Health

Over the past few years, I’ve become an avid collector. Not of stamps but of new diseases. Whenever I see a fresh one, I feel compelled to rip the relevant report out of the newspaper and file it under “New Maladies”. I have not had any of these new diseases but the way things are headed, perhaps I should say that I have not had one yet.

The kinds of things that are now clamouring to be diagnosed as bona fide illnesses are an eclectic mix, including “chronic shift work sleep disorder”, electrosensitivity, baldness, high cholesterol, shyness (or “social anxiety syndrome”), stress (one in four are said to have a mental illness at some point in life), restless legs, tired legs, “hurried women syndrome” (allegedly 30m in the US alone) and female sexual dysfunction (43 per cent of women, some surveys claim).

Depending on who is reporting, the general tenor is that doctors are “under-recognising” such complaints, thus undertreating the problems and hence, in almost wilful ignorance, contributing to the suffering.

At the same time, the net of previously acknowledged diseases catches more. For example, the level at which doctors treat high blood pressure has fallen during the past few decades. And awareness campaigns have ensured that other conditions are taken far more seriously. So incontinence is no longer the (often transient) after-childbirth inconvenience you were once told to live with. Chances are you will be handed sample bottles and given an appointment for the nurse specialist before you have had time to say: “It’s only when I laugh.”

Isn’t this a good thing? Relieving suffering, that’s what we’re surely here for. If we have a solution – even if it is only something to ease symptoms and not a cure – then surely we should use it?

Or should we? Several campaigns in the 1990s highlighted the need for doctors to diagnose more depression and to be more “aware” of the need to prescribe antidepressants – counselling being as effective, but rather more difficult to come by. Yet earlier this year, the British Medical Journal published a study questioning the value of antidepressants. Depression awareness, they say, certainly contributed towards increased prescribing of antidepressants – a rise in numbers of prescriptions by an astonishing 253 per cent during a 10-year period.

In a review of the research, the writers concluded that the effect of modern SSRI [Selective Serotonin Reuptake Inhibitor] antidepressant drugs “do not have a clinically meaningful advantage over placebo” and “claims that antidepressants are more effective in more severe conditions have little evidence to support them.” They added: “Antidepressants have not been convincingly shown to affect the long-term outcome of depression or suicide rates.”

The conclusion is hardly cheering: we have treated more depression with more medication, but many of these prescriptions are likely to have been a waste of time – and a waste of time with side effects attached. Of course, picking up the signs of depression and offering human comfort, reassurance and empathy is a doctor’s job and can in itself make people feel better. The problem is that in so many diseases with broad membership, the same label for all degrees of severity often comes with expectations of a “cure” attached.

Never mind the cure, even the existence of some “new diseases” is in doubt. Last summer, I read that Pfizer had filed for a patent for a drug treatment for “premature female orgasm”. Yet there isn’t a great deal to suggest this is a disease at all.

Disregarding diagnoses that don’t appear in textbooks, there are plenty of other parts of normal life we are now being encouraged to make a pathology of and “do something” about. Backache can be miserable, restless legs can be a menace to sleep and to marriages. Incontinence can be embarrassing and distressing. But many such conditions may also be minor and, ultimately, part and parcel of a fully lived life. In other words, some of what we are being encouraged to call “stress” or even “depression” may in fact be transient and a normal variant of life.

We do no one any favours by insisting that transient – or normal – stress is anything like depression. For the real issue is that many such diagnoses swing through a wide “catch-all”, a vast spectrum where the severity ranges from minor and self-limiting, with straightforward causes and solutions – like many cases of work-related stress – to the far more complex and severe, for example, a depressive psychosis with a high risk of suicide.

Here is the rub: does the same label attached to the whole range of such conditions make a difference to the person being diagnosed? Clearly, if there is good treatment available, then the advantages of a medical diagnosis – and treatment – are more certain. But what if there is no clear advantage to treatment, as is the case for so many of these “new diseases”?

Restless legs, for example, are common. Some people have a severe form, others have mild symptoms and many don’t actually want treatment. Yet, despite the fact there is no specific licensed drug in the UK for the condition, an enormous PR campaign has recently been increasing awareness of it. Can we be sure that there is still an advantage to having the “label”? In other words, is the label itself a treatment, and is our apparently sick society advantaged for being described as such?

Labelling a full spectrum of distress as “illness” may be counterproductive. After the London bombings in July, there were loud calls for immediate counselling to be set up for all those who were affected. But was the “post-traumatic” label and treatment going to be of use to all who had seen the bombings?

Professor Simon Wessely of King’s College London, wrote in an editorial in the New England Journal of Medicine that in such situations provision of blanket immediate psychological debriefing does not work. He argued: “In fact, the people who seemed to be harmed by this intervention were those who had been especially upset at the time – precisely those who one might think ought to be treated. Instead, what people need during the first few days is the support of their family and friends and assistance with information, finances, travel and the planning of funerals.”

In other words, people do have innate coping mechanisms and many do better using these rather than being affixed an immediate label and “treatment”, which actually has the potential to do harm.

The truth is that a lot of the time conditions we commonly see in primary care get better no matter what we do or don’t do. In diagnosing a disease, the locus of control is taken from the patient and placed with the doctor. So we can become “ill” when really what we have is a variation of what we used to regard as normal.

In describing the advantages that the sick role may have for an individual, the talk is traditionally of “secondary gain”. In modern terms, this is rather short-sighted. There are significant “tertiary gains” for others in having an “iller” society – for public relations firms employed to generate “awareness” and expectations of “cures”; and for pharmacological manufacturers filling the fresh markets. Doctors have to answer to the charge that they are not diagnosing enough of what we are made “aware” of, thus putting us more in the employ of public relations teams than answerable to our own patients.

We are on the brink of describing an entire section of the populace as potentially requiring treatment – the only deciding factor being age, probably about 55. The US Centers for Disease Control are in support of a preventative “polypill” – a combination of cholesterol and blood pressure-lowering drugs that statistical research suggests will reduce heart attacks and strokes. The first “in vivo” trial has been designed to assess its effects; in the meantime, there have been suggestions that a version of the polypill will appear on the subcontinent by the end of this year. This may be a preventative treatment that could reduce mortality for those prepared to take it in the long-term – but it will also brand a subsection of society as at-risk, unhealthy and potentially ill, with medication, not lifestyle, as the key to prevention.

There is a balance to be struck. I wouldn’t wish anyone to avoid discussing something that concerns them with their GP. What I would wish, though, is for the trend to medicalise normality to be removed. Expectations of pharmacological treatment are not always warranted in many conditions. This requires us to be critical of what can often be very persuasive publicity to the contrary – difficult, given that the “education” in awareness campaigns is usually biased towards a pharmacological treatment.

For what is really happening with the advance of the “new diseases” is a belief that deep down, we are all ill and requiring a diagnosis and a cure.

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