6 ms·

Diagnostic criteria for anxiety and depression are very broad because they are necessary as tools for practicing doctors seeing patients (as opposed to applying

Diagnostic criteria for anxiety and depression are very broad because they are necessary as tools for practicing doctors seeing patients (as opposed to applying them to a random selection of people). If you turn the process back, and just ask how many people in the population fit under them, you'll always, even in normal times, get an unexpectedly large number. That doesn't imply that anything is wrong or that anything needs to be done about it, doctors don't use them like that. This is approximately the same phenomenon that causes medical students to self-diagnose themselves with every disease they learn about: one of the fundamental factors missing from such a diagnosis is that they haven't walked into a clinic. It's not a bug in the diagnostic criteria, it's just a misapplication of them. One of the main ways of fighting over-diagnosis is to not apply diagnostic criteria for every known condition to random people who you have no a priori reason to suspect they might have those conditions.

ssivark 6y ago
This is an important point about the role of priors — especially if one is using a statistical (correlation based) proxy for what is actually a causal question. But here’s a practical question: imagine a universal healthcare mandate which allows people to get a mental health check-up every year. What criteria should the doctors use? Would the diagnostics have to change significantly?
- bobthepanda 6y ago
  What do practitioners do in countries with universal healthcare?
  - chipperyman573 6y ago
    You still need to actively persue the healthcare even if your country pays for it.
    - AnotherGoodName 6y ago
      I will say the barriers are definitely lower though when i compare my home country Australia to my adopted country the USA. Sure you need to actively pursue healthcare in Australia but the barriers are just so much lower. A great example is http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/bowel-cancer-screeningkit-eligibility http://www.cancerscreening.gov.au/internet/screening/publish... You fill in the details and you're mailed a reply post paid bowel cancer screening kit.
      - AnotherGoodName 6y ago
        Oh and more relevant, the portal for mental health care. https://headtohealth.gov.au/ https://headtohealth.gov.au/ I suspect the US government won't have anything quite like this since the healthcare is not centralized.
  - dmix 6y ago
    In Canada shrinks aren’t covered by our public health insurance. They are just as expensive as they are in the states.
  - nalllar 6y ago
    If you really think you need it, you go privately or join a long (years) waiting list for mental health service, maybe get a group therapy session if you're lucky while you wait. UK mental health service doesn't work currently.
rjkennedy98 6y ago
> very broad because they are necessary as tools for practicing doctors seeing patients This is such nonsense. These criteria are supposed to be scientifically valid and not a tool. What other medical speciality calls their diagnostic criteria tools. That's like saying the standards for diagnosing cancer are just a tool and anyone could be diagnosed with cancer if the doctor thought you would benefit from chemo drugs. Amazing the mental gymnastics people will go to defend an obviously corrupt discipline like psychiatry.
- Spivak 6y ago
  In a cool future universe where we can introspect the brain like we do with code the need for statistics based diagnostic criteria might disappear but it's what we've got. Meeting the criteria is a good sign that you should talk to someone about it and figure out if that's the best explanation for what's happening. It's not a checklist and then "you've got the GAD."
  - rjkennedy98 6y ago
    > In a cool future universe where we can introspect the brain like we do... We can do that. It's called fMRI. > It's not a checklist and then "you've got the GAD." Yes it is. That's literally exactly what is it.
    - arcticbull 6y ago
      > We can do that. It's called fMRI. It's clearly not sufficient or not ready yet otherwise it would be used as such. > Yes it is. That's literally exactly what is it. That's not a fair assessment.
fwip 6y ago
The article shows the rise in people that meet these criteria over time, based on the same criteria self-reported in the same way.
- cma 6y ago
  Aren't somebody the criteria overkill in extenuating circumstances? Usually they will have caveats like "not immediately after death of a family member", etc.
westoncb 6y ago
> This is approximately the same phenomenon that causes medical students to self-diagnose themselves with every disease they learn about Could you say more about this? It seems pretty counter-intuitive that medical students could look at some diagnostic criteria—which I assume often contain some fairly straightforward things like, "green spots on armpits" or whatever—and come out convinced they have the disease. When you say diagnostic criteria function as a "tool," what is the purpose of the tool? My only guess so far is that it's about leaving things up to the doctor's case-by-case judgement by leaving the criteria overly broad. Maybe this ties into legal concerns as well as the fuzzy nature of real instances of diseases (i.e. it's rare to be able to exactly specify the symptoms in a way that works for all cases)?
- cortesoft 6y ago
  I think the idea is that an implied symptom in diagnostic criteria is that the person was distressed enough to seek treatment. That bit of info is important for determining likelihood of having the disease. Say you have a test for someone having a heart attack that is 99.9% accurate. If someone comes in complaining of chest pains, and the test says they are having a heart attack, then it is pretty certain they are having a heart attack. Now, if you gave that same test to everyone in the United States, and you see that you have been diagnosed with a heart attack, most likely you AREN'T having a heart attack. If you give this test to 300 million people, and 1 in 1000 tests give the wrong result, you are going to get a lot of false results.... 300,000 or so, in fact. Given that the vast majority of people are not currently having a heart attack, the vast majority of those false results will be false positives. This is why knowing the prior base rates is so important for diagnostic tests.
  - westoncb 6y ago
    Hmm. So that looks like two separate issues to me, but maybe I'm missing something. I see: 1. Additional always-present criterion of distress 2. Knowledge of prior base rates as a means of estimating a proportion of false positives. The first one makes sense to me in connection with the earlier comment. We aren't great at definitively reading our own states: it's easy for us to imagine symptoms, especially when prompted. But if something is actually wrong, an element of distress is typically present. The second one seems like a separate issues though, or at least I don't see the connection. It seems like there are two important bits of information for correcting false positives. The first is that you have a known accuracy which suggests a 1 in 1000 chance of any diagnosis being incorrect; the second is that through historical record you can estimate how many people in e.g. the US are having a hard attack at any given moment on average. I don't see the connection between either of those pieces of information and loose diagnostic criteria though.
anbende 6y ago
I'm a PhD in clinical psychology, currently working with clients, whose research has focused on the psychometric evaluation of questionnaire measures. I have no idea what you're talking about. The diagnostic criteria are not "very broad because they are necessary as tools". The diagnostic criteria are meant to be sufficient criteria for diagnosing a disorder. Questionnaire-based measures act as a scientifically validated proxy for a clinical interview to determine this. With a sufficient score on one of several validated diagnostic questionnaires, you can typically say with 80-90% certainty (specificity is the technical term for that percentage) that the person would receive a diagnosis from a clinical interview. Psychologists and epidemiologists can and do research prevalence of mental health conditions by randomly sampling the population. This does not "over-diagnose" mental health disorders. That's absolute nonsense. Over-diagnosis is only an issue in cases where prevalence is below the false positive rate (technical term is "sensitivity") of the test. That is not the case here. If you looked at the linked CDC study, they even mentioned the instruments that were used to support this statement. The PHQ2 and GAD2 are validated very brief measures of depression and anxiety that are sufficient for estimating the likelihood of a depression or anxiety diagnosis respectively. Likelihood of a false positive on the PHQ2[1] and GAD2[2] are both around 20% (100-specificity), which is just fine. Both of these are more than sufficient for epidemiological purposes if not for individual Dx. The fact of the matter is that nationwide prevalence for diagnosable disorders IS high, and it's on the rise. Coronavirus has made people anxious and quarantine has made them depressed. And a LOT of people need help. [1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2906530/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2906530/ [2] https://www.hiv.uw.edu/page/mental-health-screening/gad-2 https://www.hiv.uw.edu/page/mental-health-screening/gad-2
- imgabe 6y ago
  Is feeling anxious in a potentially dangerous situation or depressed in a depressing situation really a disorder that needs to be treated? It seems like a normal response and what needs to change is the situation, not people's reaction to it.
  - TomMarius 6y ago
    Isn't this like asking "is it weird to feel ill during an illness"? What I mean - shouldn't humans be able to cope with these situations as "sad", but not "depressing", as depression reduces their ability to move forward?

