication of DSM-III in 1980 and b) the aggressive marketing strategies of drug companies.

... Using their vast financial resources and marketing prowess, the[pharmaceutical companies] were successful in selling the psychiatric ills to peddle the psychotropic pills. The advertising was aimed at stimulating demand, taking advantage of the lack of objective tests and clear diagnostic boundaries in psychiatry.

Worldwide pharmaceutical sales amount to more than US$700 billion a year, with North American sales constituting around half of this market and European sales amounting to one quarter (Williams et al., 2011). Drug companies spend twice as much money on pharmaceutical promotion as on research and development. In 2004, $57.5 billion was spent on pharmaceutical promotion in the United States alone, twice as much as the budget for research and development (Gagnon and Lexchin, 2008). Industry funding of clinical trials is more prevalent in psychiatry than in general medicine, and psychiatrists receive more money from pharmaceutical companies than do other medical specialists (Insel, 2010). The industry is ubiquitous. More than half of the experts working on DSM-IV had some relationship with the pharmaceutical industry (Cosgrove et al., 2006). Similar ties between industry and experts have also been documented for clinical practice guidelines (Cosgrove et al., 2009), medication prescription recommendations (Wazana, 2000), research outcomes favoring the sponsor’s product (Perlis et al., 2005), industry-sponsored medical education biased in favor of the sponsor’s products (Sierles, 2005), support of patient advocacy groups (Mintzes, 2007), and in programs targeted to school systems (Phillips, 2006).
In the United States, aggressive direct-to-consumer promotional campaigns appear in the print media, on television, and on the Internet in an effort to promote consumer familiarity with diagnoses and drugs (Applbaum, 2006; Metzl, 2007). Drug companies hire celebrities to promote the latest medicine and the illnesses that go with them (Moynihan, 2008). Kravitz et al. (2005) showed that requests from patients have a profound effect on physician prescribing in major depression and adjustment disorder. In major depression, rates of antidepressant prescription were 53% and 76% for fake patients making brand-specific and general requests vs. 31% for patients making no requests. For patients faking adjustment disorder, antidepressant prescribing rates were 55%, 39%, and 10% respectively, so patients not meeting the criteria for depression too were much more likely to receive antidepressants if they requested the drugs.
Medical journals have also been heavily influenced by the pharmaceutical industry. When a journal publishes an industry-supported clinical trial, it gains financially because the industry buys large amounts of reprints for distributing to key clinicians. Publication of industry-supported trials boosts the journal’s impact factor (Lundh et al., 2010). Drug advertising in medical journals is highly effective for drug companies, generating at least US$2 to US$5 in revenue per dollar spent (Fugh-Berman et al., 2006). There is growing evidence that the industry distorts research findings and engages in dubious and unethical advertising practices (Othman et al., 2009).

The situation is particularly problematic in psychiatry. Compared with advertisements for nonpsychotropics, those for psychotropic drugs contain less text, are less likely to include specific information about the drug and its efficacy, and use more negative images portraying individuals as troubled, inactive, and passive (Foster, 2010). Spielmans et al. (2008) examined the accuracy of 69 medical journal advertisements for psychiatric medications and concluded that claims were often not supported by their cited sources and, in more than half of the cases, were linked with sources that were unattainable.

TALK DOES NOT PAY

The pharmaceutical industry has effectively promoted the idea that DSM mental disorders are caused simply by imbalances in brain chemicals, not related to psychology or life events. The focus of psychiatric treatment has shifted away from persons and toward disorders and symptoms. Treatments have become more and more pharmacological (Jenkins et al., 2009; Kessler et al., 2005b; Leslie and Wolraich, 2007), despite numerous studies showing equivalent results using psychotherapy for those with mild to moderate symptoms (Otto et al., 2000; Roshanaei-Moghaddam et al., 2011; Spielmans et al., 2011). The percentage of visits to psychiatrists that included psychotherapy dropped from 44% in 1996 to 1997 to 29% in 2004 to 2005 (Mojtabai and Olfson, 2008). This is not surprising, considering that those psychiatrists who provide psychotherapy along with medication during a 45-minute outpatient visit earn 41% less than do psychiatrists who provide three 15-minute medication management sessions (West et al., 2003). Insurance companies have been happy to rely on pharmaceuticals in a short-term effort to contain costs, even though these are likely to be much higher in the long-term (Dewan, 1999).

