Is There Risk in Screening for Mental Health Disorders? 

Claudia Gold, MD
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Recent calls for screening for a range of mental health problems point to an important recognition of the need to identify and address emotional suffering. Such screening offers an opportunity to decrease the stigma and shame that often accompany emotional pain.

A powerful new documentary, The Dark Side of the Full Moon, calls attention to the under-recognition and under-treatment of postpartum depression. In one scene, a mother refers to resistance from doctors who lack resources to address positive screens as “absurd.” She is correct, if the alternative to screening is to look the other way in the face of women who are suffering.

But she is highlighting a real dilemma. For the value of screening lies in being able to listen to, and offer healing for, the diverse range of struggles of individuals and families that fall under the umbrella of postpartum depression, or other DSM defined mental illness.

This summer the US Preventive Services Task Force (USPSTF) called for universal screening of depression in teens, and also made a similar call for screening for depression in pregnant and postpartum women. Screening is an essential first step in alleviating emotional suffering. However, universal screening for mental health disorders, in the absence of opportunity to listen to the full complexity of the experience of a child and family, may lead to massive increases in prescribing of psychiatric medication.  Medication may have an important role to play, and may at times be lifesaving. However, as I argue in my forthcoming book, prescribing of medication in the absence of protected space and time for listening may actually interfere in development.

In Massachusetts a new program, MCPAP for Moms, helps obstetricians to find resources for mothers with symptoms of postpartum depression. While the idea is to offer a broad range of services, often the intervention consists of a psychiatrist consulting over the phone to help a primary care clinician feel comfortable prescribing psychiatric medication to a pregnant or lactating mother.

When a teenager screens positive for depression, in a primary care practice, given our culture’s condoning of use of medication alone in this population (a recent CDC study showed that only half of teens prescribed medication have seen a therapist in the past year) medication may similarly be the primary treatment offered.

When a person feels alone and overwhelmed, whether a socially isolated sleep-deprived mom with a fussy baby, or a teen struggling to make sense of a new explosion of feelings that accompany this stage of separation and identify formation, healing starts with being heard and understood. An hour of listening, particularly with someone with whom we have a longstanding trusting relationship, can have great healing power.

Decades of longitudinal research in developmental psychology offer evidence that when people who are important to us listen for the meaning of behavior rather than responding to the behavior itself, we develop the capacity for empathy, flexible thinking, emotional regulation and resilience.

Connectedness regulates our physiology and protects against the harmful effects of stress. Charles Darwin, in a work less well known but equally significant to the Origin of Species, addresses the evolution of the capacity to express emotion. He identifies the highly intricate system of facial muscles, and similarly complex systems of muscle modulating tone and rhythm, or prosody, of voice that exist only in humans. These biologically based capacities indicate that emotional engagement is central to our evolutionary success.

These recommendations for screening can be understood as a well-intentioned effort to bring attention to the troubled state of mental health care in our society.  But as we move forward to address the vast scope of problems that we will uncover, we need to think very carefully. The value of listening cannot be underestimated.

27 COMMENTS

    • In my home town on Charleston, the private hospital is advertising
      depression screenings. They do an excess amount of radio ads
      generally-is this common else where. Also, they were recently denied a
      permit to build a high fence around their property to keep people in.

    • “If the mental health system were in fact a solution rather than a problem, then this idea could have merit. As long as psychiatry retains and employs the power to destroy lives, this will be a bad idea.”

      I agree. “Mental health screening” in out MHS means more and earlier opportunities to subject vulnerable people to neurotoxic treatments; and scapegoat (conduct witchhunts against) people labeled as mentally ill.

  1. “Is there a risk in screening for mental health disorders?”

    Yes, certainly, three words, “mental health disorders”. More specifically, drug company market sales expansion. NIMH gives the yearly mental ill health rate at 18.2 %, but this is nonsense because we are not talking real disease, in other words, be screened for mental health disorder at your own peril.

