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Are Americans over-diagnosed and over-treated for depression, as claimed by a new study conducted at the Johns Hopkins University? The study examined over 5000 adults who had been told by a clinician that they suffered from depression. The major finding was when these same people were independently assessed for major depressive episodes using a structured interview, (face-to-face interviews that are the "gold standard" of psychiatric evaluations), only a minority (38.4 percent), met all of the official diagnostic criteria for depression in the last year. Nevertheless, strong majorities of study participants were prescribed and used psychiatric medications
The press release framed matters like this: "Depression over-diagnosis and over-treatment is common in the U.S. and frankly the numbers are staggering," said Ramin J. Mojtabai, PhD, author of the study and an associate professor with the Bloomberg School's Department of Mental Health. "Among study participants who were 65 years old or older with clinician-identified depression, 6 out of every 7 did not meet the 12-month major-depressive-episodes criteria. While participants who did not meet the criteria used significantly fewer services and treatment contacts, the majority of both groups used prescription psychiatric medication."
Media outlets appear to take the report at face value (Altantic story; CBS).
Let's dig a little deeper into the report.
A paraphrase of the main result is that the majority of people who believe that their doctor or counselor believes that they have had depression in the last year do not meet all the formal interview criteria for depression over the same year. What might this mean?
It likely underscores that most real-world assessments of depression tend to be very informal. Certainly, it would be rare for a primary care physician to do a structured clinical interview for depression or any other psychiatric category. A comprehensive psychiatric interview could take hours. Even mental health professions tend not to do formal assessments but often rely on rules of thumb and their intuitions to guide a conversation. Informal or hasty assessments can lead to diagnostic errors.
However, I am concerned about any reading of this paper that suggests that depression is just another term for the "worried well," and that we should all just relax about depression as a public health problem. The data in the report say otherwise: Of those patients who did not meet the 12 month interview criteria for depression, the majority likely had probable serious mental illness, based on their answers concerning significant distress and impairment in their lives (according to K6/WHODAS criteria). More than 4 out 5 had received mental health treatment in the past year. In my experience, people who are doing well in life tend not to seek out mental health treatment. Treatment can be expensive, uncomfortable, and there remains a significant stigma associated with receiving it. It is doubtful that this study has identified a group of the worried well.
There also is a danger of reifying the DSM-IV (now DSM-V) criteria for a major depressive epsidode, with the implication that anything that does not meet those criteria is not depression. As I have posted previously, minor depression--persistent symptoms of depression that full short of a MDE--is not minor by any stretch. People with minor depression, who are bothered by a low mood that they can't shake, or unable to enjoy things, are likely to develop serious depression in the future, even if they have only a few depression symptoms now.
The Moral: Two Implications
1. When they receive a diagnostic label, patients need to ask more questions about its basis. We don't know exactly why the participants in this study thought that their clinician believed that they were depressed. Was this based on a casual comment, with depression simply thrown out as a hypothesis? Was it based on detailed discussion of the symptoms? Is it possible that some patients in fact misunderstood the communication from the doctor? Was depression asserted to be the primary problem, or was it one among a number of mental health issues that the clinican had stated might be a significant issue for the client (i.e., marital distress, drinking problem, body image problem, etc)? How much time did the clinician spend with the patient before indicating that depression was a possibility? Given the possibility of a hasty assessment and miscommunication, patients in our medical and mental system need to resist their historical deference to the doctor and ask more questions about their diagnostic label, and certainly about any recommendations for treatment. Which brings me to the next point.
2. Psychiatric medications are likely overprescribed. About 80 percent of the sample was receiving psychiatric medications (probably many on more than one drug). This is a very high percentage. The report does not specify what percent were receiving medications only to address their issues, but my hunch would be that medication-only was an extremely common treatment. Clearly, it would be much healthier to see a wider mix of therapies, including psychologically-based therapies, used as stand-alone treatments. Based on the interview results, we certainly cannot be confident that the 4 out of 5 people who had taken psychiatric drugs in the past year were taking a drug demonstrated to be effective for their condition. Overprescription is not a new problem; it is old problem, and it is a particular problem with antidepressants. This brings us to the same moral: Patients need to ask tougher questions in the consulting room, and assume greater responsibility for their own care.
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