Medicalisation and Overdiagnosis: What Society Does to Medicine

The diffusion of diagnosis and its implications for the epistemology and ontology of disease

Rather than confining the categories health and sickness to a biomedical conception of the biological organism, there is growing recognition of epistemological and ontological multiplicity in the realm of diagnosis and, indeed, in the very realm of disease itself. In short, the empirical manifestations of health and illness as well as the processes thought to cause them are now understood to assume a much wider variety of both biological and other forms. This essay considers the underlying epistemological and ontological opportunities and challenges of taking what we are calling this diffusion of diagnosis seriously. By diffusion we mean the movement from a concentrated understanding of diagnostic authority as confined to scientific biomedicine to a less concentrated appreciation of the diverse approaches to diagnosis throughout the world. We consider the extent to which, and the manner in which, we as sociologists of diagnosis might not only critique these various processes but perhaps also take them seriously in an ethnographic sense as locally produced, evaluated and legitimated forms of health care.

Cervical cancer (over-)screening in Europe: Balancing organised and opportunistic programmes

AIMS

Cervical cancer (CC) over-screening has been understudied in Europe, yet is relevant for approaching inequalities in screening uptake. Focusing on countries' screening strategies (opportunistic systems versus organised programmes), we assess in which contexts CC over-screening is more prevalent, and which women are more likely to have engaged in cervical cancer screening (CCS) within the past year.

METHODS

A two-level (multilevel) design among screening women (N = 80,761) nested in 31 European countries was used to analyse data from the second wave (2013-2015) of the European Health Interview Survey. We focused on over-screening, defined as screening more frequently than the three-yearly screening interval prescribed in the European guidelines - that is, having screened within the past year.

RESULTS

Higher levels of over-screening were observed in opportunistic systems compared to systems with organised programmes. In opportunistic systems, women with a higher socioeconomic position had a higher likelihood of being screened within the past year than their socioeconomic counterparts. Moreover, these differences diminished under organised programmes.

CONCLUSIONS

Contexts with organised CCS programmes are more efficiently reducing over-screening, and enforcing the European guidelines. We suggest that the physician-patient relationship is an essential pathway for explaining socioeconomic differences in CC (over-)screening and for future interventions.

What factors do physical therapists consider when determining patient prognosis: A mixed methods study

INTRODUCTION

A prognosis provides valuable information to expected progress and anticipated outcome over the course of care. Although it is known that physical therapists can accurately prognose, it is unknown what factors are utilised in clinical practice.

OBJECTIVE

The purpose of this study was to determine the prognostic domains and factors that influenced a PT's clinical reasoning processes.

DESIGN

Mixed Methods Design, affirming the prognostic ability of the physical therapists and the qualitative exploration of the prognostic factors considered by physical therapists.

METHODS

Twenty-nine physical therapists participated in this study. Participants underwent semi-structured qualitative interviews that were coded to populate a prognostic framework. In addition, de-identified patient data was used to determine the ability of the PT to form a prognosis. Linear regression was used to determine if an initial prognostic score was related to function at discharge.

RESULTS

There were significant relationships (p = <0.05) between the prognosis score and Focus on Therapeutic Outcomes (B = 2.25), Numeric Pain Rating Scale (B = 0.257), and GROC (B = 0.289) upon patient discharge. Qualitative factors were categorised into prognostic domains (prevalence): Mood, Motivation, Pain Behaviours (100%), Disease Severity (93.1%), Health Status (86.2%), Social, Occupation, Environmental (67.0%), and Genetics, Biology, Biomarkers (44.8%). Factors that did not fit established domains were reported and categorised as Other (86.2%).

CONCLUSION

Our findings support the relationship between PT prognosis of patients with musculoskeletal pain and patient outcomes. In addition, the domains and factors PTs use to formulate prognosis during evaluation present a complex biopsychosocial framework, suggesting that PTs consider factors from multiple domains when forming a prognosis.

Presenting a Comprehensive Definition of Unnecessary Healthcare Services and Their Drivers: A Systematic Review and Meta-synthesis

Background

Providing unnecessary healthcare services is a major common problem in every health system. The scope and cause of healthcare services must be identified in order to be managed and controlled. Finding the most complete definition of the problem and its causes are the goals of this meta-synthesis.

Methods

A comprehensive search strategy was performed using a wide range of keywords and databases. Based on the defined inclusion and exclusion criteria, 22 articles were selected for content analysis and meta-synthesis. The Graneheim and Lundman method was used for content analysis. The MAXQDA software Version 18.2.0 was used for the first round of content analysis. Content analysis and meta-synthesis were used to comprehensively define the term "unnecessary healthcare services" and find the etiologic factors driving healthcare providers to unnecessary healthcare services.

Results

The term "unnecessary healthcare services" is defined as "overproviding healthcare services that could be harmful, low-value, insufficient, and inappropriate." The etiologic pattern of unnecessary healthcare services shows intrinsic and extrinsic factors as a driving force for unnecessary healthcare services.

Conclusion

A multilayer strategy for efficient management and prevention of unnecessary healthcare services is appropriate due to the multifaceted character of these services. This approach consists of the modification of the intrinsic factors and extrinsic drivers.

