Saturday, 8 December 2012

Limits to medicalization?


The character Syndrome from The Incredibles pictured a world where everybody had super powers: “because when everyone is super, no one will be”. If more than 50% of the population have depression, then what is ‘normal’? What if it was 75% of the population? Are we witnessing a gradual approach to a situation where we will reach the Last Well Person? Is a well person simply a patient who has not been completely worked up?

There is a difference between being upset, sad, grieved, annoyed with work, tired or having backache, headache, listlessness, low libido, dizziness, altered bowel motions, baldness, worn out joints, disturbed sleep, and anxiety on the one hand, and being diseased on the other. The latter comes under the medical domain and demands labelling, documentation of disability, and above all, treatment. 

In 1975, Ivan Illich wrote “Limits to Medicine”, a stinging attack on medicine, highlighting the medicalization of ‘life’, and iatrogenesis (medical harm), and questioning whether the balance of benefit and harm from medicine was a positive one. Since then, medicalization has gone ahead in leaps and bounds, forming an insatiable medical-industrial monster that is consuming larger and larger portions of government and personal money, time and parts of our lives previously thought to be just that: part of life. But is there a limit to medicalization? This article explores medicalization, in a ‘1-to-100’ format. Feel free to bookmark it and come back later to browse. I intend updating it when new examples arise.