    A good example is postpartum depression. If you’re screening for it in pregnant women, and the result were anti-depressant prescriptions, another result might be an increase in birth defects and miscarriages. Google prepartum, and there is an article on 5 signs of prepartum depression. This is bunk. Ladies, learn to love yourself and your child before you deliver. Don’t be pressured into delivering an unwanted child. Duh! The “mental ill health” excuse is full of potential disastrous consequences.

    “Mental health” screening is the way drug markets expand through an expanding “mental ill health” treatment system. You want an epidemic of “mental illness”. Test people for it. All you have to do is design tests that catch people up on their insecurities. Either people 1. don’t take the test, 2. take the test and lie, or 3. get caught up in this web of intrigue and quackery. Doctors don’t have any reliable way to detect “mental health”, much less “mental disorder”. The best assurance of “mental stability” is found a firm decision not to be screened for “mental disorder”.

    Do we need drug companies, psychiatrists, and governments in our schools, workplaces, and bedrooms? You tell me. I think it’s a little bit like asking if excess kitchen help, backseat drivers, and armchair experts aren’t readily available. We are experiencing an epidemic in mental disorders currently. We are experiencing an epidemic in mental disorders, not because the mental health system is broken, or because there are crazed killers at large in the world, We are experiencing an epidemic in mental disorders because it pays off for the mental health profession to have such an epidemic. Want to do something about this epidemic? Cure more people of mental health profession as a career choice.

    The inter-dependency of the mental health profession and mental ill health should be obvious. One feeds off the other. Obviously, it is more advantageous to be predator than prey. Also, of course, you need a much larger prey to predator population. Should the prey population wither appreciably. The predator population is going to go kaput with it. What am I saying? When it comes to love and marriage, mental health professional and mental patient don’t always make such a ideal match. This applies to the treatment realm as well.. An important precondition, not always present in cases of psychiatric labeling, for actual healing to take place is real injury.

    There’s a heck of a lot of selling of “mental illness” going on these days. When it’s not done through mental health screening, it’s done through campaigning against “stigma”. My impression is that any article playing up mental health screening is doing just that. You would imagine that at some point there might be a shame reaction from some of the people who engage in this sort of thing. You would think at some point somebody might have a few moral scruples. I’m still waiting for those scruples to amount to anything. I would think that about anything else one could imagine has got to be a better enterprise to engage in.

  2. I have fought adamantly against screening for depressed moods for many years. (see “McGill University is wasting Bell $500,000 donation, http://www.drnormanhoffman.com) There are many important aspects as to why screening is inappropriate.

    1) Screening tools are poorly validated, and are only validated for a diagnosis of Major Depression. Many depressed moods do not fall into simplistic diagnostic schemas, and so people are likely to be misdiagnosed as having a “mental illness” rather than emotional problems.
    2) Treatment resources usually are inadequate. There is no point trying to assess more people when there are not good resources. Money is better spent trying to create resources.
    3) Given points 1 & 2, the most common outcome of depression screening is people being placed on medication without proper therapy. This is clearly bad treatment.
    4) While this may not apply as much to a postpartum population, it is unlikely that people with the most severe forms of depression will participate in a screening, making it even more likely that false diagnoses will be made.
    5) Many screening tools have been developed with funding from the pharmaceutical industry, with items that promote the idea of a biological cause fro depressed moods.

    The issue of postpartum depression is important, but all practitioners need to be more sensitive to the many issues, both emotional and hormonal that may affect people in the postpartum period. Screening can tend to decrease the responsibility that a professional may feel to actually talk to the new parent, leading to many important emotional issues being missed.
    Like many initiatives we see these days in mental health, the emphasis is often on campaigns that make the bureaucrats and marketers feel good, but that actually do nothing to help people.

