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)
For all their struggles, many “patients” have learned two things:
1. “Going to the doctor” for non-medical problems is the road to hell, and
2. Waiting for “experts” to find their balls is a waste of time –
And “psychiatric”/psychological problems are NOT medical –
“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”.
Blah, blah, blah…
Haven’t they tried this already? And what good would it do if they did? It sounds like they just want more ways of doing what they’re already doing. Genius.
So how DO you move from “rhetoric and scattered evidence” to “actionable evidence and measurable impact” when rhetoric is all you’ve got? They’ll have better luck herding cats.
“A second area of change would be to embrace the evidence from observational and real-world data…”
Doesn’t count…unscientific, anecdotal. (That’s what psychiatric survivors have been told for decades.)
“Another study has found that sexual minorities are overdiagnosed with borderline personality disorder.”
Please, enough already! Borderline isn’t “overdiagnosed” in any population. The subtext of this statement is so obvious. Borderline personality disorder is a made-up diagnosis that destroys lives. It’s a wastebasket diagnosis…it needs to be disposed of.
Doctors have lost all credibility. They have presided over an era of “health care” that has destroyed so many lives. It’s time to let the victims speak.
You are right! How can you “overdiagnose” something when there is no objective way to determine who “has it,” and so no way to determine what the “right” level of “diagnosis” is? Perhaps we should talk instead about sexual minorities being more likely to be subjected to the most shaming and destructive label in the DSM arsenal.
That’s the thing, these articles and studies saying that borderliine is “over diagnosed” in certain populations make very clear that the diagnosis itself is a punishment. It’s not meant to help. What they’re actually saying is, “hey these people (whichever marginalized group) have it hard enough, save the borderline diagnosis for the wealthy white women, they can handle it. You know it’s just to take them down a few notches because they talk back.”
It’s not science. It’s not medicine. It’s punitive. We already have a criminal justice system for people who break the law/people accused of crimes.
Punitive Medicine – that’s a good way to describe (mainstream) psychiatry. It certainly fits their DSM.
As a former client for 11 years with the “lifetime” diagnosis of bipolar (Dr. was on Seroquel/AstraZeneca payroll, my 1st scrip-ACA/ProPublica reporting) the ‘borderline’ tag came into the convo in my 2nd year of CMO-guided titration/withdrawal of the antipsychotic/benzo/’mood stabilizer’ (hahahaha) ‘treatment’.
This rare, momentous process was driven by the threat of a lawsuit (unspoken) for yet another (9 years of ER’s) life-threatening ADR-Anaphylaxis (!) as it could NOT be ‘attributed’ to my “worsening mental illness”…and I was alarmingly (!) organized & credible regarding the history of drug damages & specious origin of diagnosis..My health was rapidly failing & I knew I was close to institutionalization. I had nothing to lose, everything (health, freedom, joy) to gain.
It was my last, best shot & I took it, knowing “If u come for the King, u best not miss”. “Denial” of ‘my’ diagnosis would only energize my keepers to characterize me as ‘decompensating’…as MIA readers know what that would bring.
It went like this 2 years into withdrawal….”Well Dr., do u think I’m bipolar?”
THE question asked out loud.
Loooong pause, tenting of fingers, frowning at the floor, imaginary line drawn on desk, short ‘continuum’ speech…”You’re slightly depressed.”
Pause, pause…then he said…”What about ‘borderline’, Krista?”
I abruptly stopped my internal celebration…then came the shock, realizing he was asking if I would accept ANOTHER, murkier mental illness…. please.
I actually had to turn him down, ‘No, no thanks’….never to be spoken of again. Onward & OUT.
It was surreal, pitiful & frightening….
Thanks for this article.
I noted it mentioned that BMJ itself released a theme in 2002 highlighting the dangers of too much medicine.
So 20 years ago.
What’s been happening since then?
I have observed countless articles released right here on MIA, with alarming statistics on the increasing amount of over-medicating of children and adults along with over-diagnosis.
I have also observed point after point being made that we need to take action.
And here we are today. Where does the absolute control lie? In the hands of the people wanting changes, or with the those making money off of them.
I don’t mean to oversimplify and assume everyone’s feelings or experiences. This is me- expressing my frustration with the lack of progress.
I’ve had my own journey with mental health – a diagnosis – medication, finding my own path.
Perhaps I’m not seeing where to find a glimmer of hope that a change for the better has actually happened and more is on the way.
Part of the problem is that “overdiagnosis” and “overmedication” are not concepts that can be applied to psychiatric “treatment,” because there is no objective way to determine who does and does not qualify for a “diagnosis” made from a checklist of behaviors. So we decry “overmedication,” but the next person who comes in “depressed” for whatever reason can be reasoned to “qualify” for “major depressive disorder” and thereby be drugged once again. Add in the strong financial incentives to drug anyone who comes in the door, and you get the disaster that is “mental health treatment” today.
“…strong financial incentives to drug anyone who comes in their door…”
I dare mainstream psychiatrists to explain the difference between their DSM checklists and drug pushers on the street –
Re: The period following the Allen Frances-led DSM-IV publication (1995) intentionally expanding bipolar ‘symptoms’ at pharma’s direction, and begat the explosion of false (“over”) diagnoses in the U.S that has gone un-abated……David Healy’s (RxISK.org) article for PLoS One in 2006 nailed this topic. “Selling Bipolar Disorder: The Latest Mania” made me weep when I found it during my fight out of the psychiatric industry in 2013. And yes, David Healy is controversial. He was absolutely correct on this topic.
THIS article was my ‘gateway’ to the truth. I was energized, comforted, & validated when I found the community of professionals pushing back hard on the calamity I had escaped…Paula Caplan, Gary Greenberg, James Davies, Robert Whitaker, Marcia Angell, et al.
It is discouraging to find this (& other) genteel, carefully worded, mild rebuke(s) to psychiatric corruption pop up here and there, over the years…from folks who are in a position to instigate meaningful change.
And by ‘change’ I mean to purposefully eliminate targeted, exploitive, for-profit misery & death in psychiatry and the growing acceptance for daily, infinite ‘sedation’.
The American public has never been more aware of, and inve$ted in, good-health practices, yet drop a ‘zanny-bar’ at the first twinge of anxiety. The definition of ‘anxiety’ has been expanded much like ‘bipolar’ was at the early 2000’s….normalized and easily smothered by drugs…oops, sorry…medication..
This is yet another of pharma’s ‘long-game’ tactics in action: billions of tax-payer dollars being thrown at ‘mental health services’ to ‘fix’ gun violence is another…
Uber-profitable & effective.
Meanwhile THESE articles are wispy, thought-balloons…that could have, should have been a loud, insistent call for specific action by authors with an established platform & megaphone (Insel redux)….targeting legislators & bigger media-influencers.
The term “overdiagnosis” itself is a euphemism for malpractice, drugging people for no known cause. Let’s not mince words here! It’s not “overdiagnosis,” it is FRAUD, and it is financially incentivized instead of penalized as it ought to be!
“….the growing acceptance of daily, infinite ‘sedation’”
We’ve become a nation of drugged people –