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Transcript of Psychiatry ISSC
Overdiagnosis in Psychiatry and its Consequences
Definition = the diagnosis of a condition more often than it is actually present
Why does this matter?
Very topical following release of DSM-V in May 2013
Non-Medical Causes for Overdiagnosis...
Case Presentation: The story of Mr D
Harmonisation or New Classification?
Critique of the Literature
Some meta analyses, many review papers with negative overview
WHY MIGHT WE OVERDIAGNOSE?
=> No family history
=> No manic episodes - alcohol and gambling???
=> Persecutory delusions???
Has Mr D been misdiagnosed?
Is bipolar disorder therefore being overdiagnosed?
By Lucy Williams (email: firstname.lastname@example.org)
Bipolar Affective Disorder
Two deaths in partner's family, very stressful
Mr D assaults partner
Found by police days later
Admitted to Canadian hospital for 1 month
Diagnosed with Bipolar Affective Disorder
Treated with 400mg lithium once daily for 9 months.
Both Mr D and partner stopped drinking
VISA expired in September 2013, deported back to UK (partner still in Canada)
Mental State Examination
Childhood and Family
Born in the UK, has x1 sister
Parents divorced when 8 years old
Mr D began working on real estate development in Nevada
Appearance and Behaviour
Unkempt, loosing dirty clothing. Distracted eye contact. Restless leg movement. Rapport okay but obviously suspicious of me.
PC: 45M Section 2 MHA => Increased Anxiety
HPC: Police found, increased anxiety and low mood, reduced sleep and poor appetite. Worsening over 3-4 months.
Monosyllabic, non-elaborative content. Hesitant. Monotonous tone. Quiet volume. Normal rate.
Subjectively, "I'm okay, maybe a little low". Objectively, low mood and very anxious and agitated.
Form and content normal. Collateral history mentioned potential persecutory delusions.
Appropriate response to external stimuli
Fully alert and orientated to TPP
Disagrees with BPAD, "I don't think I need to be here", acknowledges anxiety as an issue
PREDISPOSING BIOPSYCHOSOCIAL FACTORS
Started to heavy drink, gamble and smoke
Business collapsed and became unemployed
Moved out to Las Vegas in 2004
PRECIPITATING BIOPSYCHOSOCIAL FACTORS
Declared bankrupt - owes $630,000
Meets current partner in 2009
Both continue to drink heavily, violent relationship
Mr D and partner move to Canada (her home)
PRECIPITATING AND PROTECTIVE BIOPSYCHOSOCIAL FACTORS
PRECIPITATING BIOPSYCHOSOCIAL FACTORS
Referred to community psychiatric services
Currently taking 10mg escitalopram and 7.5mg zopiclone once daily at night (no allergies)
Mother and sister very supportive
PRECIPITATING AND PROLONGING BIOPSYCHOSOCIAL FACTORS
PROTECTIVE BIOPSYCHOSOCIAL FACTORS
Generalised Anxiety Disorder
Avoidant Personality Disorder
Bipolar II Disorder
Bipolar I Disorder...
Increase of 8.5% in DALYs (per 100,000) for bipolar disorder between 1990 and 2010
=> Are more people mentally unwell?
Implications for professionals and patients...
Medical vs. Non-Medical
Medical Causes for Overdiagnosis...
Classification of Mental Disorders
New 'Fuzzy' Diagnoses
E.g. Bipolar Disorder
Internet and Health Journalism
=> Disorder focused websites
Media - Direct-to-Consumer Campaigns
=> US Food and Drug Administration
Consequences of Overdiagnosis...
Stepped Diagnosis Approach
Step 1: Gather Baseline Data
Step 2: Normalise Problems
Step 3: Watchful Waiting
Step 4: Minimal Interventions
Step 5: Brief Counselling
Step 6: Definitive Diagnosis and Treatment
Overdiagnosis is potentially as dangerous as underdiagnosis
Stepped diagnosis approach - a potential solution
DSM not the problem - it's how we use it
Better appreciate the extent of the problem
Useful for future practise - lists!!
Batstra L, Frances A. Holding the line against diagnostic inflation in psychiatry. Psychotherapy and Psychosomatics 2012; 81(1): 5-10.
Batstra L, Frances A. Diagnostic inflation: causes and a suggested cure. Journal of Nervous and Mental Disease 2012; 200(6): 474-479.
Bolton D. Overdiagnosis problems in the DSM-IV and the new DSM-5: Can they be resolved by the Distress-Impairment Criterion? Canadian Journal of Psychiatry 2013; 58(11): 612-617.
Day M. Drug industry is partly to blame for overdiagnosis of bipolar disorder, researchers claim. BMJ 2008; 336(7653): 1092-1093.
Doust J, Glasziou P. Is the problem that everything is a diagnosis? Australian Family Physician 2013; 42(12): 856-859.
Frances A, Widiger T. Psychiatric diagnosis: lessons from the DSM-IV past and cautions for the DSM-5 future. Annual Review of Clinical Psychology 2012; 8: 109-130.
Ghouse A, Sanches M, Zupta-Soares G, Swann A, Soares J. Overdiagnosis of Bipolar Disorder: A Critical Analysis of the Literature. The Scientific World Journal 2013; 2013.
Goldberg J, Garno J, Callahan A, Kearns D, Kerner B, Ackerman S. Overdiagnosis in bipolar disorder among substance use disorder inpatients with mood instability. Journal of Clinical Psychiatry 2008; 69(11): 1751-1757.
Insel T. Psychiatrists’ relationships with pharmaceutical companies: part of the problem or part of the solution? Journal of the American Medical Association 2010; 303(12): 1192-1193.
Leeman E. Driven crazy by DSM criteria. The Lancet 1998; 351(9105): 842-843.
Metzl J. If direct-to-consumer advertisements come to Europe: lessons from the USA. The Lancet 2007; 363(9562): 704-706.
Murray C. Disability-adjusted life years (DALYs) for 291 diseases and injuries in 21 regions, 1990-2010: a systematic analysis for the Global Burden of Disease Study 2010. The Lancet 2012; 380(9859): 2197-2223.
Psychiatric Times. DSM-V won’t solve the overdiagnosis problem – but clinicians can [Internet]. 2013 [Updated May 2013; cited Jan 2014]. Available from http://www.psychiatrictimes.com/bipolar-disorder/dsm-5-won%E2%80%99t-solve-overdiagnosis-problem%E2%80%94-clinicians-can
Stewart C, El-Mallakh R. Is bipolar disorder overdiagnosed among patients with substance abuse? Bipolar Disorders 2007; 9(6): 646-648.
Zimmerman M. Would broadening the diagnostic criteria for bipolar disorder do more harm than good? Implications from longitudinal studies of subthreshold conditions. Journal of Clinical Psychiatry 2012; 73(4): 437-443.
Zimmerman M, Galione J, Ruggero C, Chelminski I, Dalrymple K, Young D. Overdiagnosis of bipolar disorder and disability payments. Journal of Nervous and Mental Disease 2010; 198(6): 452-454.
Zimmerman M, Ruggero C, Chelminski I, Young D. Is bipolar disorder overdiagnosed? Journal of Clinical Psychiatry 2008; 69(6): 935-940.
Large sample sizes, but little variation in demographics (white, female, health insurance), not generalisable
Limited interview bias - "highly trained diagnostic interviewers"
No loss to follow up bias - retrospective studies
Measurement bias and recall bias - patients use own reports not medical records, and different nosologies and healthcare systems
Potential confounders - how did they gain their diagnosis