Regular readers, you know I write often about the mess issues clustering around diagnosis and the DSM. And in the past couple of weeks, I have run across several articles and ads that have continued my questioning about the diagnostic enterprise.
For a number of weeks now, if you watch much television, you likely have seen Brooke Shields talking about Latisse, which purports to make eyelashes longer and thicker. Only instead of being a new kind of mascara, it is actually a prescription medication applied to the eyelid. Now that is a first in my experience -- an ad for a prescription only cosmetic. And in the ad, we hear the term "inadequate lashes", implying a disorder. Which of course sets up the consumer believing her lashes to be too thin or shorter than she would like to now believe her "condition" has a name -- inadequate lashes. As noted by Rob Walker in the NY Times,
"When it sinks in that this is something you need a doctor to obtain, it’s oddly reassuring. Inadequate eyelashes aren’t simply a matter of looks; they’re a problem serious enough that the F.D.A. itself had to be brought in to sign off on a treatment, right? Clearly the logic I’ve just suggested is wrongheaded: the Food and Drug Administration doesn’t offer opinions about what needs treating; it evaluates drugs containing certain ingredients that require approval.But we don’t always evaluate sales pitches with perfect logic. (Well, you do, I’m sure, but you probably know somebody who doesn’t.) And in any case, Allergan isn’t making a disease-related claim about Latisse but rather positioning it, like Botox, as part of what the company calls a “science of rejuvenation.”
John Mack, who publishes the e-newsletter Pharma Marketing News, notes that some critics of contemporary medicine complain of disease mongering — the conversion of what used to be routine dissatisfactions of life into medical conditions, often treatable with drugs. But he agrees that Latisse, like Botox, makes no pretense of addressing a medical condition, just a cosmetic one. What he wonders about are consumers who hear “F.D.A. approved” as meaning “completely safe.” The ad mentions potential side effects like itching and redness and that if Latisse comes into regular contact with the eye there is “potential for increased brown iris pigmentation, which is likely permanent.” The latter had Mack somewhat jokingly fretting on his blog about whether Shields’s baby blues might turn brown. His real point: “Many people don’t read the side effects.”
Hypotrichosis aside, then, Latisse isn’t disease mongering. But is it inadequacy mongering? Defining eyelash adequacy is largely subjective. And if Brooke Shields — who, after all, is basically great-looking for a living — didn’t have adequate eyelashes, who does? Grant says that this is a matter for a patient and a doctor to discuss. He also notes that mascara is a billion-dollar business in the United States.
“Let’s just put it this way,” he says. “There is a very large demand for eyelash enhancement. Eyelashes are a very important part of a woman’s beauty regimen.” Any given individual’s eyelashes may not look inadequate to other people, he allows, but that person still “may feel they are inadequate.” And that, perhaps, is all it takes."
Now, consider these data points:
1. BBC News reports GPs have difficulty spotting depression among their patients, a review of research suggests.
"The researchers, who examined a total of 41 trials, found GPs were able to recognise only about half of people who had clinical depression.
For a typical GP trying to spot depression in an urban practice and seeing 100 cases over two days, there would be 20 true cases of depression.
The GP would correctly diagnose 10 people as depressed but miss about the same number with depression.
Of the remaining 80 non-depressed patients, the GP would be likely to over-diagnose 15 people, and correctly reassure the other 65."
It seems unlikely that US primary care physicians are any more accurate than their British counterparts. And, considering that a large percentage of the prescriptions for antidepressants are written by primary care physicians, we might guess that there are many people given such prescriptions who don't need them and some who do not receive them, or referral to treatment, who do need them.
2. Neuroskeptic, reviewing a study showing St. John's Wort is effective in treating depression, in Germany, concludes"
"The case of St John's Wort also highlights the weaknesses of our current diagnostic systems for depression. According to DSM-IV someone who feels miserable, cries a lot and comfort-eats icecream has the same disorder - "major depression" - as someone who is unable to eat or sleep with severe melancholic symptoms. The concept is so broad as to encompass a huge range of problems, and doctors in different cultures may apply the word "depression" very differently."
How do we know that professionals within the US, coming from differing cultural backgrounds do not also apply the word "depression" differently? The answer? We don't know. No one has looked to see.
3. From Science Daily:
"research involved the study of 82 psychiatric outpatients who reported that they received a previous diagnosis of bipolar disorder that was not later confirmed through the use of the SCID. The diagnoses in these patients were compared to 528 patients who were not previously diagnosed with bipolar disorder. The study was conducted between May 2001 and March 2005.
Zimmerman, who is also an associate professor of psychiatry and human behavior at The Warren Alpert Medical School of Brown University, says, "In our study, one quarter of the patients over-diagnosed with bipolar disorder met DSM-IV criteria for borderline personality disorder. Looking at these results another way, nearly 40 percent (20 of 52) of patients diagnosed with DSM-IV borderline personality disorder had been over-diagnosed with bipolar disorder."
The results of the study also indicate that patients who had been over-diagnosed with bipolar disorder were more frequently diagnosed with major depressive disorder, antisocial personality disorder, posttraumatic stress disorder and eating and impulse disorders.
Zimmerman and colleagues note that "we hypothesize that in patients with mood instability, physicians are inclined to diagnose a potentially medication-responsive disorder such as bipolar disorder rather than a disorder such as borderline personality disorder that is less medication-responsive." (text made bold by me)
So even without the concerns being voiced about the process being used to develop the DSM V -- and I will talk more about them soon -- here we can see that the existing system is fraught with problems due to examiner bias, cultural differences, and professional expectations. With these kinds of variance in diagnosis and lack of reliability, I find it hard to have much faith in reported incidence of depression, bipolar illness and other commonly known psychiatric problems. What we see in these incidence figures is how frequently these diagnoses are applied, not how many people actually suffer from these problems.
Also reported all over the news in the last few days is that the number of Americans prescribed antidepressants doubled in the period from 1996 - 2005 while the number of those receiving psychotherapy fell in the same period. The majority of the prescriptions, on the order of 80%, were written by physicians who are not psychiatrists.
None of this is good news.