Denmark is now screening pregnant women for depression.
Here, Peter Gøtzsche imagines one of the conversations
that might take place.
(First published in Danish, in Månedsskrift for Almen Praksis, April 2014)
“How’s the pregnancy going?”
“Fine, I don’t have any problems.”
“And you’re not worried about whether you can manage to look after the baby?”
“No, not at all. I am a housewife and have time to take care of it.”
“Are you aware that it’s possible to have depression without knowing it?”
“No, I didn’t know that, but I’m fine.”
“Yes, but … uhmmm … well … you see … if you are suffering from a depression, it would be good to find out.”
“But I’m perfectly fine.”
“I still think you should undergo this test for depression.”
“So what if it’s positive?”
“Then you may get a drug that will help you.”
“Well … I … There is nothing wrong with me, so why should I undergo this test?”
“The National Board of Health recommends it1.”
“Can’t you just unsubscribe from the Board of Health? Sorry, that was a joke!”
“No, we are obliged to follow the Board’s recommendations.”
“But a test like that is a screening test, is there a Cochrane review about it?”
“Yes, and it recommends that one shouldn’t screen healthy people for depression2.”
“Then why on earth does the Board of Health recommend screening pregnant women like me who are healthy?”
“I cannot understand this either, but the Board of Health has consulted experts in psychiatry who think it’s a good idea.”
“And how many of those who are healthy will get a wrong depression diagnosis with this screening test?”
“About one third3.”
“Holy smoke! How does the drug work?”
“It works like amphetamine. It’s also difficult for the patients to quit, just like for amphetamine and other narcotic drugs; half of the patients have difficulty stopping4,5.”
“And what do these experts say about the side effects of the drug? What is the most common side effect?”
“Sexual problems. They occur in half of the patients6. It can be lack of sex drive, impotence and lack of orgasm, even for the man if he receives the drug.”
“And how about suicide? Depressed people are at high risk of committing suicide, and I assume that this medication will prevent that from happening?”
“No, on the contrary, for someone as young as you, the drug increases the risk of suicide4,7. It can also cause birth defects8,9. The risk is small but it is clearly increased.”
“My goodness! Many thanks for all this information, doc. Count me out. You don’t need to give me that test. I don’t want to risk getting a wrong diagnosis of depression and get treated. My husband and I love sex. And I have no wish to get a narcotic on prescription, or to commit suicide, or to give birth to a deformed child.”
In my opinion, this contrived dialogue, with its fortunate outcome, requires three things: The doctor needs to be exceptionally well informed about the facts; the woman needs to ask relevant questions; and the doctor needs to reply adequately to them. The clinical reality is not like this very often. On the other hand, many doctors will not settle for a questionnaire but will ask clarifying questions and possibly use an additional instrument, which is recommended by the National Board of Health, e.g. the Major Depression Inventory (MDI), a self-assessment questionnaire that uses the diagnostic criteria directly from the ICD-101. Obviously, the use of such additional instruments will reduce the proportion of false positives, but they are also very uncertain. Screening healthy people will therefore inevitably lead to many false positive diagnoses, and many healthy people will be treated with antidepressants that harm them.
The risk of birth defects has been evaluated in several studies, and a large Danish cohort study of 500,000 children showed that the risk of heart septum defect is doubled9. This is not a trivial harm, as 1 % of those treated will get a septum defect. Cardiac birth defects are exactly what we would expect to see because serotonin plays a major role for the functioning of this organ. We have seen deadly valvular defects in adults who ate diet pills that increase serotonin levels, and these drugs have been withdrawn from the market4.
As far as I can see, screening pregnant women for depression is a very bad idea also because the beneficial effect of antidepressants is very modest. Under optimal conditions, where the woman have severe depression (which you do not need a questionnaire to find out), antidepressants benefit only every 10th patient10. This effect has even been considerably overestimated for a variety of reasons, where one of the most important ones is that we cannot blind studies effectively that compare an antidepressant with placebo because of the drug’s side effects4. As the assessment of the effect is pretty subjective, this fact causes so much bias in the effect evaluation4 that several psychiatrists quite legitimately have raised the question whether the newer antidepressants have any therapeutic effect4,11.
In any case, very few patients with depression benefit from the treatment. Many patients feel that the treatment helps them, which is often interpreted either as an effect of the pills, a placebo effect, or both. However, this is not what is important. What the patients feel is mainly the spontaneous remission of the depression4, and spontaneous recovery needs no medication.
* * * * *
Conflicts of interest: none.
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