By Vicki Fox Smith
In conjunction with the 2002 American Psychiatric Association (APA) convention in Philadelphia several high visibility press releases were issued designed to become the source of news articles in the mainstream press. Given the overwhelming drug company sponsorship, both of the convention and the "research" that has been highlighted, it should be no great surprise that they purport to demonstrate that more people then ever before have mental illnesses that benefit from drug treatment and that diagnosis can be expedited so that the diagnostic process fits well into the all too typical seven minute office visit.
The first article associated with the 2002 APA that fits this pattern appeared in the Washington Post ^1^ on May 21. It begins with the following sentence: "PHILADELPHIA, May 20 -- A top independent advisory panel today recommended that doctors begin routinely screening all patients for depression, saying that America's primary care doctors are missing and mistreating more than half of all cases of the common mental disorder." The article was based on a report by the [U.S. Preventive Services Task Force]][^2^ that began in this way: " The U.S. Preventive Services Task Force(USPSTF) recommends screening adults for depression in clinical practices that have systems in place to assure accurate diagnosis, effective treatment, and followup. The USPSTF concludes the evidence is insufficient to recommend for or against routine screening of children or adolescents for depression."
The Washington Post article goes on to link the Preventive Services Task Force report to prescribing psychiatric drugs and opens the door to aggressive follow up for patients who may not wish to be treated in this way: "But screening is only the first step in the task force's recommendation. "Asking, 'Are you depressed?' and having the patient say, 'Yes,' and then moving on doesn't cut it," Berg (note: a source also quoted in thepress release ^^ --- but not mentioning medication --- issued by the task force) said. "You have to have access to the right therapy or medicines. Patients must have access to medicines. There should be follow-up if the patient doesn't show up two weeks later."
Contrast this to language used in the Task Force findings: "Psychosocial and psychotherapeutic interventions are probably as effective as antidepressant medications for major depression, but they are clearly more time-intensive". Although the Post takes a swipe at presenting this information as well, their emphasis is clearly on promoting the use of medication as a preferred treatment.
Several questions come to mind. How sophisticated does one have to be to appreciate the difference between the two statements? Is it reasonable to expect that medical writers for major publications like the Washington Post actually read the source material (especially when it is freely available on the Internet) before turning press releases or reports of other kinds into news articles? Given that newspapers and non-peer reviewed publications are often the interface between science (or what passes for science) and the public, don't reporters, editors, and publishers have a responsibility to do a better job? And finally, what factors come into play as reporters add extraneous information that may be of marked contrast to that which is contained within the source material?
The 2002 APA also produced another major story; one purported to show an increase in the number of people who could be diagnosed with bi-polar disorder. GlaxoSmithKline sponsored the research. GlaxoSmithKline is a Big Pharma giant that markets Lamictal, an antiepileptic medication, which is currently under investigation in Phase III development for the acute treatment of bipolar depression. New data on the efficacy of Lamictal was presented on May 21 at the American Psychiatric Association annual conference. GlaxoSmithKline also markets Paxil and a variety of other psychiatric drugs.
This questionably newsworthy study by psychiatrist RM Hirschfeld was presented at the APA convention on May 21, 2002. The National Depressive and Manic Depressive Association (NDMDA) issued a press release through PR Newswire ^4^ regarding the study. The release states (among other things) that ][that three times as many people may suffer from bipolar disorder than previously estimated. NDMDA, a NAMI wanna be---at least in terms of the organization's ability to attract drug company financing--- is either not able to objectively look at drug company funded research or is so blinded by the possibility of increasing its funding base that objectivity and good science are not a concern.
This particular research design included mailing out a 13 question research instrument , the Mood Disorder Questionnaire ^5^, developed by Hirschfeld to [127,800 U.S. adults who had been chosen in such away as to match US Census data. 67 percent (85,358 individuals) returned the surveys, and without any knowledge at all about the difference between those who completed the screening and those who did not, any actual professional/personal contact or any contextual knowledge about those who decided to respond, Hirschfeld (or should we say GlaxoSmithKline) has magically created a market for psychiatric drugging that is 3 to 4 times as large as the one that would exist if the prevalence figures established through more rigorous science, like epidemiology studies cited as part of the Surgeon General's Report on Mental Health ^6^, are to be believed.
