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I'm a PhD in clinical psychology, currently working with clients, whose research has focused on the psychometric evaluation of questionnaire measures. I have n

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?
- anbende 6y ago
  Anxiety and sadness can both be adaptive, yes. How we cope with those emotions can also be adaptive or maladaptive. Both anxiety and depression, even in circumstances where they are reasonable responses, can benefit from supportive counseling, acceptance, self-compassion, etc. It's important to note that a therapist can "treat a problem" and "support and facilitate". In the second sense, all suffering can be "treated", even if it is not considered pathological.
skissane 6y ago
> 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. The term "overdiagnosis" is actually ambiguous. As [1] points out, the word is used in two different ways: (a) to argue that the diagnostic criteria (such as in the DSM-5) are overly broad, and are labelling people as having a "disorder" who shouldn't be so labelled ("pathologising of normal human experience"); (b) to argue that the diagnostic criteria are being systematically over-applied, where people who don't actually meet the formal diagnostic criteria are nonetheless frequently being given the diagnosis. [1] https://aifs.gov.au/cfca/publications/diagnosis-child-mental-health/3-overdiagnosis-child-mental-health-conditions https://aifs.gov.au/cfca/publications/diagnosis-child-mental...
- anbende 6y ago
  This is a fair point. I read the op's comment as using the former definition. The latter definition wouldn't really apply as this is being determined by standardized testing. Unless one thinks that the standardized tests are overly liberal (their criteria are based on correlations with in-person diagnoses, so it's possible).
  - skissane 6y ago
    Well, it is a legitimate question of how well the standardised tests actually fit the diagnostic criteria for various disorders. [1] argues that the fit between the commonly used standardised tests for ASD and the DSM-5 diagnostic criteria is less than ideal. (And I doubt this finding is unique to ASD, I think it likely if you repeated the authors' exercise for other diagnoses you would get similar results.) [1] https://link.springer.com/article/10.1007%2Fs00787-020-01481-z https://link.springer.com/article/10.1007%2Fs00787-020-01481...
Jon_Lowtek 6y ago
20% false positives is not "just fine". That is a huge error.
- skissane 6y ago
  I agree with you, but in psychiatry and clinical psychology, a 20% false positive rate is considered "acceptable". Consider for example the Cochrane review of autism diagnostic instruments in preschoolers [1]. It found that on average (in research contexts), the main diagnostic test used for ASD, the ADOS[2], had a specificity of 0.80 (in other words, a 20% false positive rate). The Cochrane authors considered that acceptable. Now, professionals may consider that acceptable – but how many parents are told that the test used to diagnose their child has a 20% false positive rate? Added to that, there is evidence that the tests are actually less accurate in non-research contexts (the standards for administering them are certainly lower), which may make the false positive rate in non-research contexts even higher (on that topic see [3]). [1] https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009044.pub2/full https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD... [2] actually the original ADOS has now been superseded by a newer version, the ADOS-2, but the Cochrane reviewers couldn't find any studies of the ADOS-2 that met their inclusion criteria. In any case, I doubt the accuracy of the new version is substantially different from the original one. [3] https://link.springer.com/article/10.1007/s00787-018-1143-y https://link.springer.com/article/10.1007/s00787-018-1143-y
- anbende 6y ago
  These are screening tools. They are not meant to make definitive diagnoses for the most part. They are used for epidemiology and flagging clients for further assessment. There's always a balance to be made between sensitivity (picking up on real positives) and specificity (not producing false positives). The balance for these instruments is at about 80-85%. If a person is depressed, there's an 80-85% chance they will be correctly classified. If a person is not depressed, there is an 80-85% chance they will be correct classified. Raise the threshold and you'll be more specific but less sensitive. Lower the threshold and you'll be less specific but more sensitive. It's just how the game works and why questionnaires are only first-pass tools.
cshimmin 6y ago
Hold on, do I understand correctly your comment about the 20% false positive rate? So even if exactly ZERO Americans were experiencing depression, a random sampling would indicate 20% of Americans are showing signs of depression? And if it's 20% for both tests, that would would correspond to a 36% false positive rate for at least one condition [0]. So the headline that a third of Americans are showing signs of anxiety or depression is consistent with what you'd expect to observe if there was zero (or very small) true prevalence? How does that work out? [0] assuming test results for anxiety and depression are uncorrelated, which seems unlikely. But even if they were 100% correlated, the joint FPR would still be 20%.
- nullc 6y ago
  https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1861033 https://jamanetwork.com/journals/jamainternalmedicine/fullar... https://blogs.cornell.edu/info2040/2014/11/12/doctors-dont-know-bayes-theorem/ https://blogs.cornell.edu/info2040/2014/11/12/doctors-dont-k...
- anbende 6y ago
  The situation is a little more complicated as these tests ALSO have a false negative rate. And that false negative rate is also about 20%. As well, the false positive rate is for scores at threshold, which is 3 out of 5. If they score a 4 or a 5, the false positive rate drops dramatically. As well, this isn't an antibody test. Diagnosis is not dichotomous but dimensional. A false positive on depression inventory does not mean the person actually has zero symptoms. It means that their symptoms might actually be mild rather than moderate because of the way they interpreted one or more of the questionnaire items. In general, the way to look at this is that of the people who took the test, 80% of those who scored at threshold would likely receive a diagnosis from a clinician.
  - conistonwater 6y ago
    This doesn't address in any way the point being made about false positives leading to overly high estimates of prevalence in the general population, whereas nullc's comment is probably quite close to explaining the issue.
rhema 6y ago
>"very broad because they are necessary as tools" >"diagnostic criteria are meant to be sufficient criteria for diagnosing a disorder" Aren't these equivalent ideas? I don't think the parent comment was meant to be critical so much as it was to make an assessment. An overall rate of 80% accurate for a questionnaire instrument seems like a fine tool.
- anbende 6y ago
  I read the comment as implying that they were overly broad and so should not be applied to the larger population outside of a professionals supervision. My counter-argument was that they were properly narrow and could indeed be applied to the general population, though this would not provide definitive diagnoses only prevalence information. I read the OP as saying that these statistics were not representative of the actual underlying mental health phenomena. I believe and asserted that they are.

