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The shrink has shrunk: Antidepressants, open access bias and the sell out of psychiatry
Dissemintating Misleading Information about Major Depression in Primary Care
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Hagen Sandholzer, Leipzig, Germany Professor, University of Leipzig, Department of general Practice
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Sir, I read the paper by Gaynes and collegues with interest(1). No day in practice without a pharmaceutical representative showing up with papers of best quality journals written by the top creating psychiatrists worldwide. No postgraduate education activity without psychiatric screens. As a practising family physician and editor of a widespread German Journal of Primary care I am aware of a worldwide campaign to raise antidepressant prescribing in primary care. Even, for an editorial in the NEJM which "was for antidepressant prescribing" one could not find authors without conflict of interest (2). If, for instance, you search "Pfizer" and "depression" in Pubmed one could come to the conclusion that this company sells questionnaires for primary care physicians (3) :Conversely, if you look for instruments for detecting psychiatric morbidity in primary care one could guess that psychiatrics work in pharmaceutical industry. As a consequence normality was found to be rather the exception as the rule as only 19% of our primary care patients had a normal psychological test result, no subthreshold disorder or any psychiatric diagnosis 1994 (4). At that time it was usual practice to blame primary care physicians for overseeing an iceberg of morbidity. Consequently simple screening questionnaires sponsored by Pfizer and others are en vogue leaving out any paraphernalia on false positives or diagnostic manuals usually considered as the gold standard in the profession of psychiatry (3-9). Now one pushes the hypothesis that depressed psychiatric patients and general practice patients are the same (1). This paper which is a serious flawed "tautological" study as the inclusion criterion include the world’s oldest and robust index of depression severity, the Hamilton rating scale of depression to find out that in both settings the severity was about the same. In fact, the tails of two distinct skewed distributions of psychiatric scores were cut out to make depression in different settings look the same. This research question has not been poorly, but deliberately been translated into a research methodology which finds out what is wanted – a tautology. What is disturbing that those papers appear quite often open access thus shaping the knowledge of the medical speciality? What is more disturbing that it is increasingly difficult for independent researchers in this field to succeed with their own publication as the community of potential peer reviewers is small. I suggest as a rule of thumb : if the section of conflict of interest and funding support is larger that the abstract a paper should not be read by a primary care physician. Coming back to daily practice and research: the most valid difference between primary care and specialist care psychiatric setting is insight of the patient in psychogenesis of his/hers complaint. No one would consult a "shrink" without attributing his complaints to mental health. Two thirds of primary care patients at baseline have, however - no psychosomatic/psychiatric insight which makes the start of any specific treatment difficult for the general practitioner (10). Multimorbidity and the lack of treatment security are impediments as well (11,12,1). Interestingly, while reviewing guidelines on depression we found that there is a paucity of data how often a primary care physician should see a patient treated with antidepressants in contrast to the evidence base of drug treatments (12). Within the context of pay for performance one should be extremely cautious in blaming GPS for under treatment of depression using clinical standards (11). Some time ago German GPS prescribed 15%, 34% and 53% psycho tropics for psychiatrically ill patients in a large quality improvement trial at baseline (10). In looking at the recent meta-analysis on antidepressants and suicide risk differently one could come to the conclusion that antidepressants are effective in the elderly, as good as placebos in middle age and harmful in youth (5 see figure 1). In conclusion the average physician seemed to be wise and well 10 years ahead of scientific evidence. I hope that we will not see the same happening with antidepressants as with antiarrythmics before the CASS study. In