It is probably safe to say that no competent mental health professional would diagnose a person as having bi-polar disorder solely on the basis of responses to this much abbreviated screening tool. Because it cannot be accurately used as the determinant of diagnosis, it should also not be used for developing epidemiology data. Questions such as "Has there ever been a period of time when you were not your usual self and you were so irritable that you shouted at people or started fights or arguments?" and "Has there ever been a period of time when you were not your usual self and you were so easily distracted by things around you that you had trouble concentrating or staying on track?" do indeed "get at" factors that could lead those who rely on the DSM IV to suspect the presence of that disorder, but that does not transform this mail order study into good science. It is just too easy to get false positives (even when seven positive responses are required and the individual believes that these factors have disrupted their lives) from groups as diverse as those struggling with substance abuse and college students frantically studying for exams.
Bad science like this is particularly chilling. It contributes to the perception that mental illness is a growing epidemic and a public health menace that justifies forced treatment. It is no coincidence, of course, that the treatment people would be forced into largely consists of ingestion of the drugs that the study's funders market. A more subtle, but not necessarily less damaging, effect is that the organizations that should be promoting societal changes that truly benefit people diagnosed with mental illnesses, things like adequate housing, peer support, reduced discrimination, and employment opportunities are transformed into pitchmen for the pharmaceutical companies. Like the two question screening promoted by U.S. Preventive Services Task Force, this kind of reporting is used to transform the complex art of diagnosis and effective treatment into an automated process that poorly trained professionals can, in combination with whatever samples the drug company rep has dropped off that day, view as "good enough". It isn't.
In the face of increasing instances of shoddy science and bad reporting we need to press for substantial changes. Professional organizations must get off the drug company gravy train and resist the considerable pressure from Big Pharma to publicize their self-serving pseudo studies. Individual professionals must band together to force change upon the insurance companies so that the seven-minute visit is replaced by actual communication between patient and professional. Advocacy organizations need to learn to "just say no" to the siren call of drug company dollars. Science and health reporters need to critically examine the press releases that form the basis of all too many of their articles that purport to be factual and learn to avoid being the unwitting dupes of individuals and organizations that are motivated by greed or an organizational agenda. Editors for publications, including industry-specific periodicals like Psychiatric Times, and those who approve mainstream media op-eds need to insist on quality peer review so that their publications do not become the gateway that transforms unsubstantiated opinion into generally accepted "truth". Publishers need to devote the resources necessary so that ethical reporters can develop reputable sources and pry themselves away from sound bite reporting of statements by official mouthpieces for questionably funded organizations. Activists need to spend less time talking to each other and more time establishing their expertise so they too are seen as reputable sources of information.
Perhaps if we begin to implement these changes now, next year's APA convention will be less of a disgrace to the profession of psychiatry and less harmful to the public.
Source material (all accessed May 22, 2002)
Shankar Vedantam, Routine Screening for Depression Urged, Washington Post May 21, 2002; Page A01
Alfred O. Berg, MD, MPH, Chair, U.S. Preventive Services Task Force; c/o David Atkins, MD, MPH, Scientific and Technical Editor, U.S. Preventive Services Task Force; Agency for Healthcare Research and Quality, Center for Practice and Technology Assessment, http://www.ahcpr.gov/clinic/3rduspstf/depression/
U.S. Preventive Services Task Force Now Finds Sufficient Evidence to Recommend Screening Adults for Depression Press Release Date: May 20, 2002, http://www.ahcpr.gov/news/press/pr2002/deprespr.htm.
New Data Suggest Bipolar Disorder May Affect Three Times More Americans Than Believed-Nationwide Study Presented at APA Shows 4 Out of 5 Go Undiagnosed, Many More Misdiagnosed PR Newswire - May 21, 2002, http://www.psycport.com/stories/comtex_2002_05_21_pr_0000-2186-pa-national-dmda.xml.html
Mood Disorders Questionnaire, http://www.psycheducation.org/depression/MDQ.htm
Copyright © Vicki Fox Smith for MadNation, May 2002
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