Patient-centered empirical research on ethically relevant psychosocial and cultural aspects of cochlear, glaucoma and cardiovascular implants - a scoping review

BACKGROUND

The significance of medical implants goes beyond technical functioning and reaches into everyday life, with consequences for individuals as well as society. Ethical aspects associated with the everyday use of implants are relevant for individuals' lifeworlds and need to be considered in implant care and in the course of technical developments.

METHODS

This scoping review aimed to provide a synthesis of the existing evidence regarding ethically relevant psychosocial and cultural aspects in cochlear, glaucoma and cardiovascular implants in patient-centered empirical research. Systematic literature searches were conducted in EBSCOhost, Philpapers, PsycNET, Pubmed, Web of Science and BELIT databases. Eligible studies were articles in German or English language published since 2000 dealing with ethically relevant aspects of cochlear, glaucoma and passive cardiovascular implants based on empirical findings from the perspective of (prospective) implant-wearers and their significant others. Following a descriptive-analytical approach, a data extraction form was developed and relevant data were extracted accordingly. We combined a basic numerical analysis of study characteristics with a thematically organized narrative synthesis of the data.

RESULTS

Sixty-nine studies were included in the present analysis. Fifty were in the field of cochlear implants, sixteen in the field of passive cardiovascular implants and three in the field of glaucoma implants. Implant-related aspects were mainly found in connection with autonomy, freedom, identity, participation and justice, whereas little to no data was found with regards to ethical principles of privacy, safety or sustainability.

CONCLUSIONS

Empirical research on ethical aspects of implant use in everyday life is highly relevant, but marked by ambiguity and unclarity in the operationalization of ethical terms and contextualization. A transparent orientation framework for the exploration and acknowledgment of ethical aspects in "lived experiences" may contribute to the improvement of individual care, healthcare programs and research quality in this area. Ethics-sensitive care requires creating awareness for cultural and identity-related issues, promoting health literacy to strengthen patient autonomy as well as adjusting healthcare programs accordingly. More consideration needs to be given to sustainability issues in implant development and care according to an approach of ethics-by-design.

Changes in private health service utilisation and access to the Italian National Health Service between 2006 and 2019: a cross-sectional comparative study

OBJECTIVES

Previous research highlighted that in the early 2000s a significant share of the Italian population used and paid out of pocket for private healthcare services even when they could potentially have received the same treatments from the National Health Service (NHS). The decrease in public investments in healthcare and the increase in health needs due to the population ageing may have modified the use of private health services and equity of access to the Italian NHS. This study aims to investigate the change in the prevalence of individuals who have fully paid out of pocket for accessing healthcare services in Italy between 2006 and 2019 and the main reasons behind this choice.

DESIGN

Cross-sectional comparative study.

PARTICIPANTS AND COMPARISON

Two representative samples of the Italian population were collected in 2006 and 2019.

OUTCOME MEASURES

Prevalence of access to fully paid out-of-pocket private health services; type of service of the last fully paid out-of-pocket access; main reasons for the last fully paid out-of-pocket access.

RESULTS

We found an increase in the prevalence of people who declared having fully paid out of pocket at least one access to health services during their lifetime from 79.0% in 2006 to 91.9% in 2019 (adjusted OR 2.66; 95% CI 1.98 to 3.58). 'To avoid waiting times' was the main reason and it was significantly more frequent in 2019 compared with 2006 (adjusted OR 1.75; 95% CI 1.45 to 2.11).

CONCLUSIONS

This comparative study, conducted the year before the outbreak of the COVID-19 pandemic, highlighted an increase in the prevalence of Italian residents who have fully paid out of pocket for access to health services to overcome long waiting times. Our findings may indicate a reduced access and possible worsening of the equity of access to the public and universalistic Italian NHS between 2006 and 2019.

The Sovereignty of Medicine in Our Lives: Medicalization

Medical practices change dramatically because of the recent scientific and technological developments in areas such as genetics, biotechnology and digital technologies. As the boundaries of medicine have become blurred, the focus of physicians has shifted from “What we can treat?” to “What we should treat?”. In such a rapidly changing world, medicine and technology are intertwined more than ever before, and this has affected medical processes, particularly the nature of medical knowledge. The transformation of medicine to an unhesitating and powerful authority, accelerated by the development of modern medicine, is strengthened with more successful results in diagnosis and treatment. The medical authority holds the reins of power to determine who is sick, healthy, or normal, or what conditions should or should not be considered as a disease. Today, many phenomena including birth, childhood, eating and drinking habits, mental states, adolescence, sexuality, pregnancy, agedness or death have been included in the field of medicine. Hence medicine has declared its sovereignty in our lives. This condition, called medicalization, although comes to the fore in the 1960s-70s, is a concept that still maintains its importance today and needs to be addressed. Medical interventions to the human body, human mind and human behavior are increasing day by day, and the scope of medical activities is expanding. Despite the fact that medicalization and treatment of cases that should not be under the influence of medicine cause many harms at the individual and societal level, this situation has been so widely accepted without questioning.