looking in psychotropic prescribing over decades in Germany (12) one could see that new drugs often announced as safe as efficient soon became substituted by others because of serious side effects. Barbiturates, benzodiazepines, and low dose neuroleptics were soon replaced by tricyclics and serotonin-reuptake- inhibitors. What comes next? The next generation of sponsored studies refer to medicalization of common symptoms in primary care such as MUPS, sleep, pain and others and to internet (self-)diagnosis of psychiatric disorders. What is medically unexplained is not psychiatric morbidity: it is unexplained! One must not forget that some patients will develop psychiatric disease in lifetime but most often symptoms appear and disappear without a clear-cut diagnosis. The expression coined by Robert N. Braun “Abwartendes Offenlassen” is far more precise as its English translation “Waitful watching” as the latter implies that quite frequently in primary care a diagnostic label is not appropriate. For instance, no cardiologist promotes to be watchful in simple shortness of breath because lifetime prevalence of heart failure is some 20%. Our patients are different from those in randomized controlled trials, post marketing studies or specialist care due to selective referral (13,14). TThis holds true with respect of depression (14). The Authors should wtch out for trials outside USA while claiming their work as the most important one. As we know that the patients of the two health care sectors are different quite often we do not know how. In the case of depression I suppose it is both severity, attitude to illness the therapeutic setting and outcome (10, 14). I deeply respect my psychiatric colleagues as they do a good, exhausting and difficult job to save the lives and restore well being in psychiatric patients. This complex task cannot be reduced to screening questionnaires and antidepressant prescribing in a fire and forget technique. The task of a family physician isn’t easier either: we are not little psychiatrists”: the shrink has not shrunk! Kind regards Hagen. Sandholzer, MD,PhD Board Certified Specialist in A&E, Internal and Family Medicine Leipzig 1. Friedman RA, Leon AC. Expanding the Black Box -- Depression, Antidepressants, and the Risk of Suicide. N Engl J Med. 2007 May 7; [Epub ahead of print] 2. Gynes et al. Major depression in primary care and psychiatric care settings: a cross sectional analysis. Ann Int Med 2007; 5: 126-134 3. Kochhar PH, Rajadhyaksha SS, Suvarna VR. Translation and validation of brief patient health questionnaire against DSM IV as a tool to diagnose major depressive disorder in Indian patients. J Postgrad Med. 2007 Apr- Jun;53(2):102-7. 4.Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self- report version of PRIME-MD: JAMA. 1999 Nov 10;282(18):1737-44. 5 . Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006 May 22;166(10):1092-7. 6: Kroenke K, Spitzer RL, Williams JB, Monahan PO, Lowe B. Anxiety disorders in primary care: prevalence, impairment, comorbidity, and detection. Ann Intern Med. 2007 Mar 6;146(5):317-25. 7: Spitzer RL, Kroenke K, Williams JB, Lowe B. A brief measure for assessing generalized anxiety disorder: the GAD- 7. Arch Intern Med. 2006 May 22;166(10):1092-7. PMID: 16717171 [PubMed - indexed for MEDLINE] 8: Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self- report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient HealthQuestionnaire. JAMA. 1999 Nov 10;282(18):1737-44. PMID: 10568646 [PubMed - indexed for MEDLINE] 9: Whooley MA, Avins AL, Miranda J, Browner WS. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med. 1997 Jul;12(7):439-45. 10. Sandholzer H, Pelz J. Age specific access to primary care psychiatry. in: Quality assurance in primary care psychiatry. Results of a Nationwide Trial in Quality assurance in primary care. German Ministry of Health, Nomos, Baden-Baden 1999 ISSN 3-7890-6119-0 11. Boyd CM, Darer J, Boult C, Fried LP, Boult L, Wu AW. Clinical practice guidelines and quality of care for older patients with multiple comorbid diseases: implications for pay for performance. JAMA. 2005 Aug 10;294(6):716-24. 12. Becker, Haen, Härter, de Jong-Meyer, Linden, Niebling,Pientka, Sandholzer, Windeler, Weingart. Critical Appraisal of CPGs on Depression. http://www.leitlinien.de/clearingverfahren/english/07depression/view 12: Schwabe Paffrat (EDS) Arzneiverordnungsreport Stuttgart: Fischer 2006 13. Sox HC Jr, Hickam DH, Marton KI, Moses L, Skeff KM, Sox CH, Neal EA. Using the patient's history to estimate the probability of coronary artery disease: a comparison of primary care and referral practices.Am J Med. 1990 Jul;89(1):7-14. Erratum in: Am J Med 1990 Oct;89(4):550. 14: Poutanen O, Mattila A, Seppala NH, Groth L, Koivisto AM, Salokangas RK. Seven-year outcome of depression in primary and psychiatric outpatient care: results of the TADEP (Tampere Depression) II Study. Nord J Psychiatry. 2007;61(1):62-70. Competing interests: I was scientific project leader of a nationwide project in Germany on quality improvement in primary care psychiatry which was made possible by a two grants of the German minstry of health (1.200.000 Euro). I took part in the Clearing process of CPG on depression funded by the National Guideline Clearinghouse in Germany. |
