Are we living in an age of overmedicalisation? Irish-born doctor Dr Suzanne O’Sullivan, a consultant in neurology based in London, has written The Age of Diagnosis, which challenges the increase in diagnosis in conditions such as autism, ADHD and long Covid.
You say we are not getting sicker; we are attributing more to sickness. Can you elaborate on what you mean by that?
I see a lot of young people – people in their 20s or 30s who have long lists of medical labels. I feel that labels are being given to things that were not considered to be medical problems.
I don’t think the fact that we have so many young people with depression, autism and a variety of health conditions is anything to do with lifestyle. It is to do with the relaxation of how we diagnose people in order to diagnose milder cases.
You write about difficulties you have with cancer screening. You state that some screening programmes are potentially of limited value.
It is of value to somebody. There is no doubt that screening will save lives, but what people do not understand is that there is always a trade-off and the trade-off is that, if you screen enough people, you will save lives, but a much higher number of people will undergo treatment that they do not really need to save those lives. Prostate cancer screening using PSA is not standard any longer ...
You say that a psychosomatic explanation for people with long Covid has not featured nearly enough in public discourse. What do you mean by that?
I volunteered in intensive care during the pandemic. Anyone who ended up in intensive care and ended up on those machines, they would have lasting symptoms. You don’t get away scot-free from that. Obviously, there will be people who have a post-viral syndrome. The pandemic created the perfect storm for a psychosomatic epidemic. What do you need to develop psychosomatic symptoms?
Firstly, you need to be asked to pay worried, anxious attention to your bodies. Anybody working in medicine would expect that people would get psychosomatic symptoms during the pandemic.
Does long Covid exist in some people?
The term long Covid is not useful. Do hospitalised patients have persistent symptoms? One hundred per cent. That could be called long Covid because they have had organ damage, the consequences of being in intensive care causes physical change.
There will also be people with post-viral syndrome that causes chronic fatigue for six months or a year. That is well recognised after many viruses.
There will unequivocally be people with persistent post-viral fatigue and they will have long Covid.
...[Separately] people still think psychosomatic [means] that there is nothing wrong with you, you are imagining it, and that is why the conversation has been really stifled. It would be a different conversation if people understood that psychosomatic symptoms are as disabling as any other symptoms.
I assumed that if somebody had a psychosomatic illness, that there was nothing physically wrong with them, that it was all in their head?
No, there is something very physically wrong with them. The physical symptoms you get with psychosomatic disorders are real physical symptoms for starters. Just because they are psychosomatic does not mean they are less severe. That’s where the difficulties arise.
You believe autism is overdiagnosed. Can you explain what you mean?
A child with severe autism is very disabled by it. Therefore, the medical diagnosis is required to get them treatment pathways. The fact that they are labelled autistic is not terribly harmful because that person is so disadvantaged by their disabilities that the label doesn’t matter that much in a negative way.
Take the other end of the spectrum: let’s say that a child, who is now a teenager who has been managing okay, and perhaps there are certain pressures at school and their difficulties start showing. They are at the very mild end of the spectrum.
Is this definitely a neurodevelopmental problem or not? When you get to that point, the interventions are less useful because they have less to gain from the treatment. That’s where you can really meet the harm of being labelled.
Is that not a function of the treatment rather than the diagnosis? In other words, you could say to a 14-year-old child that: “We think you are autistic, but there is nothing that you can’t do.”
I would say the opposite. The minute you label somebody, they can unconsciously take on the features of that label. It doesn’t matter how you present it to them. They will learn in the world what being autistic means.
In Ireland the number of children being diagnosed with autism has tripled in the last decade. Why is that?
When I went to school, there was no special education. There was a major thing we needed to correct. I was in a class with 120 pupils. None of them were described as having any special needs. Clearly, there was a chronic underdiagnosis problem and a chronic neglect of children who could have benefited from extra support in school.
In order to correct that, the concept of what autism is has been gradually adjusted. When it was first conceptualised, it was described as severe autistic aloneness and really only affected people with learning disabilities who could not function in the world at all.
I deal with very severe autism, and it is very hard to compare that to some of the much milder cases of autism. We have got Elon Musk and Anthony Hopkins and Bill Gates being diagnosed as autistic by their own admission.
