Volume 176 - Issue 4
SPHERE: A National Depression Project
Authors: Nicole Phillips, Michael J Oldmeadow and Natalie Krapivensky
Med J Aust 2002; 176 (4): 193-194. || doi: 10.5694/j.1326-5377.2002.tb04364.x
Published online: 18 February 2002
Published online: 18 February 2002
To the Editor: The recent supplement by Hickie et al looking at the mental health of Australians attending general practice1 would have us believe that we are quite a mentally unwell nation indeed!
The authors propose a broad concept of "mental disorder" which they found in 49% of general practice attenders based on 12 questionnaire items (the SPHERE-12). These 12 items include six relating to psychiatric symptoms (PSYCH-6) and six relating to somatic symptoms (SOMA-6).2 The SOMA-6 items are muscle pain after activity, needing to sleep longer, prolonged tiredness after activity, poor sleep, poor concentration, and tired muscles after activity. Patients with a total score of two or more in PSYCH-6 and/or three or more on SOMA-6 were classified as having a "mental disorder".
Firstly, the SPHERE-12 is grossly oversensitive, as the six somatic items detect many medical conditions, glandular fever being just one example. Other validity issues include the two-week cut-off for symptoms (further adding to the overinclusiveness because of temporary distress and minor illnesses), and the lack of discussion regarding transcultural and inter-rater reliability, particularly with so many general practitioners involved.
Secondly, the authors' interchangeable use of neurasthenia and chronic fatigue syndrome and somatisation needs discussion. Ten years ago, Hickie and several New South Wales physicians were dismissive of an article linking chronic fatigue syndrome and neurasthenia: "We have demonstrated immunological abnormalities in patients with chronic fatigue syndrome as compared with both normal controls and patients with major depression. Further, the demonstration of abnormal cytokine production in patients with chronic fatigue syndrome may underpin 'acquired neurasthenia'."3 All the SOMA-6 items are key symptoms of chronic fatigue syndrome. With the overwhelming amount of biological data now available, purely psychological theories about chronic fatigue syndrome (as opposed to chronic fatigue) are totally untenable, as is the use of the term neurasthenia, introduced into medicine in 1869 and discarded by the American Psychiatric Association's Diagnostic and statistical manual of mental disorders4 as invalid.5 A recent study from the Fatigue Clinic, King's College Hospital, UK,6 found that an astonishing 68% of patients had been inappropriately misdiagnosed with a psychiatric illness. This is surely a warning for overzealous psychiatrists.
Thirdly, treatment implications are a concern. The authors comment that "only 27% of patients with Level 1 disorders received pharmacological interventions" (Level 1 implying positivity for PSYCH and SOMA items). They say that general practitioners mostly used "relatively ineffective non-pharmacological strategies", and that they had responded to missing all this "unmet need" by "criticising the oversensitivity of the screening instrument and inappropriateness of diagnostic systems used", implying an underprescribing of antidepressants. The recent National Survey of Mental Health and Well-being7 showed that somewhere between two-thirds and a half of the 23% of the population diagnosed with psychiatric disorders did not visit their general practitioner. How does this fit in with the 49% found by Hickie et al?
In summary, the authors' broad and idiosyncratic conceptualisation of "mental disorder" and their use of a screening tool which labels many physically ill people with or without concurrent distress as cases of "mental disorder" implies that general practitioners need to prescribe more antidepressants — at what cost and for whose benefit?
References
- SPHERE: A National Depression Project. Med J Aust 2001; 175 (16 July Suppl): S1-S55.
- Hickie I, Davenport T, Scott E, et al. Unmet need for recognition of common mental disorders in Australian general practice. Med J Aust 2001; 175 (16 July Suppl): S18-S24. i1146839
- Hickie I, Lloyd A, Wilson A, Wakefield D. Taking chronic fatigue syndrome seriously. Am J Psychiatry 1992; 149: 1755-1756. i1146841
- American Psychiatric Association. Diagnostic and statistical manual of mental disorders, 4th ed (DSM-IV). Washington, DC: APA, 1994. i1146843
- Phillips N. Response to prolonged fatigue, anxiety and depression: exploring relationships in a primary care sample [letter]. Aust N Z J Psychiatry 2000; 34: 692-693. i1146845
- Deale A, Wessely S. Diagnosis of psychiatric disorder in clinical evaluation of chronic fatigue syndrome. J Roy Soc Med 2000; 93: 310-312. i1146847
- Andrews G, Henderson S, Hall W. Prevalence, co-morbidity, disability and service utilisation: an overview of the Australian National Mental Health Survey. Br J Psychiatry 2001; 178: 145-153. i1146849
- Philips N. Response to "Prolonged fatigue, anxiety and depression: exploring relationships in a primary care sample" [letter]. Aust N Z J Psychiatry 2000; 34: 692-694.
- Koschera A, Hickie I, Hadzi-Pavlovic D, et al. Prolonged fatigue, anxiety and depression: exploring relationships in a primary care sample. Aust N Z J Psychiatry 1999; 33: 545-552. CHDJJIDD
- Lloyd AR, Hickie IB, Loblay RH. Illness or disease? The case of chronic fatigue syndrome. Med J Aust 2000; 172: 471-472. <eMJA full text>
- Hickie IB, Scott EM, Davenport TA. Somatic distress: developing more integrated concepts. Curr Opin Psychiatry 1998; 11: 153-158. CHDGAAHF
- Andrews G, Henderson S, Hall W. Prevalence, comorbidity, disability and service utilisation. Overview of the Australian National Mental Health Survey. Br J Psychiatry2001; 178: 145-153. i1146844
- Harris MF, Silove D, Kehag E, et al. Anxiety and depression in general practice patients: prevalence and management. Med J Aust 1996; 164: 526-529. i1146846
- Ustun TB, Sartorius N, editors. Mental illness in general health care: an international study. Chichester: John Wiley & Sons, 1995. i1146848