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James C. Coyne, Philadelphia, PA Professor, Department of Psychiatry, University of Pennsylvania School of Medicine
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Gaynes and colleagues seemingly recommend inappropriately aggressive treatment of depression in primary care with antidepressants. Very few primary care physicians obtain Hamilton Depression Rating Scale (HAM-D) scores for their patients, and so there is the temptation to accept at face Gaynes and colleagues’ comparison of depressed primary care and psychiatric patients. Yet, it would be misleading to generalize to either typical patients with major depression in primary care or typical patients being treated by primary care physicians as depressed. Gaynes and colleagues’ arbitrary minimum HAM-D (14) would exclude the average depressed primary care patient, and the mean score for their resulting sample of depressed primary care patients (19.6) is substantially higher than for samples of primary care patients with major depression detected by their primary care physicians and recruited without such an inclusion criterion (13.9).1 Many patients treated as depressed by primary care physicians do not meet formal criteria for a current episode of depression and would also have been excluded by Gaynes and colleagues. For some of these patients, treatment may nonetheless be appropriate because such dichotomous diagnostic categorization does not adequately accommodate patients’ progression in or out of an episode or common impairing interepisode residual symptomatology. 2 However, other patients have had treatment initiated without formal application of diagnostic criteria and represent a poorly documented, but apparently growing problem of prescription of antidepressants to patients who do not meet indications for such treatment. The mild to moderate severity of symptoms of many depressed primary care patients is such that the benefit of antidepressant may be limited. Some empirically based guidelines recommend honoring patient preferences and exhausting other options before initiating antidepressant treatment.3 A further misleading aspect of the report by Gaynes and colleagues is that it reinforces the notion that clinicians and researchers can rely exclusively on self-report for diagnosis of depression. There is modest and sometimes only chance agreement between formal diagnosis of depression based on semi-structured interview and the results of assessments in which patients’ self-reports are accepted without the opportunity for querying and elaboration of initial responses. 4 The dissemination of the report by Gaynes and colleagues with its potentially misleading implications highlights the need for more appropriate research with more representative samples of primary care patients with major depression and patients being treated as depressed by their primary care physicians and with valid diagnosis based on semi- structured interviews administered by trained professionals. 1. Schwenk, T.L., Coyne, J.C. & Fechner-Bates, S.: Differences between detected and undetected depressed patients in primary care and depressed psychiatric patients. Gen Hosp Psychiatry;1996; 18: 407-415. 2. Klinkman, M.S., Coyne, J.C., Gallo, S., & Schwenk, T.L.: False positives, false negatives, and the validity of the diagnosis of major depression in primary care. Arch Fam Med. 1998, 7 (5): 451-461. 3. Depression: management of depression in primary and secondary care - NICE guidance. http://www.nice.org.uk/CG023 (Checked April 2, 2007. 4. Williams, DR., Hector M. González; HM., Neighbors, H, Nesse, R., Jamie M. Abelson, JA., Julie Sweetman, J, & Jackson, JS. Prevalence and Distribution of Major Depressive Disorder in African Americans, Caribbean Blacks, and Non-Hispanic Whites: Results From the National Survey of American Life. Arch Gen Psychiatry. 2007;64:305-315. Competing interests: None declared |
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