Overdiagnosis and overtreatment: Beware of guidelines with expanded disease definition
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Along with other aspirations, shared decision malting (SDM) has the laudable aim of bringing more scrutiny of evidence into our health care choices. More valuable still, the approach reminds us to examine risks and benefits of all treatments options, including where appropriate, doing nothing, or watching and waiting (Hoffmann et al., 2014). In the era of too much medicine (Glasziou et al., 2013), such an approach is prudent. But as evidence about the problem of overdiagnosis grows, we may need to bring more attention to the risks and benefits of a diagnostic label, even before any scrutiny of the pros and cons of possible treatments. Changes to disease definitions, often arising from clinical guidelines from heavily conflicted expert panels, are lowering diagnostic thresholds and expanding the pool of those labelled as sick, medicalizing more and more people with milder symptoms or at lower risk (Moynihan et al., 2013). Such changes may benefit some, but for others among the newly diagnosed, the deleterious impacts of a label and subsequent treatment may do more harm than good. Former head of the DSM IV task force Allen Frances argues conflicts of interest, both financial and intellectual, mean all guidelines which define disease thresholds are suspect, and former president of the UK Royal College of General Practitioners Iona Heath suggests provocatively that if guidelines drive overdiagnosis or overtreatment, it's our responsibility 'not to follow the rules: (Heath, 2014) As explored in this chapter, genuine controversy exists within the scientific literature over many recently widened disease definitions, including, for example, gestational diabetes, chronic lddney disease, and attention deficit hyperactivity disorder (ADHD).
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