Imaginaries of patienthood: Constructions of HIV patients by HIV specialist health professionals

This paper explores the ways in which HIV specialists based in the United Kingdom (UK) construct, conceptualise and imagine their patient group via the concept of the 'imaginary', a notion encompassing the symbols, concepts and values through which people make sense of their social environment. In discussing their work with men who have sex with men (MSM), practitioners described patients as knowledgeable and highly adherent to treatment, yet apt to pursue hedonistic lives involving sex and recreational drugs. Recent innovations in treatment were formulated in terms of optimism and progress and the ascent of biomedical approaches was cast as an advance over former emphases on psychosocial interventions and attempts to facilitate behaviour change. In contrast to the imaginary of patients who were well-informed and highly compliant with treatment, participants also sought to explain those who were not easily enfolded within modern treatment regimens or who were seen to be overly emotional. These patients, it was said, had some pre-existing psychological problem or perhaps were especially vulnerable to societal pressures. Overall, the imaginary of the public was pervaded by therapeutic optimism, a sense of progress and an invigoration of biomedical themes in overcoming the challenges of delivering services to MSM.

Learning Analytics Applied to Clinical Diagnostic Reasoning Using a Natural Language Processing-Based Virtual Patient Simulator: Case Study

BACKGROUND

Virtual patient simulators (VPSs) log all users' actions, thereby enabling the creation of a multidimensional representation of students' medical knowledge. This representation can be used to create metrics providing teachers with valuable learning information.

OBJECTIVE

The aim of this study is to describe the metrics we developed to analyze the clinical diagnostic reasoning of medical students, provide examples of their application, and preliminarily validate these metrics on a class of undergraduate medical students. The metrics are computed from the data obtained through a novel VPS embedding natural language processing techniques.

METHODS

A total of 2 clinical case simulations (tests) were created to test our metrics. During each simulation, the students' step-by-step actions were logged into the program database for offline analysis. The students' performance was divided into seven dimensions: the identification of relevant information in the given clinical scenario, history taking, physical examination, medical test ordering, diagnostic hypothesis setting, binary analysis fulfillment, and final diagnosis setting. Sensitivity (percentage of relevant information found) and precision (percentage of correct actions performed) metrics were computed for each issue and combined into a harmonic mean (F₁), thereby obtaining a single score evaluating the students' performance. The 7 metrics were further grouped to reflect the students' capability to collect and to analyze information to obtain an overall performance score. A methodological score was computed based on the discordance between the diagnostic pathway followed by students and the reference one previously defined by the teacher. In total, 25 students attending the fifth year of the School of Medicine at Humanitas University underwent test 1, which simulated a patient with dyspnea. Test 2 dealt with abdominal pain and was attended by 36 students on a different day. For validation, we assessed the Spearman rank correlation between the performance on these scores and the score obtained by each student in the hematology curricular examination.

RESULTS

The mean overall scores were consistent between test 1 (mean 0.59, SD 0.05) and test 2 (mean 0.54, SD 0.12). For each student, the overall performance was achieved through a different contribution in collecting and analyzing information. Methodological scores highlighted discordances between the reference diagnostic pattern previously set by the teacher and the one pursued by the student. No significant correlation was found between the VPS scores and hematology examination scores.

CONCLUSIONS

Different components of the students' diagnostic process may be disentangled and quantified by appropriate metrics applied to students' actions recorded while addressing a virtual case. Such an approach may help teachers provide students with individualized feedback aimed at filling competence drawbacks and methodological inconsistencies. There was no correlation between the hematology curricular examination score and any of the proposed scores as these scores address different aspects of students' medical knowledge.

Consequences of a Diagnostic Label: A Systematic Scoping Review and Thematic Framework

Objectives: To develop a thematic framework for the range of consequences arising from a diagnostic label from an individual, family/caregiver, healthcare professional, and community perspective.

Design: Systematic scoping review of qualitative studies.

Search Strategy: We searched PubMed, Embase, PsycINFO, Cochrane, and CINAHL for primary studies and syntheses of primary studies that explore the consequences of labelling non-cancer diagnoses. Reference lists of included studies were screened, and forward citation searches undertaken.

Study Selection: We included peer reviewed publications describing the perceived consequences for individuals labelled with a non-cancer diagnostic label from four perspectives: that of the individual, their family/caregiver, healthcare professional and/or community members. We excluded studies using hypothetical scenarios.

Data Extraction and Synthesis: Data extraction used a three-staged process: one third was used to develop a preliminary framework, the next third for framework validation, and the final third coded if thematic saturation was not achieved. Author themes and supporting quotes were extracted, and analysed from the perspective of individual, family/caregiver, healthcare professional, or community member.

Results: After deduplication, searches identified 7,379 unique articles. Following screening, 146 articles, consisting of 128 primary studies and 18 reviews, were included. The developed framework consisted of five overarching themes relevant to the four perspectives: psychosocial impact (e.g., positive/negative psychological impact, social- and self-identity, stigma), support (e.g., increased, decreased, relationship changes, professional interactions), future planning (e.g., action and uncertainty), behaviour (e.g., beneficial or detrimental modifications), and treatment expectations (e.g., positive/negative experiences). Perspectives of individuals were most frequently reported.

