Category Archives: Diagnosis

Depression: Overdiagnosed by the Overwhelmed

(Full disclosure: Dr. Mojtabai kindly furnished a copy of his article for review. I don’t think this freebie altered my judgement but then, no one ever does.)

A new study shows that 3/5ths of those diagnosed with depression don’t have Major Depressive Disorder. Damning proof America’s mental health system is riddled with quacks, right? Actually, no. But it suggests a worrisome disconnect between those with mild depressive symptoms and those trained to treat them.

Ramin Mojtabai, MD, PHD, MPH

Ramin Mojtabai, MD, PHD, MPH

Ramin Mojtabai of the Johns Hopkins Bloomberg School of Public Health studied 5,639 adults who reported, “a doctor or other medical professional,” diagnosed them with  depression in 2009 or 2010. He found only 38.4% had met criteria for a major depressive episode in the past twelve months. Nearly three-quarters of those who did not meet criteria had been prescribed medication.

Who’s making these diagnoses? Probably primary care doctors – the people we’re most likely to talk to if we gain weight, lose energy or have trouble sleeping. In 2011, Mojtabai found 7% of all doctor visits involved a prescription for antidepressants.[i]  For his current study, he started with data collected through the United States National Survey of Drug Use and Health. While this study didn’t ask participants what type of medical professional diagnosed them, he found only 34.6% of those who hadn’t met criteria for a major depressive episode received outpatient mental health services. It’s not much of a leap to surmise primary-care doctors are responsible – especially considering  Mitchell and Vaze’s 2009 study, which found such doctors misdiagnosed depression more often than they identified it correctly.[ii]

Is it a problem if family doctors reach for a quick fix when they encounter mild-to-subclinical depression? Per the studies Mojtabai cites, there’s little evidence antidepressants help such cases. Effective treatments include a referral to counseling, advice on boosting one’s mood with diet and exercise, or watchful waiting. Instead of these, three-quarters of those with only mild depressive symptoms got a prescription.

Three possible solutions come to mind. None would be quick, easy or cheap.

"I need more training in what, now?" (photo: Adam Ciesielski © 2013)

“I need more training in what, now?” (photo: Adam Ciesielski © 2013)

1. Better training in diagnosis

If misdiagnosis is the problem, more training is the answer, right? Bear in mind, for every public health problem, the initial thought is, “Let’s get the primary care doctors on the case.”  Family doctors are expected to follow up on everything from lead exposure to trampoline safety.  Depression has to compete with every other disease in need of greater public awareness.

2. Counter-programming

Primary care doctors are barraged by pharmaceutical companies which promise quick and easy solutions, based on often-dubious research. Olfson and Marcus found antidepressant use doubled from 1996 to 2005. In the same period, the number of patients who received therapy as well as antidepressants dropped by a third.[iii]  (Essay question: Should we allow unscrupulous Big Pharma to exploit human suffering by placing profit ahead of facts and the public’s health, or should jackbooted government thugs trample free speech by placing unaccountable technocrats in charge?)

Organizations such as the American Counseling Association and the American Psychology Association should return fire with their own brochures. On the front cover: fit, attractive people of all ages and cultures beaming over the success of their non-pharmaceutical treatment. Inside: large-print bullet-points on how to differentiate the different intensities of depression, and the relative efficacy of medication, lifestyle improvements and counseling. Last page: a handy list of local therapists for referrals.

3.  A nationwide program

In his article, Mojtabai mentions the United Kingdom’s National Health Services’ “Improving Access to Psychological Therapies“. This program trained thousands in cognitive-behavioral therapies and provided general practitioners with free on-line training about depression. As a result, patients move easily from a more-accurate diagnosis to a simpler referral for help.

In the U.S., surveys show we dislike government programs and government spending, but we do like the benefits that spending on government programs brings. Per NHS data, their big-government program moved 45,000 workers off public benefits by getting them back to work. It also benefited the UK’s economy by an estimated £272,000,000 by preventing the need for more expensive treatments.  The program has been criticized for restricting the range of therapies available and providing lightly-trained staff. Even with these limitations, it has delivered a respectable (if non-astonishing) recovery rate of 42.5%.

