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Depressed woman

Feeling low? Doctors and psychiatrists could be seriously over-estimating the number of people who are depressed, and wrongly prescribing drugs to thousands who are healthy

The great depression swindle

JEROME BURNE Last updated at 12:22pm on 24th April 2007

The test GPs use to diagnose depression is worse than useless, according to new research. Under the latest government guidelines, doctors are paid extra to ask patients two simple questions. Your answers are supposed to show if you are depressed or not.

But, a study has found that 62 per cent of patients diagnosed as depressed weren't in fact depressed at all.

As a result, doctors and psychiatrists could be seriously over-estimating the number of people who are depressed - and prescribing drugs to thousands who are healthy, says the study's author, Dr Alex Mitchell, a consultant psychiatrist at Leicester General Hospital.

Article continues below and (thank you)

 

Under current guidelines, with mild to moderate depression are meant to be offered talking therapies - psychological treatments which help people change their attitudes or behaviour patterns.

Research by the mental health charity SANE has found that only and studies have found they can two per cent of patients were having cognitive behavioural therapy (CBT) and more than 80per cent of patients were being treated with medication.

Anti-depressants come with a range of side-effects. About 25 per cent of patients have problems when they try to stop taking them and studies have found they can cause a rise in suicidal thoughts and actions. Patients also report a loss of libido.

Two recent studies have linked the drugs with a drop in bone density leading to osteoporosis and a dramatic fall in the number of sperm a man can produce.

Given all this, you would expect those two questions, approved by the National Institute for Clinical Excellence (NICE) in 2004, to be exacting.

In fact they are absurdly simplistic and, worryingly, if you answer yes to both you could be put on Prozac.

The two questions are:

• During the past month have you been bothered by feeling down, depressed or hopeless?
• During the past month have you been bothered by having little interest or pleasure in doing things?

The GPs' two-question test isn't the only one the experts have got badly wrong. Dr Mitchell's other shocking discovery is that the latest guidelines to detect post-natal depression (PND) are even more inaccurate, but in the opposite direction.

A new three-question test fails to spot an astonishing 80 per cent of the women who actually are depressed.

"It uses the same two questions as for regular depression and then adds a third: "Do you want help?" This reduces the accuracy of the test to just 17 per cent," explains Dr Mitchell.

NICE is now in discussion with Dr Mitchell about the PND test.

According to the doctors' newspaper Pulse, many GPs are dropping the depression test because they don't believe it is good for patient care, even though they will lose income as a result. It's mainly aimed at high risk patients, such as those with heart disease or diabetes.

Many GPs say they don't have the time for longer, more accurate testing - the reason for introducing the shorter test in the first place.

The useless tests also threaten to make a nonsense of a new government initiative to make CBT available to many online.

Last year, a group of charities, including the Mental Health Foundation and Mind, called for a "large sustained cash injection to improve psychological treatments'.

They said CBT was as effective as drugs and that more than half of GPs believed it was the best option.

The internet scheme, unveiled by Health Secretary Patricia Hewitt last month, has been designed to meet criticism that, even though CBT is recognised as the best treatment for depression, waiting times can be more than a year because the health service needs 10,000 more therapists.

If you rate as depressed on the flawed test, you get eight onehour interactive computer sessions on a program called Beating The Blues with homework projects and GP progress reports - much cheaper than training 10,000 therapists.

The aim, said Ms Hewitt, was to allow patients to access the right sort of therapy "instead of just being prescribed medication".

One doctor who has been using the system in Swindon, Wiltshire, for three years was enthusiastic.

Dr Peter Crouch said: "It has significantly helped patients cope with anxiety, insomnia and stress." But, of course, how useful it is depends on how accurately people are diagnosed.

Indeed, what is the point of rolling out a programme that will be offered to hundreds who don't need it - or if it isn't provided to those who do? Soon many will be spending hours at their keyboard doing CBT exercises for no reason.

The 'good' news is that computers and the internet are likely to be much more widely used to spot who needs help - and at least these seem more accurate than the two-question test.

A recent report by researchers in Taiwan reported that an online questionnaire filled in by more than 500 people identified 38 per cent as depressed and 46 per cent as not. When they were tested by a psychiatrist, 75 per cent of the diagnoses were correct.

Soon patients may be asked to fill in longer questionnaires of this sort, while they are in the waiting room.

And if it is done on a computer the doctor could then have the results during the session. For the moment, what can you do to increase your chances of getting the right sort of help?

Dr Mitchell's research into how GPs diagnose depression also provides some useful tips. "Doctors tend to be influenced by how patients describe their problems," he says.

"If you talk about physical symptoms - how tired you are, how you can't sleep - your doctor will usually suspect a physical cause even though those are also signs of depression.

"Be clear about your main symptom. So if feeling down or low is what's really making your life miserable, talk about that."

