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Will changes in the DSM lead to millions of people being mislabelled as mentally ill?

MD-FM Thursday 28 March, 2012





GENERIQUE
Carillon
 
Sarah:
MD FM — Medical News from around the world with Peter Goodwin.

P1

PETER:
Hello, and with me is Sarah Maxell.

To begin with, millions of people could be misdiagnosed as mentally ill, when a new category of disorder is added to the upcoming edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, DSM-5, psychiatry's bible of diagnoses…

SARAH:
Yes, changes in the DSM-5’s definition of "Somatic Symptom Disorder" risk many people being misclassified with mentally ill and inappropriate medical decisions being made by practitioners. That’s according to a letter, published in the British Medical Journal, from Allen Frances, chair of the current DSM-4 task force. In DSM-4, if a patient complained about physical symptoms that were medically unexplained, were they diagnosed with somatic symptom disorder, not mental illness. But the updated DSM-5 definition, will have a broader scope for classification and rule this criterion out, so even patients who worry too much about existing somatic symptoms could also be mislabeled as mentally ill:

Bob-Frances:

In the DSM-4, there was a much more rigorous definition and the people that the DSM-5 people were trying to solve was that it was so rigorous that is was practically never used. So they’ve gone way overboard in the other direction, creating such a loose definition it’s almost meaningless. 1 in 4 people with chronic pain or irritable bowel will get a mental disorder diagnosis, and even more amazingly 1 in 6 people with cancer or heart disease will get a mental disorder diagnosis. This is such a widely over-inclusive diagnosis that it will result in the labeling of essentially normal people with mental disorder that can be much more harmful than helpful to them.

SARAH:
That was Allen Frances, from North Carolina, who said physicians should ignore this diagnosis. Other DSM-5 experts however, don’t necessarily agree. Doctor Marc-Antoine Crocq from France says, in practice, it’s not reasonable to claim a symptom has "no medical explanation":

Bob-Crocq: When the patient has a complaint, even if clinically it’s obvious that there’s a lot of psychological factors that intervene, almost always you also have biological or physiological components so it’s only a purely theoretical situation that doesn’t exist in practice that you can say that it’s only psychological or only medical.

SARAH:
Marc-Antoine Crocq, from Rouffach in France, added that it’s a good thing to abandon the "medically unexplained" criteria and reassures that physicians will have other serious criteria to rely on to make their diagnosis.

VIRGULE MUSICALE

P2

PETER:
For patients with bronchiectasis, an obstructive lung disease with no licensed medication, long-term macrolide therapy appears to reduce exacerbations by about 50%…
 
SARAH:
Yes, two studies in JAMA, show robust, one-year data supporting long-term macrolide maintenance therapy: The first, compared erythromycin with placebo, and the second looked at azithromycin versus placebo. However, both drugs significantly increased the proportion of macrolide-resistant strains, so authors recommend limiting treatment to patients with at least two exacerbations a year…
 
Bob-Elborn: The recommendation is to monitor sputum culture 6-monthly to yearly and also check for infection with non-tuberculosis mycobacteria, which are not a very common but sometimes a very complicated infection in bronchiectasis
 
SARAH:
That was Stuart Elborn, from Belfast in Ireland, who wrote an editorial about the studies and said, for practitioners choosing a macrolide, both drugs are as effective as each other and have similar effects on resistance. However, David Serisier from Australia, who led the study on erythromycin, said azitrhromycin should be avoided:

Bob-Serisier: If you’re going to use macrolides we would say that you should be using erythromycin rather than azitrhromycin in this particular population because all the available data suggest it’s a safer drug to use in terms of the development of macrolide-antibiotic-resistance, and the reason for that predominantly is that it’s a shorter acting agent than azitrhromycin.”

SARAH:
Doctor David Serisier, from Brisbane in Australia. Both experts added that all patients should also have an electrocardiogram before starting a macrolide treatment.

P3
PETER:
And patients with lung infections, like pneumonia or chronic obstructive pulmonary disease, who are treated with clarithromycin, another commonly used macrolide antibiotic, are at greater risk of having a cardiac event than those treated with other antibiotics such as ß-lactams. That’s according to two prospective cohort studies, published in the British Medical Journal, that add to the growing body of evidence suggesting a link between macrolides and long-term cardiovascular risks.