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?
anbende 6y ago
Anxiety and sadness can both be adaptive, yes. How we cope with those emotions can also be adaptive or maladaptive. Both anxiety and depression, even in circumstances where they are reasonable responses, can benefit from supportive counseling, acceptance, self-compassion, etc. It's important to note that a therapist can "treat a problem" and "support and facilitate". In the second sense, all suffering can be "treated", even if it is not considered pathological.

skissane 6y ago

> 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. The term "overdiagnosis" is actually ambiguous. As [1] points out, the word is used in two different ways: (a) to argue that the diagnostic criteria (such as in the DSM-5) are overly broad, and are labelling people as having a "disorder" who shouldn't be so labelled ("pathologising of normal human experience"); (b) to argue that the diagnostic criteria are being systematically over-applied, where people who don't actually meet the formal diagnostic criteria are nonetheless frequently being given the diagnosis. [1] https://aifs.gov.au/cfca/publications/diagnosis-child-mental-health/3-overdiagnosis-child-mental-health-conditions https://aifs.gov.au/cfca/publications/diagnosis-child-mental...

anbende 6y ago
This is a fair point. I read the op's comment as using the former definition. The latter definition wouldn't really apply as this is being determined by standardized testing. Unless one thinks that the standardized tests are overly liberal (their criteria are based on correlations with in-person diagnoses, so it's possible).
- skissane 6y ago
  Well, it is a legitimate question of how well the standardised tests actually fit the diagnostic criteria for various disorders. [1] argues that the fit between the commonly used standardised tests for ASD and the DSM-5 diagnostic criteria is less than ideal. (And I doubt this finding is unique to ASD, I think it likely if you repeated the authors' exercise for other diagnoses you would get similar results.) [1] https://link.springer.com/article/10.1007%2Fs00787-020-01481-z https://link.springer.com/article/10.1007%2Fs00787-020-01481...