Conclusions: This review developed and validated a framework of five domains of consequences following diagnostic labelling. Further research is required to test the external validity and acceptability of the framework for individuals and their family/caregiver, healthcare professionals, and community.

'The Drugs Did For Me What I Couldn't Do For Myself': A Qualitative Exploration of the Relationship Between Mental Health and Amphetamine-Type Stimulant (ATS) Use

Substance use and mental ill health constitute a major public health burden, and a key global policy priority is to reduce illicit and other harmful substance use. Amphetamine-type stimulants (ATS) are the second most used class of illicit drugs and a range of mental health issues have been documented amongst users. This paper explores the relationship between mental health and ATS use, through a thematic analysis of qualitative interviews with n = 18 current and former ATS users in England. The findings are presented by trajectory point of; (1) Initiation of ATS use; (2) continued and increased ATS use and (3) decreased and remitted ATS use. This work helps to develop understanding around the complex and bi-directional relationship between ATS use and mental health. Many ATS users lead chaotic lives and engage in multiple risk behaviours, however there is a need to better understand and conceptualise the dynamic interaction between different individual, social, environment and cultural factors that determine individuals’ mental health and substance use. There is no ‘one size fits all’ approach to prevention and treatment, and these findings highlight the need for more joined-up, tailored and holistic approaches to intervention development.

A Narrative Review of Alzheimer's Disease Stigma

As the most common form of senile dementia, Alzheimer’s disease (AD) is accompanied by a great deal of uncertainty which can lead to fear and stigma for those identified with this devastating disease. As the AD definition evolves from a syndromal to a biological construct, and early diagnoses becomes more commonplace, more confusion and stigma may result. We conducted a narrative review of the literature on AD stigma to consolidate information on this body of research. From the perspective of several stigma theories, we identified relevant studies to inform our understanding of the way in which implementation of the new framework for a biological based AD diagnosis may have resulted in new and emerging stigma. Herein, we discuss the emergence of new AD stigma as our understanding of the definition of the disease changes. We further propose recommendations for future research to reduce the stigma associated with AD.

Overdiagnosis: one concept, three perspectives, and a model

Defining, estimating, communicating about, and dealing with overdiagnosis is challenging. One reason for this is because overdiagnosis is a complex phenomenon. In this article we try to show that the complexity can be analysed and addressed in terms of three perspectives, i.e., that of the person, the professional, and the population. Individuals are informed about overdiagnosis based on population-based estimates. These estimates depend on professionals' conceptions and models of disease and diagnostic criteria. These conceptions in turn depend on individuals' experience of suffering, and on population level outcomes from diagnostics and treatment. As the personal, professional, and populational perspectives are not easy to reconcile, we must address them explicitly and facilitate interaction. Population-based estimates of overdiagnosis must be more directly informed by personal need for information. So must disease definitions and diagnostic criteria. Only then can individuals be appropriately informed about overdiagnosis.

[Complementary and alternative medicine and social medicalization: lack of definitions, risks, and potentials in primary healthcare]

Complementary and Alternative Medicine (CAM) need to be increasingly understood in the academic and research setting, given their growing inclusion in health institutions and scientific studies. However, vague definitions or broad generalizations are common in the Brazilian scientific literature, an example of which is the relationship between CAM and social medicalization. This study aims to discuss the medicalizing and de-medicalizing potential of the use of CAM, especially in primary healthcare (PHC). This essay summarizes the underlying lack of definition concerning the medicalizing and de-medicalizing potential of various CAM, based on the selected literature, which reports theoretical and empirical convergences. The exercise of CAM in the clinical context has a medicalizing potential, due to its positive, expanded, and holistic conception of health and its etiological multidimensionality, potentially generating so-called "holistic illness", which has been reported theoretically and empirically. CAM also have de-medicalizing potential, depending on the practitioner, due to greater interpretative flexibility, contextualization, singularization, users' participation in the care, closer clinical relationship, the values and traditions of some CAM, diversity of interventions, and the potential for enrichment of self-care. The medicalizing or de-medicalizing potential of various CAM is activated by their practitioners, and the context of PHC tends to favors the de-medicalizing potential.

The Pitfalls of Overtreatment: Why More Care is not Necessarily Beneficial

Overtreatment refers to interventions that do not benefit the patient, or where the risk of harm from the intervention is likely to outweigh any benefit the patient will receive. It can account for up to 30% of health care costs, and is increasingly recognised as a widespread problem across nations and within clinical and scientific communities. There are a number of inter-related factors that drive overtreatment including the expanding definition of diseases, advertising and the influence of the pharmaceutical industry, how doctors are trained and remunerated, demands from patients (and their families) and the fear of complaints leading doctors to practise defensively. This paper discusses a number of ethical and practical issues arising from overtreatment that doctors and patients should be aware of. It also considers the flow-on effects of overtreatment such as the increased cost of care, increase in work load for health professionals, and wastage as resources are diverted from more genuine and pressing needs. In addition, there are references to a number of Medical Council of New Zealand statements about what good medical practice means in an environment of resource limitation. The paper concludes with a few measures that doctors and patients could take to reduce overtreatment but acknowledges that health care is extremely complex so it would be unrealistic to eliminate overtreatment entirely.