1% of population account for 1/5 of healthcare spending.
2% prevalence of Chronic Fatigue Syndrome in primary care – and up to 25% incidence of “prolonged fatigue”.
3% of boys in New Jersey have ‘Autism-spectrum disorder’.
4% of adults have PLMD (Periodic Limb Movement Disorder – a bit like RLS: Restless Legs Syndrome).
5% of adults have Restless Legs Syndrome.
6% of patients in a primary care setting have a social anxiety disorder.
7% of patients in a primary care setting have a panic disorder.
8% of patients in a primary care setting have a general anxiety disorder.
9% of all children have ADHD, but the rate varies a lot.
10% of healthy middle aged people have had a ‘silent’ stroke and don’t know it. (Should we tell them?)
11% of workers in Victoria, Australia are employed in healthcare, more than any other sector including retail and manufacturing.
12% of people with ‘forgetfulness’ want medication for it.
13%: the one-year prevalence of ‘social anxiety disorder’.
14% increase in new medical graduates in Australia in 2012, and yet they are still claiming a doctor shortage. More doctors mean more medicalization; medicine is unique in that supply drives demand (here, here, and anything from Dartmouth).
15% lifetime risk of depression in men.
16% incidence of post-natal depression. What is a normal mood after delivery?
17% of children have ‘low self-esteem’.
18% of GDP is spent on health in the USA.
19% of Australian adults smoke (Yes, smoking has been medicalized, now that there are drugs to treat it. That would be fine, but the drugs often don’t work, they just generate business).
20% of MRI scans and X-rays are done for ‘defensive medicine’.
21% prevalence of mental health disorders in children, mainly anxiety (I was anxious as a child, how come I didn’t get any drugs?)
22%: point prevalence of headache in women.
23% of Americans have “sleep or wakefulness disorder”.
24% prevalence of ‘Metabolic Syndrome’ in the US.
25% of American children take regular prescription medication.
26% of Britons diagnosed with depression.
27% of deaths in the elderly from common conditions are due to improper care (medicalization of ageing). See also overmedicating the elderly.
Up to 28% of couples have ‘involuntary childlessness’.
29% of primary care doctors in the community are practicing too aggressively, according to primary care doctors, who also consider that 42% of their patients receive too much medical care.
30% of some surgical procedures may be unnecessary (and that was from the 1980’s!)
31% of all potential life lost after spine fusion surgery is due to chronic (prescription) opioid use.
32% of the world’s unnecessary caesarean sections are done in China (2008: 2 million).
33% of men have ‘male menopause' (… and so another disease is born, and yes, we have a drug to treat that as well).
34% of middle-aged Dutch have ‘forgetfulness’, which apparently has 342 causes, 35 types and 501 symptoms.
35% of Americans are obese.
36% of referrals for cardiac stents from patients with heart attacks were found to be ‘false positives’, subjecting them to increased risks. The medicalization of heart disease is total, and the intervention rate is too high.
37% of men in the world have raised cholesterol (only another 14% and it would be normal).
38% of US doctors have ‘burnout’.
39% cumulative 10-year incidence of Major Depressive Disorders.
40% of people have low libido.
41% of middle-aged males have ‘metabolic syndrome’.
42% of patients with Fibromyalgia also have Chronic Fatigue Syndrome, 39% have Irritable Bowel Syndrome, and 45% have migraine. There are no tests or biological markers for any of these ‘diagnoses’ (read: labels).
43% of women have female sexual dysfunction (thanks to the pharmaceutical industry, that is now a disease).
44% of findings from major medical journals (usually indicating that the treatment studied is effective) are replicated by later studies. The rest are either refuted by later studies or go unchallenged. This shows that our initial impression of new treatments is an overestimate, yet it dictates treatment for years to come. Eventual reversal of medical practice is common.
45% of elderly patients presenting to emergency departments are on 5 or more medications, 20 – 40% of which are unnecessary.
45% of patients with fibromyalgia also have migraine. There is significant cross-over with such labels.
46%: the caesarean section rate in Brazil.
47% of all non-traumatic deaths in people over the age of 65 in the USA (in 2001) occurred in hospital (many of them receiving active, non-palliative treatment right up until death).
48% cesarean section rate in the private sector in Peru after introduction of “health reforms”, up from 27% 10 years earlier; compared to 19% rate in the public sector, which did not increase over that period.
49% of patient requests for interventions secondary to viewing direct-to-consumer advertising (DTCA) are considered in appropriate. Unfortunately this doesn’t stop physicians from prescribing anyway. DTCA creates demand for medical interventions; it medicalizes.
50% of heart attacks occur in people with normal or low cholesterol levels. The ‘cholesterol hypothesis’ has been questioned.
51% upper limit of lifetime risk of mental disorder in Brazil.
52% of men aged 40 to 70 have erectile dysfunction.
53% of women have ‘undiagnosed’ urinary incontinence in the last year (do they want it diagnosed?).
54% of Europeans have raised cholesterol (again, link here questioning the ‘cholesterol hypothesis’).
55% of people who have been in intensive care develop ‘psychological disorders’.
56% of screening detected prostate cancers may be ‘overdiagnosis’. The overdiagnosis rate for mammography screening is only 52%
57% of Australian adults receive appropriate (evidence based) healthcare.
58% increase in CT scans in Canada between 2003 and 2009, along with a 100% increase in MRIs, despite 30% of CT scans being inappropriate and contributing no useful information. In the US alone, it is estimated that $30 billion per year is wasted on CT and MRI scans.
59% of people ‘living with dementia’ remain undiagnosed. Why do we feel the need to diagnose (label) them?
60% lifetime risk of psychiatric disorder in New Zealand (and this number is not unique to New Zealand).
61% of patients provided with powered wheelchairs by Medicare failed to meet medical necessity guidelines.
62% of doctors surveyed think that the rates of diagnostic testing would be reduced if they did not provide financial incentives to specialists.
63% of patients over 80 receive invasive, life-prolonging care (like intensive care, intubation etc.) despite only 30% wanting such treatment.
64% of men in their 70’s have prostate cancers (found on autopsy, nearly all incidental) yet screening only detects 5-10% - these are the ones that get taken out, for little or no benefit to overall survival.
65% of all deaths in US now occur in hospital, increasing the risk of ‘futile’ end-of-life care: medicalizing dying.
66% of admissions for adverse drug reactions in the elderly are due to unintentional overdose. There are about 100,000 admissions per year in the US due to adverse drug reactions in the elderly. The problem is magnified by “polypharmacy” whereby up to 40% of elderly patients are taking unnecessary medications, and about half of the elderly take 5 or more medications.