    • Your comment is valid; screening is risky given all of the points made. It takes the place of people who are close to the individual taking the time to talk to them and find resources but people like to pass on responsibilities and to take the wait and see what happens attitude. And of course if the person screens “positive” that adds to the stigma and shifts them into a diagnosis. I firmly believe that family and friends can do the observing, identifying and guiding but then again many people with severe emotional distress have lost their support systems or their support systems are woefully dysfunctional also. Screening is a diversion and delay tactic at least at this point in time; it will look politically grand and pay salaries for computer geeks to format the docs and then others to do the screening. I bet this idea will take hold, it is politically and economically a boon for many

  3. On a related note, before a routine visit to my primary care physician, I was asked online to fill out a functional assessment questionnaire. I was outraged as it seemed very intrusive and a wrong answer could lead to a prescription for an SSRI.

    To make a long story short, I finally tracked down the person who was responsible for this and she of course blew off my concerns and said it helped physicians provide better care. Yeah right.

    Anyway, I told her that I didn’t ever want to see this questionaire online again . I am sure she thought I was a wacko patient but I didn’t care.

  4. The problem with this article is that DSM “disorders” are not valid or reliable objective categories. Therefore, creating an accurate and reliable screening program for them is impossible.

    Such screening does not “offer an opportunity to decrease stigma”. Rather, as research from John Read, Sami Timimi, and programs like Defeat Depression / Beyond Blue have demonstrated, promoting acceptance of false illness labels is likely to perversely increase stigma and distancing between “normal” from “ill” people.

    How can you screen reliably for something that cannot reliably be separated from normal experience? To take one example, for psychotic conditions, there is no sudden point at which feelings of terror, or delusions, can suddenly be validly labeled “schizophrenia” or “not schizophrenia.” These experiences exist along a continuum and are matters of degree.

    It’s not surprise this article was written by a psychiatrist. It seems like Claudia Gold has trouble seeing what the ulterior motives are behind this type of program: to increase medicalization of everyday life problems, expand psychiatrists’ clientele, and increase market share for Big Pharma companies.

  5. Dear Drs. Gold and Hoffman,

    Every once in a while, I see comments at MIA that I find totally baffling. This is one of those times.

    1. As I understand it, Robert Whitaker has shown the depressed people who take antidepressants do worse in the long run compared to unmedicated patients.

    If this is so, why would you ever prescribe antidepressants as a treatment for your patients unless you are in some kind of urgent acute situation? Your answers, Drs. Gold and Hoffman, both imply that you think that patients should normally be prescribed antidepressants, but only with some kind of additional talk therapy.

    2. As I understand it from (for instance recent MIA articles), antidepressants barely (if at all) beat placebo for depression. That means that every single one of the following therapies:

    o Any talk therapy
    o EMDR
    o Brain training
    o Exercise
    o Dietary improvement
    o Tai Chi
    o Yoga
    o Praying to the god Vishnu
    o Eating tic-tacs in the hope of getting a placebo effect

    are better than antidepressants for depression in every way. They are all at least as effective as antidepressants, apparently, and they are far superior in the sense that they are all safe for the patient. If this is so, why would you ever be using antidepressants as an initial treatment?

    Baffled in Boston, – Saul

    • ^ What he said.

      I think they need to cut back on the molasses. It’s clear: they have molasses poisoning. Too much molasses impairs cognition.

      In other words, they’re slow as molasses. They need to lean back from the screen, straighten their back, take a few deep cleansing breaths, rub their eyes, wake up, realize and recognize, and finally, have that profound, life changing moment of authentic understanding.

      • That’s true, from a hierarchical perspective. But the naive good-doers, the front line men and women who “truly want to help” people, do not yet understand the truth, the reality and the severity of the crisis the whole ordeal is.

    • Hi Saul,

      I was not implying at all that people should be treated with medication. I was just saying that screening will lead to people being prescribed medication.
      For many years an organization in Montreal tried to bring depression screening into universities. I managed to block that despite some end run attempts. Fortunately, after some years of this organization running depression screenings for the general public this program was stopped due to clear failure of actually getting people proper help.
      It is true that many doctors are now using screening questionnaires. I have never seen this cause anything but problems.

