Reviewed by SciCurious, guest reviewer
"In the mid-1990s I found myself on a committee charged with reviewing medical expenditures under my university's health plan. Like the rest of the country, the members of the plan had fallen in love with anti-depressants, which accounted for our largest single drug expense-several hundred thousand dollars annually, as I recall. When someone around the table commented that this was a lot of money to be laying out for mood-altering pills, a defender countered, "If they prevent one suicide, they're worth it!" Argument ceased. No one in the room, including myself, was aware that anti-depressants actually increase the risk of suicide, particularly in patients up to twenty-four years of age."
This opening scene from Stewart Justman's Artificial Epidemics sets the stage for a tangled, convoluted tale of two distinct diagnoses--prostate cancer and Major Depressive Disorder--and how intensive screening for these diseases has rendered us all overdiagnosed. Justman, a professor of Liberal Studies at the University of Montana, has made a long study of cancer, publishing several books including Do No Harm: How a Magic Bullet for Prostate Cancer Became a Medical Quandary and Seeds of Mortality: The Public and Private Worlds of Cancer. Artificial Epidemics, a slim, 22-page eBook appears to be an attempt to bring together his previous writing on cancer with another highly-diagnosed and talked about disease: Major Depressive Disorder.
"The campaign against depression and the campaign against prostate cancer both used inflamed arguments and appealed to fixed ideas," Justman writes. He lays the bulk of the blame for the resulting "artificial epidemic" on medical activists, who have taking screening for these diseases to large segments of the population. Justman also argues the screenings for prostate cancer and depression suffer from an “absence of appropriately discerning methods,” and thus help in the push toward the overdiagnosis of the American population.
His solution? Stop the screening, stop the treatment. We are not sick, we are overdiagnosed.
Justman’s concerns regarding prostate cancer are not particularly new. Prostate-specific antigen (PSA) testing has been controversial since the beginning. As Justman notes, “the same vial of blood divided in two may give different PSA readings.” Medical experts have also voiced criticism about the cut-off points for diagnosis for prostate cancer. Since the treatment for prostate cancer can be invasive, the U.S. Preventative Services Task Force has proposed that when men score an initial PSA that only barely reaches the threshold for cancer, they should not immediately start treatment. Instead, they should undergo so-called "watchful waiting."
Justman sees the same problems with oversensitive analyses and overdiagnosis in Major Depressive Disorder. But his argument also goes beyond against current screening practices. He's against the diagnosis of depression itself.
"The possibility that much 'depression' might not be a disorder at all has been drowned out by medical activism,” Justman writes. He scoffs at the World Health Organization's prediction that depression is soon to become the second leading cause of disability across the globe as “hubristic.” He argues that it's far too easy to diagnose, given that the symtoms include things like feeling tired, overeating, or not finding pleasure in things. "According to this checklist, I would qualify for a diagnosis of Major Depressive Disorder if I simply had too little energy and had trouble staying asleep--as in fact I do...In point of fact, my symptoms are not diagnostic of anything."
What is Justman’s response to these two ‘artificial epidemics’ of prostate cancer and depression? Sit down, relax. "Much of what is called cancer is not destined to cause death-and so too, much of what is considered depression resolves itself without medical intervention." He wants the screenings to stop, and overdiagnosis to end. Justman proposes an appeal to prudence. "Prudence deems life without sadness a utopian fantasy, silent cancer a tolerable reality, and the medicalization of the human condition an aggressive expansion of professional authority."
Unfortunately, while Justman’s statements about prostate cancer diagnoses are well researched, his mockery of Major Depressive Disorder is both insulting and ill-conceived. What's more, his arguments for both prostate cancer and depression are made in complete incoherence. The narrative jumps from prostate cancer to depression in the same paragraph. Here he even makes the leap within the same sentence: "Setting a two-month period for allowable grief is like setting the threshold for an abnormal PSA at a figure that trades off a reduction of false negatives with an inflow of false positives."
Justman composes long, run-on sentences in an effort to show how prostate cancer and Major Depressive Disorder diagnoses are similar: "Both PSA testing, which appeals to evidence presumed to exist, and testing for depression, which appeals to diagnostic criteria conceded by the psychiatrist in charge of the composition of the third edition of the DSM to be seriously defective, reveal conflicted attitudes toward evidence-based medicine itself." The net result is an exhaustive and repetitive reading experience. In the end, I’m just confused and beginning to think my prostate has been experiencing depressed mood.
In this tangle of prostate cancer and depression, the focus of the title is lost. I have yet to read how, exactly, medical activism has influenced clinicians and insurance companies to collude with them in the overdiagnosis of the nation. Instead, the book impresses the idea of overdiagnosis, without offering any clear solution except to stop diagnosing.
Here Justman confuses the ideas of diagnosis and treatment. While it makes sense to delay invasive treatments and track the progress of an already diagnosed disease, stopping screening and diagnosis would merely ignore the problems. Prostate cancer is still the second leading cause of death in men. Additionally, Justman’s flippant attitude toward Major Depressive Disorder ignores the real suffering of patients, and adds to the stigma these patients experience. But Justman clearly believes depression is not a real problem and most prostate cancers as fine.Just put on a smile, stop wallowing in your emotions. That prostate enlargement probably doesn’t mean anything.
After spending so much time reading Justman’s incoherent arguments, dismissive delivery, and his final, confusing appeal to “prudence”, my only recommendation is that if you are concerned about issues with prostate cancer or Major Depressive Disorder diagnosis and treatment, go read something else. The writing is bound to be less confusing. After suffering through 22 long pages of this ebook to write this review, I’m afraid my prostate needs an antidepressant.
Scicurious is a PhD in Physiology, and is currently a postdoc in biomedical research. She loves the brain, and so should you. She writes for The Scicurious Brain at Scientific American Blogs and Neurotic Physiology on the Scientopia Network. Follow on Twitter @Scicurious.