Jon_Lowtek 6y ago

20% false positives is not "just fine". That is a huge error.

skissane 6y ago
I agree with you, but in psychiatry and clinical psychology, a 20% false positive rate is considered "acceptable". Consider for example the Cochrane review of autism diagnostic instruments in preschoolers [1]. It found that on average (in research contexts), the main diagnostic test used for ASD, the ADOS[2], had a specificity of 0.80 (in other words, a 20% false positive rate). The Cochrane authors considered that acceptable. Now, professionals may consider that acceptable – but how many parents are told that the test used to diagnose their child has a 20% false positive rate? Added to that, there is evidence that the tests are actually less accurate in non-research contexts (the standards for administering them are certainly lower), which may make the false positive rate in non-research contexts even higher (on that topic see [3]). [1] https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD009044.pub2/full https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD... [2] actually the original ADOS has now been superseded by a newer version, the ADOS-2, but the Cochrane reviewers couldn't find any studies of the ADOS-2 that met their inclusion criteria. In any case, I doubt the accuracy of the new version is substantially different from the original one. [3] https://link.springer.com/article/10.1007/s00787-018-1143-y https://link.springer.com/article/10.1007/s00787-018-1143-y
anbende 6y ago
These are screening tools. They are not meant to make definitive diagnoses for the most part. They are used for epidemiology and flagging clients for further assessment. There's always a balance to be made between sensitivity (picking up on real positives) and specificity (not producing false positives). The balance for these instruments is at about 80-85%. If a person is depressed, there's an 80-85% chance they will be correctly classified. If a person is not depressed, there is an 80-85% chance they will be correct classified. Raise the threshold and you'll be more specific but less sensitive. Lower the threshold and you'll be less specific but more sensitive. It's just how the game works and why questionnaires are only first-pass tools.

cshimmin 6y ago

Hold on, do I understand correctly your comment about the 20% false positive rate? So even if exactly ZERO Americans were experiencing depression, a random sampling would indicate 20% of Americans are showing signs of depression? And if it's 20% for both tests, that would would correspond to a 36% false positive rate for at least one condition [0]. So the headline that a third of Americans are showing signs of anxiety or depression is consistent with what you'd expect to observe if there was zero (or very small) true prevalence? How does that work out? [0] assuming test results for anxiety and depression are uncorrelated, which seems unlikely. But even if they were 100% correlated, the joint FPR would still be 20%.

nullc 6y ago
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/1861033 https://jamanetwork.com/journals/jamainternalmedicine/fullar... https://blogs.cornell.edu/info2040/2014/11/12/doctors-dont-know-bayes-theorem/ https://blogs.cornell.edu/info2040/2014/11/12/doctors-dont-k...
anbende 6y ago
The situation is a little more complicated as these tests ALSO have a false negative rate. And that false negative rate is also about 20%. As well, the false positive rate is for scores at threshold, which is 3 out of 5. If they score a 4 or a 5, the false positive rate drops dramatically. As well, this isn't an antibody test. Diagnosis is not dichotomous but dimensional. A false positive on depression inventory does not mean the person actually has zero symptoms. It means that their symptoms might actually be mild rather than moderate because of the way they interpreted one or more of the questionnaire items. In general, the way to look at this is that of the people who took the test, 80% of those who scored at threshold would likely receive a diagnosis from a clinician.
- conistonwater 6y ago
  This doesn't address in any way the point being made about false positives leading to overly high estimates of prevalence in the general population, whereas nullc's comment is probably quite close to explaining the issue.

rhema 6y ago

>"very broad because they are necessary as tools" >"diagnostic criteria are meant to be sufficient criteria for diagnosing a disorder" Aren't these equivalent ideas? I don't think the parent comment was meant to be critical so much as it was to make an assessment. An overall rate of 80% accurate for a questionnaire instrument seems like a fine tool.

anbende 6y ago
I read the comment as implying that they were overly broad and so should not be applied to the larger population outside of a professionals supervision. My counter-argument was that they were properly narrow and could indeed be applied to the general population, though this would not provide definitive diagnoses only prevalence information. I read the OP as saying that these statistics were not representative of the actual underlying mental health phenomena. I believe and asserted that they are.