THESIS: Lately, it was possible to find a lot of facts which indicate that medicine does harm to healthy people due to overdiagnosis and widening conception of many illnesses. Overdiagnosis is not an innocuous phenomenon and covers various complications of physical and mental health.
A. Defining overdiagnosis.
B. How overdiagnosis may be harming people.
C. Causes of overdiagnosis.
II. OVERDIAGNOSIS OF MENTAL ILLNESSES.
A. Overdiagnosis of depression.
Overdiagnosis of illnesses is often more harmful than helpful for human health. Nowadays there are a lot of situations when doctors exaggerate possible outcomes and risks after getting the examination results in order to avoid any unpleasant consequences. But striving for diagnose illnesses at the early stages can be dangerous for patient's health. On the one hand, it can lead to discovering the illness, but on the other hand, a healthy person can be pinned a label of an ill patient and prescribed unnecessary treatment. That is why overdiagnosis is a studied phenomenon which is considered to be a problem in general medicine.
Nowadays there is no certain formal agreed definition for overdiagnosis, it is known as the erroneous medical report which indicates existence of the disease and related complications which do not really exist or are not so distinct as it was stated. "The narrow definition of overdiagnosis within medicine is the diagnosis (and usually, treatment) of an asymptomatic disease which will not cause early mortality (Lacasse & Leo 1309). The broader definition which is more suitable for psychiatric illnesses, associates overdiagnosis with problem of irrational medicalization and following overtreatment, changes in threshold and misdiagnosis.
Narrower and broader overdiagnosis concepts are used in various areas for different purposes: " unpacking the logical structure of overdiagnosis, explaining how it occurs, measuring it, advocating for political change, or developing practical tools to change clinical or policy practice" (Carter et al. 2). For example, from the epidemiological view, the term of overdiagnosis should be more exact and includes several suppositions for certain conditions. Sociologists explore how overdiagnosis and subsequent outcomes are considered by patients, doctors, citizens and decision makers. Fortunately, findings from studying this concept are helpful for development of strategies aimed to reduce cases of overdiagnosis. One of the most important stages in this struggle is to realize the uncertainty of medical practice and understand the risks for health.
How Overdiagnosis May Be Harming People.
Now overdiagnosis is an acknowledged problem in modern medicine which affects medical officers, patients, researchers and scientists, policy makers etc. This issue became a focus of numerous conferences, papers, discussions in journals and practices. In recent years, extolled ability of medicine to help patients is compromised by its disposition to do harm to healthy people. There are scientific publications which cause public concern about the fact that too many people become the victims of overdiagnosis, excessive treatment and overdose. Definition expansion of certain diseases means that even people with low risks can be medically "labeled" and take useless medicine till the end of their life. Such unnecessary medical interventions don't improve health state, they cause complications of diseases, worsen life quality and sometimes even lead to premature death.
It can lead to an issue when people at the low-risk group with insignificant problems are treated as ill patients. The other consequences of the overdiagnosis include negative influence of unnecessary labels pinned to people which cause psychological and social issues, damage from excessive diagnostic and therapeutic procedures, overspending of financial and other sources which could be used for treatment and prevention of real existent illnesses. Determining the nature and scope of the problem or discovering its features and causes is a complicated task.
In order for better understanding of the problem it is necessary to divide the broad concept of overdiagnosis in accordance with different aspects and ethical dimensions. "Aspects of overdiagnosis overlap with existing movements in health policy and practice such as evidence based medicine, patient centred care, strategies for disinvestment, and quality and safety in healthcare, especially preventing iatrogenic illness and low value healthcare" (Carter et al. 1). For the deeper understanding of overdiagnosis it is necessary to take into consideration both technical and moral analysis because it is difficult to define overdiagnosis only technically avoiding ethical aspects, values and context. Furthermore, it is important to pay attention to complex healthcare systems and people involved in their functioning. There is an opinion that overdiagnosis will take place in modern medicine until clinicians, patients and society know how to admit the ambiguity peculiar to medical services.
Causes of Overdiagnosis.
There are many motive factors of overdiagnosis which lie deep in the medical culture and general public; it is possible to underline some of them: high intentions and technology achievements. It was found that the opportunity to reveal insignificant deviations from the norm cause increasing frequency of occurrence of any illness. It leads to the reassessment of the therapeutic benefits because easier forms of diseases are treated while health improvement is mistakenly considered as successful results of treatment. Finally, the vicious cycle of diagnosis and treatment intensification is started and it is more likely to do harm than benefit.
Moreover, medical technicians and general public are greatly influenced by industries which profit from expanding markets of diagnostic and treatment tools because there are monetary links with professionals and patients; financing of advertising where target audience are direct consumers; research funds; campaigns which are aimed to increase awareness about the diseases and health education. Then, members of the committees which define diseases and therapeutic threshold indicators are often financially connected with companies that are interested in increasing profits through market expansion. Physicians and their associations also may be interested in increasing patient population within their specialization while involvement of diagnostic and therapeutic techniques of their commercial interest can lead to excessive diagnosing.