The enormous efforts and expenditures of the pharmaceutical industry have not been in vain. In 2009, antidepressants and antipsychotics represented two of the five top-selling classes among all medications, with combined sales of almost $25 billion in the United States alone (IMS Health Reports, n.d.). It is not anything resembling a fair fight. On one side, we have an array of forces all pushing relentlessly to expand further the bubble of psychiatric diagnostic inflation. On the other, we have no constituency advocating for normality, no push back to contain overdiagnosis.

FUTURE DIAGNOSTIC EXPANSION IN DSM-5

The bubble will likely get very much worse with the introduction of DSM-5 in 2013. DSM-5 is chasing the laudatory, but dangerous, goal of early diagnosis and preventive intervention. It proposes a number of new diagnoses intended to catch illness early to reduce lifetime burden. These include the following:
* psychosis risk syndrome
* minor neurocognitive disorder
* substance addictions

Other proposals for new diagnostic categories or for lowering diagnostic threshold for existing disorders are aimed at reducing supposed false-negatives in general. Examples are as follows:
* binge eating disorder
* behavioral addictions
* temper dysfunctional disorder with dysphoria
* mixed anxiety depressive disorder
* reduced thresholds for adult attention deficit hyperactivity disorder
* reduced thresholds for generalized anxiety disorder (GAD)
* grief rediagnosed as major depression

In published studies, the false-positive rate of the psychosis risk syndrome ranges from 50% to 84%, and this number may jump to 91% when diagnostic criteria are applied in community settings by clinicians of various backgrounds and levels of experience (Corcoran, 2010). According to Andrews and Hobbs (2010), DSM proposals for GAD may result in a 22% increase in the prevalence of this disorder in the population. Likewise, Mewton et al. (2010) estimated that under the proposed revisions, DSM-5 prevalence of alcohol use disorders in the general population would increase by 61.7% when compared with those diagnosed under DSM-IV.

The problem is that early diagnosis and preventive treatment are premature in psychiatry because there are no accurate methods of discriminating those who will go on to develop a bona fide mental disorder from those who do not. The disorders proposed for DSM-5 all have unacceptably high false-positive risks and few have a treatment with proven efficacy. Unless DSM-5 comes to its senses, the current diagnostic inflation will soon be much worse.

...

DANGERS OF DIAGNOSTIC INFLATION

The most obvious dangers arising from unnecessary diagnosis are the unnecessary medication adverse effects and complications it can cause. The antipsychotic medications (which mysteriously have achieved the unlikely status of enjoying the highest revenue of any class of medication) frequently cause obesity, with consequent diabetes, metabolic syndrome, cardiovascular disease, and perhaps reduced life expectancy (Tarricone et al., 2010).
Many patients are treated with a careless polypharmacy encompassing a cocktail of numerous psychotropics and pain medicines with powerful and interacting effects that can become lethal. The US military recently reported a spike of accidental deaths among personnel overdosed on an excess of prescribed medication (Army Health Promotion Risk Reduction Suicide Prevention Report, 2010).

Unintentional drug deaths are now more frequently caused by prescription than by street drugs (Centers for Disease Control and Prevention, 2011).
Psychotropic drugs likely play an important role in preserving the mental health of at least a part of those taking them. But there can be little doubt that extremely aggressive drug company marketing has resulted in their frequent use as extraordinarily expensive placebos. There has been a massive misallocation of resources away from the severely mentally ill who really need them toward the mildly or non-ill who derive adverse effects without commensurate benefit.

The inevitable stigma that burdens those with mental disorders (Silton et al., 2011) is a regrettable and unfortunate burden, but usually worth the cost when the individual is truly ill. The unnecessary and iatrogenic stigma that attaches to someone with a false-positive diagnosis can lead to great personal hardship with no possible gain. Diagnostic creep also has the unintended consequences of trivializing mental disorder, misallocating scarce resources, and reducing the public’s commitment to providing adequate care of the severely mentally ill.
...

DISCLOSURE

Allen Frances was chair of the DSM-IV Task Force and coauthor of several books related to the use of DSM-IV. Laura Batstra reports no conflicts of interest.
Back to top
View user's profile Send private message
Display posts from previous:   
Post new topic   Reply to topic    msspeaks Forum Index -> GENERAL All times are GMT - 7 Hours
Page 1 of 1

 
Jump to:  
You can post new topics in this forum
You can reply to topics in this forum
You can edit your posts in this forum
You can delete your posts in this forum
You cannot vote in polls in this forum
Create your own free forum now!
Terms of Service Purchase Ad Removal Forum Archive Report Abuse