For the next go-round:

Mojtabai’s study is enticingly exasperating; the kind that raises more questions than it answers. Tough questions for a follow-up:

1. Exactly who provides these misdiagnoses? Which specialty is most on-target, and which is most likely to misdiagnose? Master’s-level counselors, social workers and psychologists should all be assessed for accuracy.

2. Out of the patients who received outpatient mental health treatment, what percentage received counseling and which only received more meds from a psychiatrist?

3. How hard is it for a primary medical doctor in other countries to refer a client to therapy? How much resistance do clients offer, and what would help doctors address their concerns?

The 3/5ths of participants that grabbed the headlines may not have met criteria for Major Depressive Disorder, but it’s a safe bet they weren’t happy and fulfilled, either. More information for better diagnoses and more-appropriate treatments, please.

Citation:

Mojtabai R. Clinician-identified depression in community settings: concordance with structured-interview diagnoses. Psychother Psychosom. 2013;82(3):161-9. doi: 10.1159/000345968. Epub 2013 Mar 27.

© 2013 by Jonathan Miller. All Rights Reserved


[i] Mojtabai R, Olfson, M. Proportion Of Antidepressants Prescribed Without A Psychiatric Diagnosis Is Growing.  Health Aff August 2011 vol. 30 no. 8 1434-1442. doi: 10.1377/hlthaff.2010.1024

[ii] Mitchell A, Vaze A, Rao S. Clinical diagnosis of depression in primary care: a meta-analysis. Lancet 2009; 374: 609–19

[iii] Olfson M, Marcus SC. National Patterns in Antidepressant Medication Treatment. Arch Gen Psychiatry. 2009;66(8):848-856. doi:10.1001/archgenpsychiatry.2009.81.

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BAD THERAPY? A DISGRUNTLED EX-PSYCHOTHERAPY CLIENT SPEAKS HER PIECE

Valuable perspective from the client’s side. Can’t agree with everything that’s written here, but I count description of six significant ethics violation. Wish Disequilibrium1 knew how many ethical, competent therapists already follow her seven suggestions.

Disequilibrium1's Blog

In blogs and book reviews, I see reference by therapy professionals to the “disgruntled ex-client.”  I assume this label is pejorative and the classification perhaps is to warn therapists to create a strong filter when one hovers nearby.

So here’s my warning label: I’m a disgruntled ex-client.  My therapy mostly was harmful.   Before I’m tuned out, I hope some therapists may consider listening as I speak my piece, so they might find fewer like me at large.

I entered therapy hoping to broaden my social life and to confirm my suspicion that my typical family—wasn’t.  I never was in crisis.  My past persona was far too obliging and obeisant to authority, but not unlike a significant population percentage.  Pre-therapy I had friends, a job, occasional dates and was reasonably cheerful.  My total tally in treatment (I hate that word) was just under three years with different clinicians in different formats.

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Revolution: NIMH turns away from the DSM

dr-insel-2011

Thomas R. Insel, MD, director of the NIMH

Two weeks ago, National Institute of Mental Health director Thomas R. Insel, MD announced a revolution. The world’s largest mental-health research organization will no longer fund studies based solely on Diagnostic & Statistical Manual (DSM) diagnoses.  If, “NIMH will be re-orienting its research away from DSM categories,” sounds less subversive than, “Give me liberty or give me death,” pay attention.  The whole system of diagnosis may be upended.

The Golden Rule: Those with the gold make the rules.

When insurers began to require a DSM diagnosis,  the American Psychiatric Association (APA) cornered the market in mental health nosology. No other U.S. group has had the money, staff and interest to create a competing system.  Ambitious alternatives such as the Psychodynamic Diagnostic Manual settled for expanding on the existing design. The APA, which has earned an estimated 100 million dollars from the DSM, flaunts their monopoly in  DSM-5’s $133 cover price. By comparison, Thomas Pynchon’s “Against the Day”  is 112 pages longer,  1/10th the cost and exponentially better-written.

Forbes’s Matthew Herper believes DSM’s diagnostic weaknesses have led to failed drug trials, and so is one reason for Big Pharma’s shift from developing new psychiatric medications.  The NIMH’s 2013 budget totals nearly 1.5 billion dollars. Insel’s ready to spend some of that towards more valid diagnoses.

Reliability vs. Validity.