67% of mammography detected breast tumours are low risk, yet these questionable ‘tumours’ get treated the same as invasive cancers. This overdiagnosis (500-fold increase in diagnosis of ‘cancer-in-situ’) has led to the increase in breast cancer incidence and to the current state of overtreatment and its attendant harms. Like with prostate cancer: more people are diagnosed with ‘cancer’ each year, but the same number of people are dying of breast cancer each year, therefore the proportion of people with ‘cancer’ who die of cancer each year goes down, without saving any lives.
68% reduction in cases of whiplash after legislative change in Australia. Geographic variations in whiplash are stark (in some areas it does not exist), and the disease has all the hallmarks of a “culturally constructed illness behaviour”. This is supported by the lack of any reliable physical / investigation findings.
69%: the upper limit of the inflation in reported effectiveness between published studies of antidepressants and the reality. The fact that these drugs are largely ineffective except in major depression indicates that we are medicalizing sadness.
70% of healthcare spending is related to lifestyle.
71% of patients with low risk prostate cancer (that can reasonably be treated with observation alone) are being treated with radiotherapy. Complications from this overtreatment are listed here.
72% of common recipe ingredients are associated with cancer.
73% of Americans would rather have a full body CT scan (a complete waste of time, and possibly harmful) than be given $1,000.
74% increase in US tonsillectomy rate in decade to 2006 (despite a lack of evidence of effectiveness in most cases).
75% of men over 50 in the US have had prostate cancer screening using a PSA test, leading to false positives and overdiagnosis and overtreatment of a condition that is often non-fatal, and using a test (PSA) that is not recommended and does not result in a reduction in all-cause mortality.
76% of individuals 20-79 have an “unfavourable cardiovascular risk profile”.
77% of seniors have two or more chronic diseases. Or are they just old?
78% of healthy people aged 70-79 (without COPD - Chronic Obstructive Pulmonary Disease) would be diagnosed with COPD according to proposed diagnostic criteria from the Global Initiative for Chronic Obstructive Lung Disease.
79% prevalence of ‘repetitive strain injury’ of the neck and upper limbs amongst bank workers.
80% of people will experience back pain in their lives (so don’t act so surprised when it happens to you, and don’t demand an MRI).
81% prevalence of osteoporosis in older women. There are many drugs for that.
82% ‘psychological morbidity’ in substance misuse professionals.
82% of white men aged 71-80 will have an undiagnosed metastatic prostate cancer at the time of death (that didn’t cause the death).
83% of boys in the 1980s were circumcised (not always religious, often ‘medical’ reasons).
84%: the overtreatment rate from PSA screening.
85% of American men, by the age of 50, will have MPB (Male Pattern Baldness).
86% prevalence of obstructive sleep apnoea in diabetics.
87% of clinical guideline authors have industry ties, which may influence recommendation to increase drug sales, yet very few of these conflicts are ever reported.
88% of the reduction in breast cancer mortality is due to factors unrelated to screening. Regarding all cause mortality, breast cancer screening does not reduce overall (all cause) mortality.
89% of doctors rely on drug company reps for their information.
90%: the proportion of Americans would be on (cholesterol lowering) statins (if the drug companies had their way).
91% increase in death from poisoning amongst US teenagers from 2000 to 2009, primarily due to abuse of prescription drugs.
92% of patients with colds (viral) are prescribed antibiotics (that are not effective).
93% of children avoiding certain foods based on allergy tests were found to have no reaction to oral testing of those foods.
94% of women surveyed thought that women with breast cancers detected by mammography benefited from that diagnosis. The question of overdiagnosis and treatment, and the balance between risk and harm from mammography is not that clear.
95% of people exposed to a traumatic event experience some mental distress. 99% exposed to war satisfy the criteria for PTSD. Isn’t some degree of distress after such events normal? Does labelling and treatment help?
96% of breast cancer patients considering chemotherapy rate “living as long as possible” as their No 1 priority, according to doctors. According the patients themselves, it is only 53%. This explains why chemo is universally recommended by doctors, as quality of life is not adequately taken into consideration.
97% of people with celiac disease don’t even know they have it (so does that make it a problem or not?)
98% of children treated with medication for ADHD are initially given Ritalin, a drug that is also used as substitute therapy for cocaine addiction, is dependency forming and is associated with numerous side effects including cardiac arrest, psychosis and suicidal ideation.
99% of children screened at a New York school either previously had a tonsillectomy, or were assessed as needing one.
100% is the current world death rate, and it is holding steady.

7 comments:

  1. Fascinating and terrifying all at once...

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  2. Actually the current observed world death rate is around 93.5% since ~6.5% of all people that ever lived are still alive.

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    1. Ha! Thanks for that. I should have rephrased it to something like "100% mortality: the long term results of living"

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  3. Brilliant, brilliant post. You could publish this anywhere.

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  4. I think you can manipulate statistics anyway you want to. For instance...93% of children avoiding certain foods based on allergy tests were found to have no reaction to oral testing of those foods.
    Since food allergy testing can be IgG or IgE, this statistic makes no sense. IgG reactions are delayed reactions within the blood and can happen up to 72 hours after ingestion of the particular allergen. If all food allergy tests were based solely on IgE reactions looking for anaphylaxis then I can see how this particular statistic might make sense.

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    1. You can certainly manipulate data to make your case seem stronger. That is at least partly my point. When we have ridiculously high rates of (say) depression or ADHD, you have to ask about the definitions being used.

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  5. Re 81% prevalence of Osteoporosis. Surprised you didn't pick up on the osteoporosis diagnostic criteria - 2SD below the bone density of a 25yr old. Of course all the elderly have the 'disease', it's good for marketing. And as for the drugs, well....

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