VIRGULE MUSICALE
 
P4

PETER:
People with serious mentally illness who are overweight or obese can successfully lose weight, with targeted behavioral weight-loss interventions, according to a study reported in the New England Journal of Medicine...

SARAH:
Yes, patients with schizophrenia, bipolar disorder or major depression from psychiatric rehabilitation programs who took part in an 18-month, tailored, behavioral weight-loss intervention scheme, shed significantly more kilos than those who tried to lose weight without help:

Bob-Dickerson-1: There were group weight management sessions, which provided very simple and clear information about weight reduction and about nutritional choices. We also had individual weight management sessions and we provided group exercise sessions actually at the program. And their response was comparable to the weight loss that’s been found in interventions for persons in the general population

SARAH:     
That was study co-author Doctor Faith Dickerson, from Johns Hopkins University in Baltimore, Maryland.

PETER:
And this is actually the first study to evaluate weight loss in patients with mental illness isn’t it, even though you often find weight problems in this group…

SARAH:     
Yes indeed, often the medications they take mean they’re at higher risk of obesity, they often have limited access to places for exercise, too, and they can be stigmatized and rejected from weight loss programs…

Bob-Dickerson-2: Behavioral weight loss interventions that are tailored for persons with serious mental illness are very limited in terms of their availability, and we’re hoping that this study can lead to the implementation of interventions of this kind

SARAH:
Faith Dickerson, from Baltimore.


VIRGULE MUSICALE

P5
PETER:
Reducing medical interns work hours, under new duty-hour restrictions, did not improve their quality of life and in fact led to more medical errors! According to results of the Intern Health Study…

SARAH:
Yes, two studies, reported in JAMA internal medicine, show the 2011 duty hour reforms that limited shifts for interns to 16 hours straight, ended up having unexpected detrimental effects. Serious medical errors reported rose from 20 to 23 percent and the number of hand-offs from physician to physician increased as well. Also, schedules that used interns for night shifts sharply reduced interactions between interns and teaching hospital staff.

Bob-SEN-1: The schedules that these interns were working on changed dramatically, so they weren’t working more than 16 hours but they were working almost every waking hour... and part of the reason for that is that the change in rules was not accompanied in most places by an increase in funding, so there was no one to really pick up that extra work. So they were doing essentially more work in the same amount of time.

SARAH:
That was Dr. Srijan Sen from Ann Arbor in Michigan, whose team analyzed surveys of 2,300 first-year residents in 51 programs before and after the 2011 regulations. In the second study, residents were randomly assigned to work shifts following either the 2003 or the 2011 rules. Both studies came to roughly the same conclusions.

Bob-SEN-2: These reforms that were meant to both improve education and the health of residents and their patients are having negative effects. So we have to find ways to tweak and change the system to really realize the benefit that we’d hoped with these reforms.

SARAH:
Dr Srijan Sen from Ann Arbor, MI.

BREVE 1 Sur fond musical
 
PETER:
Finally, in brief: Variants at a gene locus known as 17q21 were associated with asthma in children who’d had rhinovirus wheezing illnesses in early childhood but not those who had respiratory syncytial virus. And these variants were also associated with expression of two genes at this locus. The paper on this in a New England Journal of Medicine notes that the expression levels of both genes was also found to have increased in response to rhinovirus stimulation — and the authors say these findings underscore the need to consider both environment and genetic factors when looking at the complex mechanisms leading to asthma.

And…
BREVE 2

Platelet rich plasma therapy added to the standard administration of bupivacaine and epinephrine proved superior for managing the pain and tenderness associated with tennis elbow compared to bupivacaine and epinephrine given alone. These are the results of a randomized prospective study presented at the annual meeting of the American Association of Orthopedic Surgeons, in Chicago last week.

That's all from MDFM for now. Sarah Maxwell and I will be back with more next week, so until then from me Peter Goodwin, goodbye!
 
JINGLE FIN     
 

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