Other important factors which can cause overdiagnosis are the wish to avoid a lawsuit and so called psychology of regret. In contrast to absence of the punishment for overdiagnosis, doctors can be penalized for ignoring early symptoms of the illnesses. Formally, prescription of many additional examinations, procedures, analyses and medicine corresponds to accepted standards of therapy, so a doctor is protected from patient's lawyer and insurance company. From the other side, overdiagnosis can be stimulated by professional quality indices; the more patients are treated the higher indices are shown and the more chances to be rewarded. Then, at the core of the problem of overdiagnosis it is possible to underline the belief in early detection of diseases which is supported by deep trust in medical technologies.
But concern about overdiagnosis should not allow people forget that many patients suffer from lack of medical care. At the same time, resources spent on unnecessary medical procedures could be used profitably for treatment of real illnesses and their prevention. The problem is to distinguish necessary treatment and spread information which can help people take right deliberate decisions in cases when medical intervention is more harmful than useful. Overdiagnosis can be understood in cases of acute care when the problem consists in risks for patient's life and there is no time and opportunity for more accurate diagnosis.
Overdiagnosis of Mental Illnesses
Speaking of the mental health, overdiagnosis in psychiatry is only harmful and unfortunately, nowadays this phenomenon is rather spread. Sometimes psychiatrists are focused on formal execution of the plan instead of orientation towards patient's interests; that is why they are often blamed for overdiagnosis of "disorders of questionable scientific validity" (Bhatia 3) and for use of unnecessary medical solutions of life problems. Moreover, there is a problem of conflict of interests; it is necessary to revise the classifications and distinguish syndromes, symptoms, normality and disorders such as depression. It is known that when working with mental illnesses there is a diagnostic overshadowing, which means that diagnosis based on the main condition leads to referring of all other issues to the same case. This tendency leads to "denial of normal personality traits, situational normal reactions, problems, transient symptoms and organic factors" (Bhatia 3). Some of the most popular examples are increase of prevalence of ADHD in children, emotional immaturity, use of drugs and stimulants in certain disorders etc. In order to avoid untimely labeling it is necessary to differentiate emotional states, reactions, and define their normality or abnormality.
There is a tendency to reveal and diagnose illnesses which could be treated with help of drugs; also there are often cases when drugs are used to treat some personal features, normal reactions, symptoms and disputable diagnoses. It is explained by the aspiration to apply medicamentous therapy to both psychological and environmental issues. It results in decrease of physical, psychological and behavioral intervention. In fact, successful results are estimated not by the number of patients who were treated with drugs but the number of cases where a psychiatrist achieved patient's recovery avoiding use of drugs. It is possible to pick out several mistakes made in diagnosing mental illnesses; psychiatrists should make more efforts to push forward primary and tertiary prevention, and they should be more resolute when transferring rights of treatment to other specialists. "Due to limited availability of mental health professionals, psychiatrist has to take the multiple roles of trainer, researcher, teacher and clinician, which is really a great challenge" (Bhatia 4).
The most common and serious issue of mental health is depression. It is characterized by depressive mood, energy decrease, interest loss, sleep and appetite disturbance, decreased concentration and self-esteem. There are different assumptions concerning the question if depression is a disease. Some view it as an adaptive mechanism which serves people and arises when people are not going well. Thus, nature moves people telling that some changes are needed. It is possible to compare with pain, which acts as the tool that warns about damage and requires urgent help. As main symptoms of depression include disturbances of sleep, appetite, decreased concentration, negative emotions and helpless feelings, nature stimulates people reconsider their lifestyle, think of nutrition, reduce use of some substances, regulate relations with family and close people, review plans and position in life in order to move towards goals.
Depressive disorders can start at any age, they affect many aspects of life and are considered to be the leading reason of disability. Depression is often viewed as the sign of one's weakness while it should be taken into account as the signal which indicates abnormal state of a person. There is much attention paid to the necessity of timely disorder detection and following treatment.
When providing competent treatment depression can be successfully cured. Though depression can be reliably detected in primary care, in numerous cases it is not revealed by a family doctor, overlooked disorder became a subject for research and discussions in mental health area. At the same time, it is necessary to remember that each person experiences sad feelings at some points in life, but it does not mean that such symptom should be treated as clinical depression. "A low threshold for diagnosing clinical depression risks treating normal emotional states as illness, challenging the model’s credibility and risking inappropriate management" (Parker 328). Underdiagnosis and overdiagnosis are closely connected with each other, the first phenomenon attracts attention of family physicians to the problem and leads to higher rates of overdiagnosis. This point of view should be taken into consideration due to the possibility of following clinical outcomes and incorrect therapeutic actions.
Many of those who receive medication for depression experience other issues which make them feel depressed. This fact is associated with more simpler interpretation of depression which was developed in the past, when it was explained by sleep and appetite loss and sadness during some period of time. There is also a fear that overdiagnosis of depression and prescription of unnecessary medicine can cause a dependency. Treatment with antidepressants is also a disputable question; many attribute these drugs to mood-altering substances such as alcohol, cocaine etc. There are many doubts if such treatment can be effective is struggle against depression.