ssivark 6y ago

This is an important point about the role of priors — especially if one is using a statistical (correlation based) proxy for what is actually a causal question. But here’s a practical question: imagine a universal healthcare mandate which allows people to get a mental health check-up every year. What criteria should the doctors use? Would the diagnostics have to change significantly?

bobthepanda 6y ago
What do practitioners do in countries with universal healthcare?
- chipperyman573 6y ago
  You still need to actively persue the healthcare even if your country pays for it.
  - AnotherGoodName 6y ago
    I will say the barriers are definitely lower though when i compare my home country Australia to my adopted country the USA. Sure you need to actively pursue healthcare in Australia but the barriers are just so much lower. A great example is http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/bowel-cancer-screeningkit-eligibility http://www.cancerscreening.gov.au/internet/screening/publish... You fill in the details and you're mailed a reply post paid bowel cancer screening kit.
    - AnotherGoodName 6y ago
      Oh and more relevant, the portal for mental health care. https://headtohealth.gov.au/ https://headtohealth.gov.au/ I suspect the US government won't have anything quite like this since the healthcare is not centralized.
- dmix 6y ago
  In Canada shrinks aren’t covered by our public health insurance. They are just as expensive as they are in the states.
- nalllar 6y ago
  If you really think you need it, you go privately or join a long (years) waiting list for mental health service, maybe get a group therapy session if you're lucky while you wait. UK mental health service doesn't work currently.

rjkennedy98 6y ago

> very broad because they are necessary as tools for practicing doctors seeing patients This is such nonsense. These criteria are supposed to be scientifically valid and not a tool. What other medical speciality calls their diagnostic criteria tools. That's like saying the standards for diagnosing cancer are just a tool and anyone could be diagnosed with cancer if the doctor thought you would benefit from chemo drugs. Amazing the mental gymnastics people will go to defend an obviously corrupt discipline like psychiatry.

