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Press releases Saturday 18 August 2007

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(1) Are too many people diagnosed as 'depressed'?
(2) More proof needed of safety and quality of electronic personal health records
(3) Umbilical cord clamping should be delayed, says expert

(1) Are too many people diagnosed as 'depressed'?
(Head to head: Is depression over-diagnosed?)
http://www.bmj.com/cgi/full/335/7615/328
http://www.bmj.com/cgi/full/335/7615/329

Are too many people now diagnosed as having depression? Two experts give their views in this week's BMJ.

Professor Gordon Parker, a psychiatrist from Australia says the current threshold for what is considered to be 'clinical depression' is too low. He fears it could lead to a diagnosis of depression becoming less credible.

It is, he says, normal to be depressed and points to his own cohort study which followed 242 teachers. Fifteen years into the study, 79% of respondents had already met the symptom and duration criteria for major, minor or sub-syndromal depression.

He blames the over-diagnosis of clinical depression on a change in its categorisation, introduced in 1980. This saw the condition split into 'major' and 'minor' disorders. He says the simplicity and gravitas of 'major depression' gave it cachet with clinicians while its descriptive profile set a low threshold.

Criterion A required a person to be in a 'dysphoric mood' for two weeks which included feeling "down in the dumps". Criterion B involved some level of appetite change, sleep disturbance, drop in libido and fatigue. This model was then extended to include what he describes as a seeming subliminal condition "sub-syndromal depression".

He argues this categorisation means we have been reduced to the absurd. He says we risk medicalising normal human distress and viewing any expression of depression as necessary of treatment. He says:

"Depression will remain a non-specific 'catch all' diagnosis until common sense prevails."

On the other side of the debate Professor Ian Hickie argues that if increased diagnosis and treatment has actually led to demonstrable benefits and is cost effective, then it is not yet being over diagnosed.

He says increased diagnosis and treatment has led to a reduction in suicides and increased productivity in the population. Furthermore the stigma of being 'depressed' has been reduced and the old demeaning labels of 'stress' and 'nervous breakdown' have been abandoned.

He says concerns about the number of new drug treatments on the market are unhelpful, arguing that new drugs to treat depression have reduced the prescribing of older, more dangerous sedatives and says that the consequences, such as suicide, of not being diagnosed or receiving treatment are rarely emphasised.

Audits carried out in the UK, Australia and New Zealand do not support the notion that the condition is over diagnosed, far from it, he says. Instead he points to the diagnosis rate of people with major depression and says this needs to be improved in which case rates of diagnosis must continue to rise.

Contacts:
Gordon Parker, School of Psychiatry, University of New South Wales, NSW, Australia
Email: g.parker@unsw.edu.au 

Ian Hickie, Executive Director, Psychiatry, University of Sydney, NSW, Australia
Email: ianh@med.usyd.edu.au 

(2) More proof needed of safety and quality of electronic personal health records
(Potential of electronic personal health records)
http://www.bmj.com/cgi/full/335/7615/330

More research must be done to prove that electronic personal health records are safe and effective, according to an article in this week's BMJ.

Although such technology offers great opportunities, significant challenges also remain over balancing security and usefulness, standardising existing systems and managing changes to accommodate the technology in today's NHS, say Dr Claudia Pagliari and colleagues.

Electronic Personal Health Records (ePHRs) are defined as electronic applications that allow patients to access and/or manage their health information in a private, secure and confidential environment.

NHS HealthSpace is a secure online personal health organiser available to all patients in England. Patients will in the future be able to access their NHS Summary Care Record via HealthSpace, making it the world's first fully national example of ePHR.

Currently, writes Dr Pagliari, a senior lecturer in primary care at University of Edinburgh, existing models of ePHRs vary in the extent to which content and right of access are controlled by the patient or their health care provider and how interactive they are.

These different systems are becoming increasingly complex and some offer features such as health and lifestyle records, ability to book appointments and appointment reminders, patient-doctor messaging and consultation summaries.

The authors say that this technology has many benefits, including empowering patients through enhanced information and shared decision making; increasing patient safety through exposing record errors; reducing unnecessary consultations; and overcoming geographical boundaries to patient care.

However, challenges still exist over security and standardising the different systems, they warn, and health professionals and patients should be involved at all stages of design, development and implementation of the technology.

"ePHR may improve the quality, safety and efficiency of care and empower patients, but further research is required to demonstrate the benefits and risks. Evidence of the impact of ePHR on clinical, safety, economic and psychosocial outcomes is urgently required," they conclude.

Contact:
Claudia Pagliari, Senior Lecturer in Primary Care, Division of Community Health Sciences, University of Edinburgh, Edinburgh, Scotland
Email: claudia.pagliari@ed.ac.uk 

(3) Umbilical cord clamping should be delayed, says expert
(Umbilical cord clamping after birth)
http://www.bmj.com/cgi/full/335/7615/312

Clamping and cutting of the umbilical cord should be delayed for three minutes after birth, particularly for pre-term infants, suggests a senior doctor in this week's BMJ.

Early clamping and cutting of the umbilical cord is widely practised as part of the management of labour, but recent studies suggest that it may be harmful to the baby. The rate of early cord clamping varies widely in Europe, from 17% of units in Denmark to 90% in France.

So Dr Andrew Weeks, a senior lecturer in obstetrics at the University of Liverpool, looked at the evidence behind cord clamping.

For the mother, trials show that early cord clamping has no ill effects, he writes. But what about the baby?

At birth, he says, the umbilical cord sends oxygen-rich blood to the lungs until breathing establishes. So as long as the cord is unclamped, the average transfusion to the newborn is equivalent to 21% of the neonate's final blood volume and three quarters of the transfusion occurs in the first minute after birth.

For babies born at term, the main effect of this large autotransfusion is to increase their iron status. This may be lifesaving in areas where anaemia is endemic.

In the developed world, however, there have been concerns that it could increase the risk of polycythaemia and hyperbilirubinaemia (abnormally high levels of red blood cells and bile pigments in the bloodstream, often leading to jaundice). But trials show this is not the case.

For pre-term babies the beneficial effects of delayed clamping may be greater, he says. Although the studies are smaller, delayed clamping is consistently associated with reductions in anaemia, bleeding in the brain (intraventricular haemorrhage), and the need for transfusion.

So how should we approach cord clamping in practice, he asks?

In normal deliveries, delaying cord clamping for three minutes with the baby on the mother's abdomen should not be too difficult.

The situation is a little more complex for babies born by caesarean section or for those who need support soon after birth. Nevertheless, it is these babies who may benefit most from a delay in cord clamping. For them, a policy of 'wait a minute' would be pragmatic, he says.

There is now considerable evidence that early cord clamping does not benefit mothers or babies and may even be harmful, he writes. Both the World Health Organisation and the International Federation of Gynecology and Obstetrics (FIGO) have dropped the practice from their guidelines.

It is time for others to follow their lead and find practical ways of incorporating delayed cord clamping into delivery routines, he concludes.

Contact:
Andrew Weeks, Senior Lecturer in Obstetrics, University of Liverpool, UK
Email: aweeks@liv.ac.uk 

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