How can you avoid being labelled as depressed when you aren't? Do what may seem like common sense and explain your problems.

What the test ignores is that sometimes people have a very good reason to feel low: you've been sacked, for example.

A recent U.S. study has found that as many as a quarter of people currently labelled as depressed are reacting perfectly normally to stressful events.

It suggested that even psychiatrists regularly miss the broad picture. Once you've ticked enough boxes for symptoms, you get diagnosed as depressed even though you may just be sad.

So if you aren't asked the obvious question about what is going on in your life, make sure you volunteer it.

Here's what readers have had to say so far.

I think this information is a good idea. The Mental Health Teams locally are absolutely useless. They just suggest tablets or going into hospital. If you go into hospital it's much worse with fighting, shouting and frightening people there.

- M Slessor, London, England

I'm not surprised. I've always refused to take 'attitude' tests of any kind, especially those used in job interviews. A test we conducted in our offices over 30 years ago showed that the success/rejection rate was just the same in employees as it was for job candidates. The scores seemed completely random, yet our employer paid a lot of money to have these tests conducted.

People never answer these things honestly anyway - only for some kind of gain, for example to get the pills, to get the job, or to please the person asking the questions.

 

New Depression Therapy Gives Reason For Hope

A study at the University Clinics of Bonn and Cologne gives people with therapy-resistant depression reason for hope. The doctors treated two men and a woman with what is known as deep brain stimulation. All three patients have been suffering from very severe depression for several years which could neither be brought under control using medication nor by other therapies. During the simulation the condition of two of the three patients improved within a few days. Initial changes were even noticeable in a matter of minutes. The research team warn against exaggerated expectations in view of the small number of patients involved. Nevertheless, the results of the preliminary study are so sensational that they have now been published in the renowned journal Neuropsychopharmacology (doi: 10.1038/ sj.npp.1301408).

In deep brain stimulation (DBS) electrodes are implanted selectively in certain areas of the brain and are stimulated using an electric pulse generator. Up to now the procedure has mainly been used in the treatment of Parkinson's. It is currently being investigated whether it also helps with certain psychiatric diseases such as compulsive behavioural disorders. Initial tests on about two dozen patients worldwide also show that it could possibly also have an effect in the case of severe depression.

Previous tests have concentrated mainly on two areas of the brain in particular. "By contrast we stimulated a third region, the nucleus accumbens," the Bonn Professor of Psychiatry, Thomas E. Schläpfer, explains. The nucleus accumbens is an important part of what is known as the "reward system". It ensures that we remember good experiences and puts us in a state of pleasurable anticipation. Without the reward system we would not make plans for the future, simply because we could not enjoy the fruits of these plans. "Inactivity and inability to enjoy things are two important signs of depression," Profesor Schläpfer emphasises. "The conclusion is therefore obvious that the nucleus accumbens plays a key role in the genesis of the disease."

Initial effects minutes after onset of therapy

In their study the researchers report on two men and a woman who have been suffering from very severe depression for years. The researchers implanted electrodes in the nucleus accumbens, which they were able to stimulate using an electric pulse generator in the chest. Some of the effects were observable instantly. "One of the patients expressed the desire to go to the top of Cologne Cathedral a minute after the start of the stimulation and put this into practice the next day," Thomas Schläpfer says. "The woman treated was similar. She said she would enjoy going bowling again." Nevertheless, the patients did not notice a direct improvement in their mood. Nor could they tell whether the pulse generator was switched on or off.

In the first few days of the DBS the symptoms of depression improved significantly in two of the three patients. Their condition remained constant for as long as they were undergoing treatment. However, as soon as the pulse generator was switched off, the depression recurred with full intensity. "The recurring symptoms were so severe that for ethical reasons we could not permit the treatment to be interrupted for as long as we had originally planned," Professor Schläpfer emphasises.

While psychotropics generally interfere with the biochemistry of the brain, DBS acts locally in the affected areas. The doctors did not observe any side effects like those occurring after the use of antidepressants. The patients only complained about post-operative pain at the site of implantation. In the long term DBS does not seem to pose any major risks. There have been patients with Parkinson"s who have been using this kind of brain pacemaker for more than ten years without experiencing any problems.

Preliminary results

Even so, the research team caution against exaggerated expectations. "Of course, with so few patients, these are only fairly preliminary results," Professor Schläpfer says. "Our follow-up experiments are showing even now that by no means every patient will respond to this therapy." In the case of operations on the brain, in particular, ethical factors also need to be taken into account, not least because such operations are always risky. For that reason, there were particularly stringent conditions attached to the patients" consent. "One thing has certainly been demonstrated by our research and that of others: DBS can help some people with depression even in cases which were assumed to be resistant to therapy."

###

Contact: Professor Thomas E. Schlaepfer
University of Bonn
 
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