El modelo médico como generador de discapacidad

La discapacidad ha tenido diferentes conceptualizaciones, incluyendo aportes religiosos, científicos, médicos y sociales. El modelo médico es fundamental en la prevención y la rehabilitación adecuada, sin embargo, es también un gran generador de discapacidad. El objetivo de este trabajo es presentar la relación del modelo médico de discapacidad y el enfoque biomédico como generadores de discapacidad y proponer una aproximación teórica a nuevos modelos y enfoques que permitan un abordaje ético-ontológico. El presente es un artículo de exposición en dos etapas: en la primera se hizo una revisión de literatura sobre discapacidad. En la segunda, se presentan los resultados de la discusión entre los autores para comparar e identificar argumentos y contraargumentos de los modelos tradicionales, con respecto a las nuevas formas de análisis con una visión desde la bioética. Una de las principales conclusiones de este análisis es que el modelo médico ha hecho aportes fundamentales en la conceptualización y clasificación de la discapacidad; sin embargo, el enfoque monocausal positivista termina favoreciendo la medicalización, la discapacidad y demanda más recursos. La discapacidad es un asunto en evolución en el que interactúan las deficiencias individuales y las barreras personales y ambientales, por lo que es necesario superar el paradigma médico y fortalecer el biopsicosocial.

The Elephant in the Room: Too Much Medicine in Musculoskeletal Practice

While advances in assessment and management of musculoskeletal conditions have improved care for many people, there have been other, less beneficial developments in the provision of care for people with musculoskeletal pain conditions, one of which is the worrying tendency to provide too much medicine. Too much medicine occurs when the provision of either investigation or intervention (or both) is unjustifiably excessive. Another concern in musculoskeletal health care is medicalizing normality-when a normal human function or condition is labeled as abnormal. In this Viewpoint, the authors argue that medicalizing normality creates health concerns where none exist, while too much medicine involves provision of care where benefits do not outweigh harms, and wastes precious health care resources. The authors (1) list 2 common examples of too much medicine, and 2 examples of medicalizing normality, relevant to physical therapy practice; (2) outline the drivers of too much medicine and medicalizing normality; and (3) make suggestions for change. J Orthop Sports Phys Ther 2020;50(1):1-4. doi:10.2519/jospt.2020.0601.

A Injustiça Epistêmica na violência obstétrica

Resumo: Temos como objetivo, no presente artigo, apontar aspectos epistêmicos presentes na violência obstétrica. Para isso, apresentaremos o conceito de injustiça epistêmica proposto por Miranda Fricker e como tem sido utilizado para reflexões sobre as práticas de saúde na literatura de epistemologia social. Posteriormente, nos deteremos em analisar relatos de casos de violência obstétrica bem como um caso de esterilização forçada, examinando o Relatório Final da CPMI acerca da incidência de esterilização em massa de mulheres no Brasil e artigos científicos que descrevem casos de violência obstétrica. Com isso, buscamos apontar que há um aspecto epistêmico em tais violações e que uma mudança na distribuição de credibilidade pode ser relevante para o enfrentamento à violência obstétrica.

"I Did Not Believe You Could Get Better"-Reversal of Diabetes Risk Through Dietary Changes in Older Persons with Prediabetes in Region Stockholm

Diabetes risk can be controlled and even reversed by making dietary changes. The aim of this study was to improve the understanding of how older persons with a high risk of developing Type 2 diabetes manage and relate to information about diabetes risk over a ten-year period. Fifteen qualitative interviews were conducted among participants from the Stockholm Diabetes Prevention Program (SDPP). The participants were asked to recall the health examinations conducted by the SDPP related to their prediabetes and to describe their experiences and potential changes related to diet and physical activity. Data were analyzed using qualitative content analysis. The main theme found was that T2D (type 2 diabetes) risk is not perceived as concrete enough to motivate lifestyle modifications, such as changing dietary patterns, without other external triggers. Diagnosis was recognized as a reason to modify diet, and social interactions were found to be important for managing behavior change. Diagnosis was also a contributing factor to lifestyle modification, while prognosis of risk was not associated with efforts to change habits. The results from this study suggest that the potential of reversing prediabetes needs to be highlighted and more clearly defined for older persons to serve as motivators for lifestyle modification.

Diagnostic dissonance and negotiations of biomedicalisation: mental health practitioners' resistance to the DSM technology and diagnostic standardisation

Previous research demonstrates that biomedicalisation and diagnostic processes are intertwined in American mental health care, but few studies examine practitioners' negotiations. This study examines how Mental Health Practitioners (MHPs) negotiate the Diagnostic and Statistical Manual (DSM), diagnosis, standardisation and biomedicalisation-in-practice. Feminist grounded theory analysis of 42 semi-structured interviews with licensed adolescent MHPs reveals accounts of discursive, everyday resistance to the DSM technology and standardisation, which I regard as key aspects of biomedicalisation. Findings demonstrate MHPs seemingly practice what I term diagnostic dissonance: a deep conflict between their professional theoretical orientations and the biomedical model legitimated in the DSM technology and insurers' diagnostic standardisation. MHPs enact dissonance by undermining the DSM, working around standardisation and by coding the social. Coding the social refers to the employment of V-codes - illegitimate secondary diagnoses - which convey social and relational conditions of mental distress. MHPs' contestations of the DSM and standardisation are responses to a healthcare infrastructure that decontextualises mental health. Practitioner resistance to biomedicalisation-in-diagnosis is important because the biomedicalisation of mental health takes focus away from the social and relational conditions and solutions to individual and community health and illness.

