Correspondence 14 www.thelancet.com/psychiatry Vol 6 January 2019 4 Zimmerman M, Ruggero CJ, Chelminski I, Young D. Is bipolar disorder overdiagnosed? J Clin Psychiatry 2008; 69: 935–40. 5 Adams J, Bledsoe GH, Armstrong JH. Are pain management questions in patient satisfaction surveys driving the opioid epidemic? Am J Public Health 2016; 106: 985–86. an enormous problem and that some people have unrealistic ideas about the contagiousness of mental illness. 4 However, we describe published research findings that offer scientific evidence for when mental illness is actually communicable. Our goal was to propose a public health approach to contain it by describing actions to decrease communicability where it occurs. The dangers of increasing awareness of mental illnesses are outweighed by the benefits. Raising awareness requires rigor and scientific methods 5 to reduce inaccurate diagnoses and to clarify the unrealistic aspects of communicability, but such concerns should not prevent proven efforts to improve the lives of people with mental illness by increasing awareness and access to evidence-based care. We declare no competing interests. *Milton Wainberg, Francine Cournos mlw35@cumc.columbia.edu New York State Psychiatric Institute and Columbia University College of Physicians and Surgeons, New York, NY 10032, UK (MW); and Mailman School of Public Health, Columbia University, New York, NY, USA 1 Wainberg ML, Helpman L, Duarte CS, et al. Curtailig the communicability of psychiatric disorders. Lancet Psychiatry 2018; 5: 940–44 2 Johnson M, Eriator I, Rodenmeyer K. Backstories on the US opioid epidemic good intentions gone bad, an industry gone rogue and watch dogs gone to sleep. Am J Med 2018; 131: 595–601. 3 Califf RM, Woodcock J, Ostroff S. A proactive response to prescription opioid abuse. N Engl J Med 2016; 374: 1480–85. 4 Thornicroft G, Mehta N, Clement S, et al. Evidence for effective interventions to reduce mental-health-related stigma and discrimination. Lancet 2016; 387: 1123–32. 5 Wei Y, McGrath PJ, Hayden J, Kutcher S. Mental health literacy measures evaluating knowledge, attitudes and help-seeking: a scoping review. BMC Psychiatry 2015; 15: 291–311. The prevalence of psychiatric iatrogenesis and how much it contributes to the overall burden of disease remain unclear. Still, if it is even somewhat common, choosing policies to reduce transmission becomes more complex. Expanded psychoeducation might help some, but also might increase the risk that others who are healthy come to think they have an illness. Screening for psychiatric illnesses can identify cases that would otherwise be missed but it also results in a high rate of false positives. 4 When diagnosis is based on self-report, self-report reflects how a person thinks of their problems, and that thinking can be influenced by public ideas about mental illness or even the very screening measure that first suggested a diagnosis, the problem of false positives is non- trivial. The contribution of increased emphasis on routine screening for pain to the opioid crisis in the USA provides a cautionary tale. 5 So, while we support an increase in education about mental illness, better efforts to recognise it, and improvement in access to services, we would also urge caution: communicable diseases, if treated incorrectly, can become epidemics. We declare no competing interests. *Brent M Kious, Benjamin R Lewis brent.kious@hsc.utah.edu University Neuropsychiatric Institute, University of Utah, Salt Lake City, Utah 84108, USA (BMK, BRL) 1 Wainberg ML, Helpman L, Duarte CS, et al. Curtailing the communicability of psychiatric disorders. Lancet Psychiatry 2018; 5: 940–44. 2 Hacking I. The social construction of what? Cambridge, MA: Harvard University Press, 1999. 3 Quinn CA. Detection of malingering in assessment of adult ADHD. Arch Clin Neuropsychol 2003; 18: 379–95. Authors’ reply We thank the authors for their interest in our Personal View. Both letters describe examples that belong in the communicability pathways we describe 1 and raise concerns about potential implications that we also address in our plan of action. Specifically, Edward Christopher and Hui Wei Leow felt the infectious and ecological pathway was brief compared with the familial or sociocultural communicability pathways. Of the pathways to explain, the infectious was the easiest and most commonly described in the literature, so we kept it brief. The other two mechanisms have more complexity and require more elaboration. We agree that our examples were not all-inclusive; we omitted many of them from our first draft to reduce the length for publication purposes. Benjamin Lewis and Brent Kious propose iatrogenic communicability, which fits in our sociocultural communicability pathway. We disagree with the assertion that screening for pain led to opioid misuse, but we see the cause as the pharmaceutical industry pressing for the unwarranted prescribing of opioids. 2 Clinicians should know whether patients have pain and manage their pain safely and effectively. 3 The same applies to mental illness. We agree with Christopher and Leow that the stigma of mental illness is