      • Hi Norman,

        I am reading your answer

        “3) Given points 1 & 2, the most common outcome of depression screening is people being placed on medication without proper therapy. This is clearly bad treatment.”

        as implying that you think that medication WITH proper therapy could be proper treatment. Isn’t that what you mean?

        Do you actually prescribe antidepressants for your own patients? If so, why? It’s an honest question on my part. I am not an expert and might be misunderstanding something.

        Your answer 3) also suggests something that I see again and again. It is not often spelled out, but there is a strong and constant implication that some combination of medication and therapy is the best treatment for depression. I don’t understand this either. Why isn’t it “some form of exercise and therapy is the best treatment for depression” or any number of other things? I don’t see how either medication or therapy have distinguished themselves as treatment for depression above all other possibilities. There is even an onion about this:

        http://www.theonion.com/article/new-study-finds-therapy-antidepressants-equally-ef-38026

        – Saul

        • Hi Saul,

          Thanks for your questions. It is good to clarify these points.
          Firstly, the commonly made statement that a combination of therapy and medication is best treatment is based on the type of simplistic and biased research that is should always have been questioned and is now coming under scrutiny. I do not believe that a combination of therapy and medication is best treatment for most people.
          I believe that DSM diagnoses are bunk for the most part, and that psychiatric medications are psychoactive drugs but do not treat the causes of distress. Psychiatric drugs are highly overused, and the whole field of psychiatry has become corrupt and unethical.
          I do prescribe medications at times, but cautiously and with full disclosure. Sometimes people are in severe distress, and it is helpful for them in the short term to have some chemical help with their distress. I prefer not to prescribe medication, and almost always start off recommending natural healthy alternatives such as omega-3 fatty acids. Some people are adamant about wanting medication, though I always spend time trying to inform them about then limits and dangers of medication.
          I strongly believe that screenings are dangerous. As I said, the most common outcome of a screening is for someone to be placed on medication without recommendations for psychotherapy. I do not feel that being placed on medication with a recommendation for therapy is proper response to a screening. Psychotherapy is always preferable to medication, and the medications inappropriately called antidepressants should rarely if ever be prescribed without psychotherapy. The psychiatric medications we have are all bad medications with little true efficacy and lots of side effects and negative long term effects. I could go into another time what I do prescribe at times and why, but that is a complex issue.

  6. In response to Claudia’s concluding message,

    “The value of listening cannot be underestimated.”

    There are next steps, after listening: understanding and response. What I find sorely lacking is both understanding (which must be mutual understanding) and response. The right response is the testament that mutual understanding has occurred. Without the right response, there really is no understanding.

  7. “In Massachusetts a new program, MCPAP for Moms, helps obstetricians to find resources for mothers with symptoms of postpartum depression. While the idea is to offer a broad range of services, often the intervention consists of a psychiatrist consulting over the phone to help a primary care clinician feel comfortable prescribing psychiatric medication to a pregnant or lactating mother. ”

    Be afraid—Be very afraid !! Comes to mind. then I think of the lamenting of psychiatrists and their scapegoats the PCPs–Who are *these doctors* prescribing 80% of OUR drugs??

    TMAP CMAP– you get confused. Who is actually responsible for so broadly disseminating a wasteland of dangerous, misinformation to every corner of this country? And who continues to dress this sham up and make it look like a pubic health service??

    Oh what a tangled web…

  8. Is there a risk? We don’t even need to ask that after psychiatry and mental health inc. have had their way in school systems for how many years now? We’re seeing the wonderful outcome of medication of kids long term and our nursing homes. I pulled my son from the public school system that wouldn’t allow him to move beyond an inaccurate diagnosis and saw him as an illness not a student. His education suffered and in the end he will be disadvantaged.
    It’s a dragnet and it’s expanding. It goes unchecked and without regulation and it’s just disturbing.