The role of stress in drug addiction. An integrative review

BACKGROUND

The high prevalence and burden to society of drug abuse and addiction is undisputed. However, its conceptualisation as a brain disease is controversial, and available interventions insufficient. Research on the role of stress in drug addiction may bridge positions and develop more effective interventions.

AIM

The aim of this paper is to integrate the most influential literature to date on the role of stress in drug addiction.

METHODS

A literature search was conducted of the core collections of Web of Science and Semantic Scholar on the topic of stress and addiction from a neurobiological perspective in humans. The most frequently cited articles and related references published in the last decade were finally redrafted into a narrative review based on 130 full-text articles.

RESULTS AND DISCUSSION

First, a brief overview of the neurobiology of stress and drug addiction is provided. Then, the role of stress in drug addiction is described. Stress is conceptualised as a major source of allostatic load, which result in progressive long-term changes in the brain, leading to a drug-prone state characterized by craving and increased risk of relapse. The effects of stress on drug addiction are mainly mediated by the action of corticotropin-releasing factor and other stress hormones, which weaken the hippocampus and prefrontal cortex and strengthen the amygdala, leading to a negative emotional state, craving and lack of executive control, increasing the risk of relapse. Both, drugs and stress result in an allostatic overload responsible for neuroadaptations involved in most of the key features of addiction: reward anticipation/craving, negative affect, and impaired executive functions, involved in three stages of addiction and relapse.

CONCLUSION

This review elucidates the crucial role of stress in drug addiction and highlights the need to incorporate the social context where brain-behaviour relationships unfold into the current model of addition.

CUIDADO CLÍNICO E SOBREMEDICALIZAÇÃO NA ATENÇÃO PRIMÁRIA À SAÚDE

Resumo Este ensaio analisa a sobremedicalização (medicalização desnecessária e indesejável) gerada no cuidado médico aos adoecidos na atenção primária à saúde, discute como ocorre e como evitá-la. Articula na análise três grupos de concepções/saberes: concepções de doença (dinâmicas/ontológicas); concepções de causação (ascendente/multidirecional); eixos conceituais estruturantes do saber médico (anatomopatológico, fisiopatológico, semiológico, epidemiológico). A sobremedicalização deriva dos movimentos cognitivos dos profissionais na elaboração diagnóstica e terapêutica. Ela nasce da associação da concepção ontológica de doença com causação ascendente (fluxo causal que vai dos elementos materiais mais simples a dimensões e níveis mais complexos), em articulação com sobrevalorização do eixo anatomopatológico, geradora de excessivas intervenções diagnósticas e farmacoterapêuticas. Para evitar a sobremedicalização, propomos a associação virtuosa da concepção dinâmica de doença, com causação multidirecional e uso equilibrado dos eixos conceituais das doenças. Isso facilita: escuta qualificada; contextualização dos casos; mais criterioso uso de exames complementares; reconhecimento dos limites diagnósticos biomédicos; superação da razão metonímica (que despreza tudo o que não é saber cientificamente consagrado); amplificação da interpretação para além das 'doenças' e dos tratamentos para além dos fármacos/cirurgias, explorando os saberes dos usuários e profissionais, práticas complementares e a devolução de problemas para o manejo autônomo apoiado.

Incidence of Placebo Adverse Events in Randomized Clinical Trials of Targeted and Immunotherapy Cancer Drugs in the Adjuvant Setting: A Systematic Review and Meta-analysis

IMPORTANCE

Several reports have associated the placebo effect with objective response and improvement of a clinical condition in oncology, but only a few studies have analyzed the adverse events (AEs) in the placebo groups of the clinical trials.

OBJECTIVE

To determine the incidence of placebo AEs reported in randomized clinical trials of modern cancer drugs in the adjuvant setting.

DATA SOURCES

Based on the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline, a systematic literature search of English-language publications from January 1, 2000, through April 15, 2018, was performed using MEDLINE (PubMed). The following search terms were used to retrieve all trials from the PubMed library: adjuvant, maintenance, consolidation, and placebo, in addition to specific cancer type-related keywords.

STUDY SELECTION

A double-blind, randomized, placebo-controlled, phase 3 design was mandatory for study inclusion. Only studies enrolling patients who had undergone macroscopically complete resections were included. No other anticancer treatments in addition to placebo were allowed in the control group. Only trials involving a targeted therapy (tyrosine kinase, BRAF, or MEK inhibitors) or immunotherapy-related drugs were included. Trials using chemotherapy, interferon, and endocrine therapy were excluded. Two authors (D.H.E. and F.D.W.) independently reviewed the studies for inclusion.

