something which is confusing to me in that it strikes at the nub of what
depression is. My knowledge of psychiatric science leads me to believe
that from the biomedical perspective and with strict application of the
science the problem of the 'feminisation' of depression is not relevant
because the science matches the diagnosis to a prognosis whereas there
is no evidence base for the prognosis associated with masculine
symptoms. On the other hand a person considering depression as the
medicalisation of misery, irrespective of the model of the application
of the paradigm of medicine to human behaviour, would probably consider
the current gender equality problem in the clinical recognition of
depression an area which needs serious attention.
I did the review of literature for Mind's Men and mental health
campaign. The feminisation of depression is part is worth readin
http://www.mind.org.uk/campaigns_and_issues/report_and_resources/898_men_and_mental_health_get_it_off_your_chest
When I was reading into the literature on women's mental health for a
review of Mind's Women and mental health factsheet I stumbled across a
paper which graphed symptom count and gender. Unfortunately I don't
remember the title of the paper nor was the paper directly considering
what I saw in the data. I think the paper was written to show how great
the cluster of symptoms approach was (i.e. good validity qnd
reliability), but looking at the graph it was interesting to consider
what the operational diagnosis approach is trying to achieve. Both
genders reported similar levels of self-report of a period of subjective
unwellness. As objectivity was applied, i.e. as more symptoms were
required up to the minimum of 5 for a DSM-IV clinical diagnosis of
depression, fewer members of both genders were counted and the rate of
decrease was higher in men. This is the empirical proof (if I could find
the paper!) to support what Mind have already said.
This information wasn't in Mind's Men and mental health report but there
was a lot of other research in there whch supports the idea that men can
externalise their symptoms in different way to women. If I remember the
timeline right the NICE depression guidelines were revised before Mind's
Men and mental health campaign but the QOF was obviously produced after
Mind's campaign. I'm unaware of whether Mind were involved with the QOF
consultation but I'm pretty sure they'd be making this point about
gender equality and depression. This report received significant
political backing and was widely disseminated and publicised as part of
Mind's Mind Week so I'm surprised their concerns weren't taken into
account as part of the process to write the depression QOF.
It is, perhaps, a moot point because I don't see an easy way to
integrate all the equality considerations with the QOFs. The QOFs are up
to 15 simple, achievable treatment tick boxes. "Do mental health
screening" in the alcohol dependence one would be something which would
work however "Check men are depressed but don't use the cluster of
symptoms approach" might not really translate well into what the Quality
Standard is. However it is still important that men's depression, and
other groups too, are recognised and treated.
I hope this isn't a totally abstract discussion. It premises something
I've been thinking a lot about as part of my activism work. The AESOP
study notes schizophrenia is disproportionately diagnosed in black
people 9 times more than their white counterparts. This doesn't happen
in the West Indies. i would suggest this is a high priority inequality
area which needs to be tackled, especially considered the results of the
Count Me in Census which details the continuing bad experiences of
mental healthcare faced by minority ethnicities.
It is a serious issue and was recognised in NICE's revised schizophrenia
guidelines and in the New Horizons consultation document. There has been
a significant amount of research effort put into understanding the cause
of the problem and how to solve it, such that a fellow member of the
ENUSP email list noted, "Another local issue here - some years ago
ethnic minorities were fed up with research into their mental health
needs, a popular topic for researchers which did not however lead to any
change." It would be great if there was a QOF aimed at solving the problem.
I found a study done in 1999 where a Jamaican psychiatrist compared
inpatient schizophrenia diagnosis with UK psychiatrists and agreed with
them about half the time.
Hickling FW, McKenzie K, Mullen R, et al. A Jamaican psychiatrist
evaluates diagnosis at a London psychiatric hospital. Br J Psychiatry.
1999;175:283–285
http://www.ncbi.nlm.nih.gov/pubmed/10645332
"Of 29 African and African-Caribbean patients diagnosed with
schizophrenia, the diagnoses of the British and the Jamaican
psychiatrists agreed in 16 instances (55%) and disagreed in 13 (45%).
Hence, interrater reliability was poor (kappa = 0.45). PSE CATEGO
diagnosed a higher proportion of subjects as having schizophrenia than
the Jamaican psychiatrist did (chi 2 = 3.74, P = 0.052)."
In nother study which I came across (while looking into men and mental
health but can't remember the title of) the authors stated that the
largest factor in psychiatrists variance in diagnosis wasn't gender,
race or age. It was where the psychiatrist studied psychiatry. I looked
into this because it was suggested that the gender of the diagnosing
physician and the patient may affect the levels of recognition of
depression.
In short, a solution to this problem may be using West Indian and
African psychiatrists to train specialist psychiatrists in high BME
areas with the purpose of offering a non-culturally biased second
opinion diagnosis. As a long term solution psychiatry students would
require similar training.
A QOf could ask for a non-culturally biased diagnosis but this would be
meaningless in clinical practice. A QOF could ask for BME diagnoses to
be checked by UK-trained ethnic psychiatrists but this may be
ineffective because of the influence of formative psychiatric education.
To correct this problem of overdiagnosis would require a long term
solution akin to what I've suggested and then q QOF could be used but a
QOF on its own won't do anything to actually achieve on the equality
duty in this instance. It may be the same with the example of men and
depression. It may, again, require training.
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