In a new editorial, Kamran Abbasi, the editor in chief of The BMJ, discusses the campaign against too much medicine, which focuses on addressing overdiagnosis and overmedication.
Abbasi explains that overdiagnosis and overtreatment are causing a significant burden on our health systems. Our willingness to uncritically diagnose has led to increased healthcare costs, pressure on staff, injured patients, and further environmental degradation. The current work argues that we need to focus on the harm this system causes to patients and optimize data to present that harm to patients and policymakers.
“A focus on the harms to patients of overdiagnosis and overtreatment would make a more powerful argument than a focus on costs,” Abbasi writes. “A second area of change would be to embrace the evidence from observational and real-world data and to optimize data to better inform clinicians and policymakers about harms, without diluting the importance and centrality of well designed randomized controlled trials.”
Many researchers have pointed to the problem of overdiagnosis and overmedication. Research has found that ADHD is likely overdiagnosed in children and teens, exposing them to harmful stimulants with little long-term benefit. Likewise, experts have warned that youth depression screening leads to overdiagnosis, subjecting children to dangerous drugs that significantly increase their risk of suicide with a lack of evidence for substantial benefits. Research has also found that only one in four pediatricians consult the DSM diagnostic criteria when applying these labels to children.
In addition to children, minorities are likely at increased risk of overdiagnosis and overmedication. For example, research has found that schizophrenia is overdiagnosed in African Americans due to clinicians misinterpreting mood disorder symptoms. Another study has found that sexual minorities are overdiagnosed with borderline personality disorder.
The problem with overdiagnosis and overmedication is not limited to children and minorities or even to the discipline of psychiatry. Research has addressed overdiagnosis in primary care for certain cancers, finding that breast cancer overdiagnosis alone likely costs the United States $4 billion annually. This problem is so pronounced in psychiatry that one author has called it a “diagnostic epidemic.”
Overdiagnosis in psychiatry exposes service users to several dangerous and ineffective drugs. For example, a depression diagnosis is often followed by a prescription for antidepressants that do not improve quality of life but pose significant health risks, including suicide. Likewise, people diagnosed with anxiety disorders are commonly given benzodiazepines, a substance that can cause physical dependence and lead to long-term injury. Additionally, some clinicians have argued that the long-term use of antipsychotics may not significantly improve outcomes and can lead to disastrous long-term effects.
The current work begins by explaining that concerns around overdiagnosis have existed for some time. BMJ itself released a theme issue in 2002 highlighting the dangers of too much medication. The authors in that theme issue spoke about the risks of medicalizing normal life processes. Unfortunately, this problem has not been appropriately addressed by the medical disciplines, as evidenced by the current push to medicalize and medicate menopause with hormone replacement therapies that are not appropriate for most women.
While many researchers and service users are concerned about overdiagnosis and overmedication, “industrialized medicine” continues nearly unabated. Industry uses its money to “sell sickness” to the unsuspecting public, relying on fear and overwhelming emotions to convince people to take dangerous and unnecessary drugs at great cost to medical professionals, service users, and the planet. Politicians and health professionals are often misled as well, compounding the problems of overdiagnosis. In addition, the author states that some populations are routinely underdiagnosed and undertreated, further complicating these discussions.
While all these problems may make it seem as if the push against too much medicine has all but lost the fight, Abbasi believes it will ultimately succeed due to the overwhelming evidence, the people within the system working in good faith, and the declining influence of industry money as societies become more open.
For the push against too much medicine to make meaningful change, the author believes the campaign needs to focus on two areas. First, they need to emphasize that “low-value healthcare” hurts people. Rather than the current focus on the financial costs of “low-value healthcare,” they should be focusing on the human cost. Second, the campaign must embrace observational and real-world evidence without compromising the standard of randomized control trials and present this evidence in palatable ways to service users and policymakers. Abbasi concludes:
“Above all, the campaign against too much medicine needs a system reset to move from rhetoric and scattered evidence to actionable evidence and measurable impact.”
Abbasi, K. (2022). A system reset for the campaign against too much medicine. BMJ, o1466. https://doi.org/10.1136/bmj.o1466 (Link)