DATA EXTRACTION AND SYNTHESIS

Data were extracted by investigators, and random-effects meta-analysis was performed to estimate the proportion of grade 3 to 4 placebo AEs in the included studies.

MAIN OUTCOMES AND MEASURES

Incidence of grade 3 to 4 placebo AEs in the placebo groups.

RESULTS

Of 731 studies screened, 10 eligible trials were found including 4 tumor types (melanoma, non-small cell lung cancer, gastrointestinal stromal tumor, and renal cell carcinoma). Overall, 11 143 patients (6270 [56.3%] in the treatment group with mean [SD] age of 55.6 [4.2] years and 4873 patients [43.7%] in the placebo group with mean [SD] age of 55.9 [4.3] years) were included. The mean incidence of any-grade placebo AEs was 85.1% (95% CI, 79.2%-91.0%). The most frequent (mean [SD]) grade 3 to 4 placebo AEs in patients were hypertension (2.8% [2.2%]), fatigue (1.0% [0.9%]), and diarrhea (0.8% [0.6%]). The overall, random-effects pooled incidence of grade 3 to 4 placebo AEs was 18% (95% CI, 15%-21%), with a high level of heterogeneity (I2 = 86%). Frequency of grade 3 to 4 placebo AEs was found to be correlated in the treatment and placebo groups (ρ = 0.7; P = .03). Mean study drug discontinuation owing to placebo AEs was 3.9% (95% CI, 2.7%-5.2%).

CONCLUSIONS AND RELEVANCE

Placebo administration was associated with a substantial incidence of grade 3 to 4 placebo AEs in modern cancer adjuvant trials. This finding should be considered by investigators, sponsors, regulatory authorities, and patient support groups.

GLA:D® Back group-based patient education integrated with exercises to support self-management of back pain - development, theories and scientific evidence

BACKGROUND

Clinical guidelines recommend that people with back pain be given information and education about their back pain, advice to remain active and at work, and exercises to improve mobility and physical activity. Guidelines, however, rarely describe how this is best delivered. The aim of this paper is to present the development, theories, and underlying evidence for 'GLA:D Back' - a group education and exercise program that translates guideline recommendations into a clinician-delivered program for the promotion of self-management in people with persistent/recurrent back pain.

METHODS

GLA:D Back, which included a rationale and objectives for the program, theory and evidence for the interventions, and program materials, was developed using an iterative process. The content of patient education and exercise programs tested in randomised trials was extracted and a multidisciplinary team of expert researchers and clinicians prioritised common elements hypothesised to improve back pain beliefs and management skills. The program was tested on eight people with persistent back pain in a university clinic and 152 patients from nine primary care physiotherapy and chiropractic clinics. Following feedback from the clinicians and patients involved, the working version of the program was created.

RESULTS

Educational components included pain mechanisms, pain modulation, active coping strategies, imaging, physical activity, and exercise that emphasised a balance between the sum of demands and the individual's capacity. These were operationalised in PowerPoint presentations with supporting text to aid clinicians in delivering two one-hour patient education lectures. The exercise program included 16 supervised one-hour sessions over 8 weeks, each comprising a warm-up section and eight types of exercises for general flexibility and strengthening of six different muscle groups at four levels of difficulty. The aims of the exercises were to improve overall back fitness and, at the same time, encourage patients to explore variations in movement by incorporating education content into the exercise sessions.

CONCLUSION

From current best evidence about prognostic factors in back pain and effective treatments for back pain, research and clinical experts developed a ready-to-use structured program - GLA:D® Back - to support self-management for people with persistent/recurrent back pain.

Getting personal on overdiagnosis: On defining overdiagnosis from the perspective of the individual person

How can overdiagnosis be defined, explained, and estimated on an individual level? The answers to this question are essential for persons to be able to make informed choices and give valid consents for tests. Traditional conceptions of overdiagnosis tend to depend on counterfactual thinking and prophetic abilities as you would have to know what would happen in the future if you did not test now. To avoid this, overdiagnosis can be defined in terms of the chance of diagnosing a person with a disease when this does not avoid or reduce manifest disease. To be able to relate this to 1's own life and deliberation, I argue that we need answers to specific questions such as the following: If I am tested, and the test and subsequent test results are positive, but I am not treated, what is the chance that I would not experience and suffer from manifest disease? A definition of overdiagnosis that aims at providing answers to this question is as follows: Prospectively overdiagnosis (of an individual person) is given by the estimated chance that a person having a positive test result would not experience and suffer from manifest disease if not treated or followed up in any way. Getting personal on overdiagnosis directs the attention of overdiagnosis estimates towards what matters in medicine: the experience of individual persons.

Preparing for a paradigm shift in aging populations: listen to the oldest old

PURPOSE

Current healthcare systems are not suitable for serving future societies in which the oldest old are commonplace. The objective of this study was to understand what the oldest old care most about in their daily lives.

METHODS

Semi-structured in-depth interviews and thematic analysis were used. Face-to-face interviews were conducted in 17 elderly residents (≥ 95 years) of Arakawa-ku, Tokyo, Japan from July to November 2017.