There was a cross-sectional study conducted "to identify the factors that determine the overdiagnosis of depression and evaluate the clinical significance of this error" (Aragonèsa et al, Introduction). It took place in 10 Primary Care Centres of Spain, involved twenty-three family doctors and consisted of two phases: a screening test and examination of subsample taken from test results in order to detect the final diagnoses. At the first phase the authors used Zung's self-rating depression scale and gathered following data: sex, age, marital status, education and social class. At the second phase they included interviews assessments, scales and questionnaires which helped to define reference diagnoses, find out symptoms of anxiety and panic and evaluate patient's health state. In other words, it was necessary to explore physical and mental health aspects and personal assessment of one's state of health. In their turn, the doctors who participated in the study were to define if a patient was suffering from depressive disorders basing on current consultation and clinical history, they did not have access to results of carried out interviews and screening.
Described analyses are based on patients who experienced different health issues, that is why the study reflects the general picture of doctor's daily work. At the same time, the study could be turned towards overdiagnosis because despite of lack of information about results of screening and psychiatric analyses, family physicians knew that patients they had worked with were prepared for the second phase where depression rates were higher.
According to the results of the study, 40% of non-depressed people were diagnosed depression at the second phase. It would be incorrect to state that mentioned findings indicate unskilled family doctors, the reason also consists in differences between patients without depression. Many patients needed consultation because of psychological reasons, were more likely to experience distress and they had lower estimation of their own health. Though there are some reasonable explanations for overdiagnosis of depression among family physicians, it is necessary to remember that "the erroneous diagnosis of depression in patients with a slight psychological malaise and little functional repercussion leads to the risk of unnecessary and potentially dangerous medicalization." (Aragonèsa Piñolb Labad, Clinical Implications).
The opposite point of view is provided which assures that increased treatment of depression has positive impact on rates of suicide and productivity. The increased rates of depression diagnosis includes following benefits: "reduced stigma, removal of structural impediments to employment and health benefits, increased access to life insurance, improved physical health outcomes, reduced alcohol and drug misuse, and wider public understanding of the risks and benefits of coming forward for care" (Hickie 329).
Medicine is the area of science which requires precise and logical definition, classification and interpretation of studied phenomena. Most of mental illnesses are syndromes which are not qualifies as diseases and called disorders. Overdiagnosis is described as a "the result of enthusiasm or zealotry, for either a theoretical concept or a treatment method" (Paris 4). Certainly, accurate diagnosing is the only way towards effective treatment and positive results in struggle against illnesses, while the concept of overdiagnosis is associated with activities which are more harmful than helpful for human health. First of all, diagnosis of mental illnesses should begin with interpretation of reasons why a patient became ill. Thus, professionals should take into account numerous aspects and refer to biopsychosocial model.
It is possible to conclude that there are several serious complications caused by overdiagnosis. One of them consists in labeling healthy people as being at risk or being ill without certain evidence, that can lead to worse state of health and well-being. The next point is connected with interrelation between undertreatment and overtreatment because increased interest and attention to extended diagnoses move resources away from seriously affected patients. The other aspect consists in the tendency to "render healthcare systems based on social solidarity unviable because of the escalating costs involved" (Heath 2). Finally, the last point is focused on the increase biotechnical activity in contrast to socioeconomic aspects of human health.
Aragonèsa, Piñolb & Labad. The Overdiagnosis of Depression in Non-depressed Patients in Primary Care. Family Practice. 2006. 23 (3): 363-368. doi: 10.1093/fampra/cmi120 Web. <http://fampra.oxfordjournals.org/content/23/3/363.full#sec-9>
Bhatia M.S. Over Diagnosis, Overshadowing and Overtreatment in Psychiatry. Department of Psychiatry, University College of Medical Sciences & G.T.B. Hospital, Delhi University, Dilshad Garden, Delhi-110095. DELHI PSYCHIATRY JOURNAL Vol. 15 No.1 Web. <http://medind.nic.in/daa/t12/i1/daat12i1p3.pdf>
Carter S.M., Rogers W., Degeling C., Doust J. & Barratt A. The Challenge of Overdiagnosis Begins With its Definition. BMJ 2015;350:h869 doi: 10.1136/bmj.h869 2015. 5 pages.
Heath, Iona. Overdiagnosis: When Good Intentions Meet Vested Interests. BMJ 2013;347:f6361 doi: 10.1136/bmj.f6361 2013. 3 pages.
Hickie, Ian. Is Depression Overdiagnosed? BMJ. 2007. Volume 335 Web. <http://depressionet.org.au/wp-content/uploads/2010/12/article_gparker_yes.pdf>
Lacasse, Jeffrey R. & Leo, Jonathan. Overdiagnosis. College of Social Work, Florida State University, Tallahassee, FL, USA. Division of Health Sciences, Lincoln Memorial University, Harrogate, TN, USA. 2014.
Paris, Joel. Overdiagnosis in Psychiatry: How Modern Psychiatry Lost Its Way While Creating a Diagnosis for Almost All of Life's Misfortunes. Oxford University Press. 2015. Print. 272 pages.
Parker, Gordon. Is depression overdiagnosed? BMJ. 2007. Volume 335