The last time the DSM was reformed, rather than revised, Robert Spitzer was chair and reliability was weak. Psychiatrists could only agree on a diagnosis  20% to 40% of the time.  Spitzer’s goal was for different assessors to reach the same diagnosis from the same facts as consistently as possible. He chaired contentious meetings of obstinate psychiatrists, and condensed the best opinions down to abstraction-free criteria of what a clinician could see and a client could report.  Reliability improved – some.

One offers valid insights into the human condition. The other is required by insurance companies.

One offers valid insights into the human condition.
The other is required by insurance companies.

Validity improved less. As the book defines Antisocial Personality Disorder, only three of seven criteria must be met for a diagnosis. It’s hard to argue this diagnosis describes an actual mental health disorder when it could fit two bad actors with nothing in common.   As Maria Konnikova points out, Spitzer’s subjective-observation-and report-only approach meant the APA bet everything on the least empirical source of data available.   While other fields of medicine have developed biological, physiological and genetic studies of physical diseases, the APA hasn’t kept up. Noted DSM critic Gary Greenberg tells a disheartening tale of how the DSM-5 committee rejected a proposed reinstatement of melancholia, in part because there was biochemical evidence it should be defined separately from depression.

RDoC: a system to break free of systems.

Also subversive and clever; an Omaha, NE punk band have named themselves "DSM-5".

Also subversive and clever; an Omaha, NE punk band have named themselves “DSM-5”.

To NIMH and many others,  the validity issue makes controversies over DSM-5’s changes as superficial and irrelevant as complaints about Bernie Madoff’s office décor.  In 2011, Insel announced the Research Domain Criteria (RDoC) project. This new approach defines disorders on multiple levels of data. Constructs such as negative affect, positive affect, cognitive processing and social-process systems would be tracked across dimensions of behavior, self-report, cells, genes and physiology.  Clients’ symptoms would be placed along a range from normal to abnormal, instead of being forced into discrete categories. If new influences on emotions and behavior are discovered, new layers of information can be incorporated into the model. Research projects involving DSM diagnoses will still be accepted, but researchers will be expected to think in broader terms than subjective assessment of symptom clusters.

Insel denies that RDoC is meant to replace the DSM-5. The NIMH is already developing “walk-across” list to align DSM and RDoC diagnoses. Given that RDoC 1.0 is probably years from public release, even critics as sharp-tongued as Allen Frances concur that the DSM is the best system of diagnosis clinicians have now.  None of that changes the existential threat to the APA’s subjective-observation-only model. If RDoC rebuilds diagnosis’ operating system and obtains  more-valid results, will insurers’ money stay with the DSM?

@ 2013 Jonathan Miller All Rights Reserved

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Hippocrates on Social Anxiety Disorder

Hippocrates of Kos (c. 460 BCE – c. 370 BCE)

Hippocrates of Kos (c. 460 BCE – c. 370 BCE)

I’m catching on that many Anxiety Disorder NOS diagnoses may be Social Phobia. To quote the Father of Medicine:

“(this man) … through bashfulness, suspicion, and timorousness, will not be seen abroad; loves darkness as life and cannot endure the light or to sit in lightsome places; his hat still in his eyes, he will neither see, nor be seen by his good will. He dare not come in company for fear he should be misused, disgraced, overshoot himself in gesture or speeches, or be sick; he thinks every man observes him.”

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Sleep Apnea: Depression’s subtle sidekick.

A client presents with irritability, drowsiness, lack of energy,  and hypersomnia. You’d suspect depression, possibly Bipolar Disorder, and you’d likely be correct. It might also be something more.

Just over a year ago, Texas governor Rick Perry was hailed as the Republican party’s best choice to win the White House in 2012.   Poor debate performances sank his candidacy, most notably when he couldn’t remember a third government department he planned to eliminate.  In his new book “Oops“,  Texas Tribune correspondent Jay Root claims Perry’s lapses were due to a sleep disorder:

“…by early October, days after the Florida fiasco, (Perry) had urgently consulted sleep specialists. After conducting overnight tests on Perry, they produced a rather startling diagnosis: He had sleep apnea, and it had gone undetected for years, probably decades.”

Rick Perry’s doctors: “Oops.”