RESULTS

Three themes emerged from the interview responses: "unshakable beliefs and social ties," "natural acceptance," and "my day-to-day life with precious moments." The oldest old strongly believe in diligence and compassion and maintain strong relationships with people around them. Despite their small social networks, they are concerned about future society. They accept their selves and their lives, including their impending deaths. Despite their functional decline, they control their lives by making very small decisions. They live on a moment-to-moment basis, cherishing simple events.

CONCLUSION

Maintaining autonomy through making small decisions and enjoying small pleasures are important to the oldest old. Understanding the needs of the oldest old is the first step towards developing optimal geriatric care for an aging population.

Systems Medicine Disease: Disease Classification and Scalability Beyond Networks and Boundary Conditions

In order to accommodate the forthcoming wealth of health and disease related information, from genome to body sensors to population and the environment, the approach to disease description and definition demands re-examination. Traditional classification methods remain trapped by history; to provide the descriptive features that are required for a comprehensive description of disease, systems science, which realizes dynamic processes, adaptive response, and asynchronous communication channels, must be applied (Wolkenhauer et al., 2013). When Disease is viewed beyond the thresholds of lines and threshold boundaries, disease definition is not only the result of reductionist, mechanistic categories which reluctantly face re-composition. Disease is process and synergy as the characteristics of Systems Biology and Systems Medicine are included. To capture the wealth of information and contribute meaningfully to medical practice and biology research, Disease classification goes beyond a single spatial biologic level or static time assignment to include the interface of Disease process and organism response (Bechtel, 2017a; Green et al., 2017).

Should UK based Physiotherapists Choose Wisely?

In 2012 the Choose Wisely campaign was launched in the United States in order to address concerns regarding medicalisation, over diagnosis and medical consumerism. The campaign has now spread internationally and includes a number of countries including Canada, Australia, New Zealand and Germany. The primary aim of the campaign is to facilitate healthcare professionals and patients to question the overall utility of medical interventions. Professionals through their professional organisations identify at least five commonly used interventions or tests, within their areas of speciality, which they feel provided no or little benefit to patients. This paper provides the background to the Choose Wisely campaign. The paper reviews the concepts of medicalisation, over diagnosis and medical consumerism, before considering the utility of the campaign in the UK alongside other forms of governance such as NICE. The paper goes on to consider distributive justice as the principal ethical issue related to the campaign. The paper concludes by asking if UK based Physiotherapists should Choose Wisely.

Overdiagnosis: An Important Issue That Demands Rigour and Precision Comment on "Medicalisation and Overdiagnosis: What Society Does to Medicine"

Van Dijk and colleagues present three cases to illustrate and discuss the relationship between medicalisation and overdiagnosis. In this commentary, I consider each of the case studies in turn, and in doing so emphasise two main points. The first is that it is not possible to assess whether overdiagnosis is occurring based solely on incidence rates: it is necessary also to have data about the benefits and harms that are produced by diagnosis. The second is that much is at stake in discussions of overdiagnosis in particular, and that it is critical that work in this area is conceptually rigorous, well-reasoned, and empirically sound. van Dijk and colleagues remind us that overdiagnosis and medicalisation are not just matters for individual patients and their clinicians: they also concern health systems, and society and citizens more broadly.

Mistaking the Map for the Territory: What Society Does With Medicine Comment on "Medicalisation and Overdiagnosis: What Society Does to Medicine"

Van Dijk et al describe how society's influence on medicine drives both medicalisation and overdiagnosis, and allege that a major political and ethical concern regarding our increasingly interpreting the world through a biomedical lens is that it serves to individualise and depoliticize social problems. I argue that for medicalisation to serve this purpose, it would have to exclude the possibility of also considering problems in other (social or political) terms; but to think that medical descriptions of the world seek to or are able to do this is to misunderstand the purpose and function of model construction in science in general, and medicine in particular. So, if medicalisation is nonetheless used for the depoliticization described by many critics, we must ask what society does with medicine to give it this exclusive authority. I propose that the problem arises from a tendency to mistake the map for the territory, and think a tool to understand certain aspects of the world gives us the complete picture. To resist this process, I suggest health workers should be more open about the purpose and limitations of medicalisation, and the value of alternative descriptions of different aspects of human experience.

On the Social Construction of Overdiagnosis Comment on "Medicalisation and Overdiagnosis: What Society Does to Medicine"

In an interesting article Wieteke van Dijk and colleagues argue that societal developments and values influence the practice of medicine, and thus can result in both medicalisation and overdiagnosis. They provide a convincing argument that overdiagnosis emerges in a social context and that it has socially constructed implications. However, they fail to show that overdiagnosis per se is socially constructed and how this construction occurs. Moreover, the authors discuss overdiagnosis on a micro level without acknowledging that overdiagnosis cannot be observed in individuals "in the doctor’s office." We cannot tell whether a diagnosed person is overdiagnosed or not. This is the core of the problem. Despite these shortcomings, Wieteke van Dijk and her colleagues are certainly on to something important, and they should be encouraged to elaborate their perspective. We certainly need to deepen our understanding of the social construction of overdiagnosis.