Wednesday, November 13, 2019

Misdiagnosing dementia

When I first started this blog several years ago now, I indicated I would return to the issue of the National Dementia Strategy (see previous post). Times have moved on and the incentivisation of GPs in the NHS to diagnose dementia, which began in 2011, has been controversial. This is because of the increased number of referrals of people with cognitive complaints not due to dementia (Bell et al, 2015). Mistakes can be made about the diagnosis of dementia and doubts have been expressed about the security of diagnosis for at least some so-called dementia advocates (Howard, 2017) (see previous post).

A systematic review of functional cognitive disorders has just been published in Lancet Psychiatry. Current views of functional neurological disorders tend to emphasise excessive attention towards physical symptoms rather than psychological stress as such in the generation of symptoms. People with functional disorders are more likely to attend alone and be worried about their memory, providing a detailed account of personal history and memory failures more than patients with neurodegenerative disease. Those with functional cognitive disorder phenotypes are at risk of iatrogenic harm because of misdiagnosis or inaccurate prediction of future decline.

Monday, November 04, 2019

Are there no problems with psychiatry?

George Dawson (who I have mentioned previously - see post) has responded in a blog post to a NEJM article by Caleb Gardner and Arthur Kleinman entitled 'Medicine and the Mind — The Consequences of Psychiatry’s Identity Crisis'. As far as Dawson is concerned there is no identity crisis in psychiatry. The only problem he recognises is that:-
most psychiatrists are working in toxic practice environments that were designed by business administrators and politicians. As a result, psychiatrists are expected to see large numbers of patients for limited periods of time and spend additional hours performing tasks that are basically designed by business administrators and politicians and have no clinical value.

Dawson is a believer in psychopharmacology, ECT and transcranial magnetic stimulation and thinks the benefits of psychosocial treatments are significantly limited. He also believes neuroscience research is translating into benefits for clinical practice, but these seem to be more about possibilities for the future rather than now.

Gardner and Kleinman (2019) recommend reducing the amount of spending on biologic research in psychiatry to support only the highest quality such research. They suggest that academic psychiatry needs to be rebuilt by more recognition of the limits of biologic research. Dawson wonders why NEJM has accepted this article, and I agree it is surprising considering how biomedical the perspective of the journal has been about psychiatry. I wonder, though, whether, like Wellcome apparently (see previous post), NEJM has become more sceptical about whether psychiatry is really being advanced by neuroscience.

I'm not saying managed care doesn't create problems for psychiatry, but there are wider conceptual issues that do need to be addressed. I agree with Dawson this issue shouldn't just be decided by rhetoric.