Sleep apnea causes sleepers to stop breathing. These pauses can last several minutes and occur  thirty times or more per hour. Unknowingly, sufferers’ wake dozens of times per night. This sleep disruption can slip past diagnosticians because it shares so many symptoms with depression. When a client presents with  fatigue, forgetfulness and lack of motivation, a family doctor might refer them to counseling instead of a sleep study.  The assessing therapist might ask the person if they ever wake up gasping for air. More likely, they’ll focus on all of the mental health questions we have to squeeze into an assessment session.

Along with serious physical risks, sleep apnea can cause depression and memory troubles, via sleep deprivation.With depressed clients who report fatigue, but no trouble sleeping, it’s smart to ask about the following:

  • Morning headaches
  • Memory or learning problems and not being able to concentrate
  • Waking up frequently to urinate
  • Dry mouth or sore throat when you wake up
  • Snoring
  • Reports from bedmates that you stop breathing in the night.

Two years ago, I started to encourage clients to report such symptoms to their family doctors. An impressive percentage have returned with a positive diagnosis for sleep apnea. So far, each who pursued treatment have reported improved mood and energy. Each was genuinely depressed; disrupted sleep made each’s depression significantly worse. With sleep apnea, sleep deprivation can hamper therapy even when a client believes they sleep all too well.

 

@ 2012 Jonathan Miller All Rights Reserved

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Can Trauma Make Us Stronger?

Stephen Joseph, PhD, professor of psychology at University of Nottingham, UK. (Photo credit: Maria Tanner at Lace Market Photography)

Great – another f***ing growth opportunity,” reads the classic bumper sticker. “Classic” here means, “old”, especially given that ‘personal growth’ seems as outdated as Esalen, hot tubs and encounter sessions. In his new book, “What Doesn’t Kill Us”, Stephen Joseph, PhD pries the concept free from associations with self-indulgence by linking it to Grandpa’s good, old-fashioned ‘character building’ – finding strength through suffering.

In 1990, Joseph conducted three-year follow-up interviews with survivors of the Herald of Free Enterprise sinking. Those who lived through the tragedy reported all of the pain, guilt and sleeplessness researchers expected. Yet, surprisingly, 43% also made comments like, “I live everyday to the fullest now,” and “I am more determined to succeed in life now.” Joseph, professor of psychology at the University of Nottingham, UK, used these findings to develop his Changes in Outlook Questionaire (CiOQ), and found it repeatedly confirmed such signs of personal growth in hundreds of trauma survivors.   Like Viktor Frankl, Joseph “… saw two sides of suffering, noting that while there might be nothing inherently good in misfortune, it might be possible to extract something good out of misfortune.” He argues against Freud’s view that therapy’s role is to get clients back to common unhappiness. Rather, the therapist’s job should be to help people lift themselves above their pre-trauma level of functioning – to grow.

"... 'terror'... 'torment'... 'tragedy' .... here it is, 'trauma'."

Every trauma survivor seeks information. They’re filled with questions such as, “ What happened? Why can’t I put it behind me? Why did this have to happen at all?” Joseph presents PTSD as an information-processing problem. To be traumatized is to be blasted with unbearable knowledge at an intolerable volume.  So much, so fast, creates an overload that destroys neurons in the hippocampus and hampers one’s ability to process the memory. These ‘uncategorizable’ recollections drift about the mind in the form of flashbacks and nightmares, like so many piles of paperwork on a desk. To file such memories away properly, the survivor’s understanding of the world must grow. A new file folder with a new category, (one that makes sense of the memory), must be labeled.  Unanswerable “Why me?” questions aren’t resistance or self-pity – they are the start of the search for meaning. 

None of Joseph’s ideas fit on a bumper sticker, and all are ripe for misinterpretation. One can sense his desire for a rubber stamp reading, “OF COURSE”.  Of course trauma survivors suffer, he says. Of course no one would choose trauma for the benefits of post-traumatic growth. Of coursePositive Psychology” doesn’t mean clients censor their pain with smiley-face stickers. He makes it clear that growth is not a guaranteed result of trauma, and lack of growth is not evidence of poor character. First, Ryan and Deci’s basic needs (such as acceptance and belonging) must be met. A client must choose to engage in the growth process before that process can begin. When a person is traumatized enough to meet criteria for post-traumatic stress disorder, growth won’t happen until those symptoms ease in treatment. A more specific, less marketable title might have been, “What Doesn’t Kill Us or Give Us PTSD.”