Spivak 6y ago
In a cool future universe where we can introspect the brain like we do with code the need for statistics based diagnostic criteria might disappear but it's what we've got. Meeting the criteria is a good sign that you should talk to someone about it and figure out if that's the best explanation for what's happening. It's not a checklist and then "you've got the GAD."
- rjkennedy98 6y ago
  > In a cool future universe where we can introspect the brain like we do... We can do that. It's called fMRI. > It's not a checklist and then "you've got the GAD." Yes it is. That's literally exactly what is it.
  - arcticbull 6y ago
    > We can do that. It's called fMRI. It's clearly not sufficient or not ready yet otherwise it would be used as such. > Yes it is. That's literally exactly what is it. That's not a fair assessment.

fwip 6y ago

The article shows the rise in people that meet these criteria over time, based on the same criteria self-reported in the same way.

cma 6y ago
Aren't somebody the criteria overkill in extenuating circumstances? Usually they will have caveats like "not immediately after death of a family member", etc.

westoncb 6y ago

> This is approximately the same phenomenon that causes medical students to self-diagnose themselves with every disease they learn about Could you say more about this? It seems pretty counter-intuitive that medical students could look at some diagnostic criteria—which I assume often contain some fairly straightforward things like, "green spots on armpits" or whatever—and come out convinced they have the disease. When you say diagnostic criteria function as a "tool," what is the purpose of the tool? My only guess so far is that it's about leaving things up to the doctor's case-by-case judgement by leaving the criteria overly broad. Maybe this ties into legal concerns as well as the fuzzy nature of real instances of diseases (i.e. it's rare to be able to exactly specify the symptoms in a way that works for all cases)?

cortesoft 6y ago
I think the idea is that an implied symptom in diagnostic criteria is that the person was distressed enough to seek treatment. That bit of info is important for determining likelihood of having the disease. Say you have a test for someone having a heart attack that is 99.9% accurate. If someone comes in complaining of chest pains, and the test says they are having a heart attack, then it is pretty certain they are having a heart attack. Now, if you gave that same test to everyone in the United States, and you see that you have been diagnosed with a heart attack, most likely you AREN'T having a heart attack. If you give this test to 300 million people, and 1 in 1000 tests give the wrong result, you are going to get a lot of false results.... 300,000 or so, in fact. Given that the vast majority of people are not currently having a heart attack, the vast majority of those false results will be false positives. This is why knowing the prior base rates is so important for diagnostic tests.
- westoncb 6y ago
  Hmm. So that looks like two separate issues to me, but maybe I'm missing something. I see: 1. Additional always-present criterion of distress 2. Knowledge of prior base rates as a means of estimating a proportion of false positives. The first one makes sense to me in connection with the earlier comment. We aren't great at definitively reading our own states: it's easy for us to imagine symptoms, especially when prompted. But if something is actually wrong, an element of distress is typically present. The second one seems like a separate issues though, or at least I don't see the connection. It seems like there are two important bits of information for correcting false positives. The first is that you have a known accuracy which suggests a 1 in 1000 chance of any diagnosis being incorrect; the second is that through historical record you can estimate how many people in e.g. the US are having a hard attack at any given moment on average. I don't see the connection between either of those pieces of information and loose diagnostic criteria though.

anbende 6y ago

I'm a PhD in clinical psychology, currently working with clients, whose research has focused on the psychometric evaluation of questionnaire measures. I have no idea what you're talking about. The diagnostic criteria are not "very broad because they are necessary as tools". The diagnostic criteria are meant to be sufficient criteria for diagnosing a disorder. Questionnaire-based measures act as a scientifically validated proxy for a clinical interview to determine this. With a sufficient score on one of several validated diagnostic questionnaires, you can typically say with 80-90% certainty (specificity is the technical term for that percentage) that the person would receive a diagnosis from a clinical interview. Psychologists and epidemiologists can and do research prevalence of mental health conditions by randomly sampling the population. This does not "over-diagnose" mental health disorders. That's absolute nonsense. Over-diagnosis is only an issue in cases where prevalence is below the false positive rate (technical term is "sensitivity") of the test. That is not the case here. If you looked at the linked CDC study, they even mentioned the instruments that were used to support this statement. The PHQ2 and GAD2 are validated very brief measures of depression and anxiety that are sufficient for estimating the likelihood of a depression or anxiety diagnosis respectively. Likelihood of a false positive on the PHQ2[1] and GAD2[2] are both around 20% (100-specificity), which is just fine. Both of these are more than sufficient for epidemiological purposes if not for individual Dx. The fact of the matter is that nationwide prevalence for diagnosable disorders IS high, and it's on the rise. Coronavirus has made people anxious and quarantine has made them depressed. And a LOT of people need help. [1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2906530/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2906530/ [2] https://www.hiv.uw.edu/page/mental-health-screening/gad-2 https://www.hiv.uw.edu/page/mental-health-screening/gad-2

imgabe 6y ago
Is feeling anxious in a potentially dangerous situation or depressed in a depressing situation really a disorder that needs to be treated? It seems like a normal response and what needs to change is the situation, not people's reaction to it.
- TomMarius 6y ago
  Isn't this like asking "is it weird to feel ill during an illness"? What I mean - shouldn't humans be able to cope with these situations as "sad", but not "depressing", as depression reduces their ability to move forward?