There is no biological marker for it, but the definition of overdiagnosis is that the diagnosis is not benefiting people.
In 2021, Elon Musk said he has Asperger’s syndrome (a form of Autism Spectrum Disorder). Do you accept that?
Knowing nothing more than what I see about Elon Musk in the news, for me, a diagnosis of autism acquires a certain set of symptoms. The other vital component for diagnosis is impairment or disability. I don’t know what Elon Musk’s impairment is, I’d have to ask. Maybe he has a set of autistic traits in his personality, but they are not impairing him from doing things that a reasonable adult should do. That feels like overdiagnosis to me.
Is his behaviour impairing others given his actions recently?
I think that is not his autistic diagnosis. You are describing his personality. The bottom line is that I don’t think it is very helpful to apply diagnostic terms to people in the public arena who are behaving badly. We need to separate the people who are very unpleasant people with those who have a medical disorder.
Do you believe that ADHD is real?
I’m far from convinced that ADHD is a single disease. There is a set of traits in some children that I don’t believe have a single cause. When these traits, hyperactivity and inattention come together in a significant amount, these kids will suffer because they won’t be able to stay in education and we know how important it is for kids to stay in education.
Do I believe those adults who are now labelled as ADHD have the same thing as those children? Well, I don’t really believe that. ADHD was a useful diagnostic concept for people who could not function at all in the world and now it has been massaged, changed and stretched to apply to a completely different set of people.
You write in the book that there is no biological explanation for ADHD. Psychiatrists believe it is caused by a deficit of the neurotransmitters dopamine and noradrenaline in the brain. Do you believe that?
For every study that tells you that dopamine is associated with ADHD, another study will show there is no association. If you take a person with very severe ADHD and you do a brain scan for abnormalities, you will not find any abnormalities.
Psychiatrists will tell you that ADHD is real because the medications used to treat it, such as Ritalin and Adderall, work.
Do they work? First of all we have to get away from the words real and not real. It may be that people have a particular set of difficulties. What we are really talking about is that whether it is a single disease that can be explained by a brain problem. The struggle is real one way or the other, but is it a brain developmental problem or is it a response to the normal stresses of life, etc? The bottom line is that, if you give a stimulant drug to [someone] anyway and it works, it doesn’t mean they have a brain disease. That’s like giving testosterone to an athlete and he performs better so therefore he must have had a testosterone deficiency. You can medicate people to change their behaviour, but that does not mean there is a disease underlying it.
Do stimulants work for adults who have poor attention? The jury is way out on that. There is a Cochrane review that has shown no benefit to adults and there is really no good evidence in telling an adult they have ADHD other than anecdotal reports that people feel validated by the diagnosis. Where is the actual evidence that they are benefiting from a diagnosis?
Even if it is only psychological, isn’t there a benefit to an adult ADHD diagnosis?
You are right. I wouldn’t want to take a diagnosis away from a person if they felt it was genuinely benefiting their lives. I do question whether that will have lasting value going forward. I hope it has lasting value, but that stands to be proven. I would also ask as to why you have to give a person a medical diagnosis so they can be kinder to themselves, especially while that diagnosis means affecting the larger population with that disorder. Children who need this support are now in a queue with 50-year-old adults for a drug that is in short supply and for clinics that are hard to access.
Why do you think depression is not caused by low levels of serotonin in the brain?
Depression was presented over and over again as being related to low serotonin levels in the brain. Actually, recent studies in Nature magazine and other publications have suggested that there is little or no association between serotonin and depression.
But the antidepressant medications, SSRIs [selective serotonin reuptake inhibitors], work, do they not?
...If people feel better on antidepressants, that’s all that matters.
There are millions of people who say the drugs have worked for them.
Yes, but that’s down to the placebo effect in a large proportion of people. That’s the effect of received wisdom. There is a lot of received wisdom in medicine. There is an assumption that something is correct. What I am saying about serotonin is a widely held view within psychiatry. These drugs are not working the way we think they have been working.
The Age of Diagnosis: Sickness, Health and Why Medicine Has Gone Too Far by Dr Suzanne O’Sullivan is published by Hodder Press