The last issue is particularly relevant, given Salon.com’s try at shoehorning the author’s ideas into an “over-diagnosis” narrative.  Joseph straddles the diagnosis debate. He observes that a PTSD diagnosis validates a client’s story. It’s undoubtedly a good thing  survivors have been moved from the file marked, “Malingering coward,” into the one labeled, “Someone with an understandable, treatable illness who is deserving of our compassion.” He’s troubled, though, that the same redefinition moves trauma from the, “I will survive this and grow stronger,” category  to the, “This is something the doctor needs to fix,” file.  In his view, our current understanding can file trauma survival under stiff-lipped perseverance or a treatable illness, but not the process of becoming someone new.

Friedrich Wilhelm Nietzsche (1844-1900). Personal-growth pioneer - not actually to blame for WWII.

Perhaps this critique of the medical model explains why the book is weakest when it addresses treatments for post-traumatic symptoms. It’s clear Joseph’s focus is to break up our thinking about trauma. He encourages therapists to speak in the disease model’s terms long enough to engage the client in the process of growth, but rushes past descriptions of how specific symptoms can be eased so growth can begin. With all of the book’s valuable advice for clients on coping with stress and finding professional help, one wishes the author spent more time on why, how, and how well different treatments work.

In “What Doesn’t Kill Us”, the author wire-walks his way between the fact-free fluff of self-help and the rigid, symptom-focused empiricism of insurance panels, to show how Nietzche‘s maxim can apply to leading a fulfilling life, not just survival in a vicious world. What doesn’t kill us provides the opportunity to nurture changes in our thoughts, behaviors and understanding of how life works. We can grow enough from adversity that the answer to, “Why did this have to happen?” becomes, “So I could be a stronger, more compassionate, more fully-alive person.”

(The New York Times has an excellent article about post-traumatic growth among members of the U.S. military here.)

@ 2012 Jonathan Miller All Rights Reserved

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PTSD is Overdiagnosed Unless … Part 2

I’m reading “What Doesn’t Kill Us“, by Stephen Joseph, mentioned in this earlier post.  No mention of over-diagnosis yet. Reader Christy wrote in to say:

Same issue at one of my old jobs. Clinicians diagnosed all the kids with PTSD because they were abused. I remember sitting in group supervision explaining why experiencing trauma does not necessarily mean that one will develop PTSD.

Grieving? Clearly. Traumatized? Possibly. Post-Traumatic Stress Disorder? The odds are 2-to-1 against it.

Unfortunately, I’ve heard similar stories at my community mental-health job. Allen Frances, MD, psychiatrist and chair of the chair of the DSM-IV Task Force, suggests that PTSD is both the most over- and under-diagnosed disorder around.

The Other Side of Sadness is an excellent book on grief and resilience. In it, author George A. Bonanno describes New Yorkers’ surprisingly low rates of post-traumatic symptoms  after the 9-11-01 attacks. He writes of how he and the original researchers sifted the data [i] to focus on the people closest to the tragedy – those who witnessed the WTC towers fall with loved ones inside:

“The people who experienced this kind of bereavement had the greatest proportion of severe trauma reactions. Just under one-third met the criteria for PTSD. That is about the highest proportion of PTSD that any event will produce. And yet just as many people who had experienced this same horror — one in three — had no trauma reaction at all.”

Exposure to trauma is not the same as post-traumatic symptoms.  Post-traumatic symptoms are not the same as Post-Traumatic Stress Disorder.  These days, there’s a lot of heat on the American Psychiatric Association over the upcoming DSM-5.  Evolving criteria for diagnosing mental illness is a much less serious threat to accuracy than those who don’t or won’t take the time to use the DSM properly.

@ 2012 Jonathan Miller All Rights Reserved


[i] Bonanno, G.A., Sandro Galea, A. Bucciarelli, and D. Vlahov. 2006. “Psychological Resilience after Disaster – New York City in the Aftermath of the September 11th Terrorist Attack.” Psychological Science, 17(3): 181-186.

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