The latest US Preventive Services Task Force (USPSTF) Guidelines on Depression Screening recommend that all adults, including pregnant and postpartum women be screened for depression in primary care. As a psychiatrist, I know all too well that serious mental distress causes immense suffering, disability, lost productivity, and worsens the outcomes of co-existing medical problems. Sometimes, it can end with suicide. But screening all for depression is a mistake for two main reasons. Firstly, this approach treats depression as a “thing” that simply exists in a vacuum, rather than appreciating that feelings of depression occur within a context and ignoring this will lead to over-diagnosis and over-treatment. Secondly, we simply do not have adequate service provision to provide good quality care to individuals who screen positive for depression. These guidelines do recommend that screening occur where there are “adequate systems in place” for further evaluation and treatment exist. But the reality is that a significant proportion of the country does not have access to such systems when 55% of all US counties do not have a single mental health provider, and 77% have a severe shortage of mental health workers.
Depression Does Not Exist in a Vacuum
As serious and debilitating as depressive illness can be, many of the symptoms screened for are fairly nebulous and include lack of energy, changes in sleep and appetite, low mood, difficulty enjoying activities – symptoms that are quite common in the general population and do not necessarily indicate a mental disorder requiring treatment. Furthermore, many of these symptoms may simply represent the effects of a chronic medical problem rather than depression. Our moods are influenced by a myriad of factors including our level of physical activity, what we eat, how financially secure we are, the quality of our relationships with others, alcohol, and drugs (both prescribed and recreational). Finally, we experience sadness and guilt within a particular context.
Life events characterized by loss, failure, and humiliation are particularly liable to lead to feelings of depression. This might require treatment or it might be a normal reaction to life’s vicissitudes. An aggressive approach to screening and treating depression leads to over-treatment of depression and pathologization of normal human experiences. When someone we care about dies, we should experience sadness. When faced with failure, we may experience worthlessness. When we are humiliated we might expect to experience shame. Sometimes a professional helping relationship can do immense good. But treating normal experiences as pathological undermines our own resiliency and sense of agency, and convinces us we are sick when we are not.
Too many people have come to view themselves as defective, and powerless to change their life situations, when this may not be the case. Conversely, individual treatment with drugs or psychotherapy may cause individuals to reframe their problems in terms of neurochemistry or thinking styles – internalizing a belief that they are the problem — when their problems exist in a wider sociopolitical milieu.
Treatment is not Without Harm
Teasing out all these complexities is part of a comprehensive mental health assessment. But most people do not get this. We know that over 60% of individuals diagnosed with depression in primary care do not even meet criteria for major depressive disorder. This rises to a staggering 80% in those over 65. Treatment is typically with antidepressant drugs. The USPSTF regards the risks of these drugs as small to moderate. Risks include sexual dysfunction, switching into a hypomanic or manic episode, increased suicidal thinking in young people, and an increased risk of gastrointestinal and brain bleeds. Many of these risks for an individual are small, but when you are treating a much larger population – many of whom neither need nor stand to benefit from such an intervention, this is not insignificant.
For milder depressive states the evidence for treatment with antidepressants does not exist. Because of the lack of availability or lack of access to psychotherapy, which is the treatment of choice for mild to moderate depression, many patients end up taking antidepressants when this is not indicated.
We Do Not Have Adequate Systems
There are some excellent examples of team-based approaches to mental illness in primary care settings. Collaborative care, where patients in primary care with mental health problems meet with a care manager who monitors their problems and provides brief psychotherapeutic treatment with consultation from a psychiatrist available is one such example. It has been shown to be effective at treating depression and anxiety in primary care, and improve healthcare outcomes. But collaborative care exists because there are so few psychiatrists and other highly trained mental health practitioners. Quite apart from the majority of counties having no mental health providers, even in metropolitan areas where they are plenty, these mental health providers do not take insurance, effectively meaning that those most in need are shut out.
The World Health Organization’s Wilson and Junger Criteria for screening set the standards of where screening for conditions is ethical. It is not ethical to screen for something if you are unable to provide adequate follow-up and treatment. Although the USPSTF states that screening is indicated only when this is the case, for too many people it is not. Screening for depression, rather than simply uncovering more cases of untreated depression, exposes the reality that we cannot provide a reasonable standard of care for people who experience serious mental distress. For others, the problem is not so much untreated depression, but homelessness, job insecurity, social inequality, loneliness, discrimination and other wider social factors that breed misery.
Symptoms of depression can occur as a result of lifestyle factors, substance use, medical illness, life events, interpersonal difficulties, and as a consequence of wider social policies. Comprehensive assessment frequently does not occur because of the lack of adequate services for those with mental health problems. The recommendation to screen all adults for depression ignores the social matrix in which depression occurs, will lead to further overdiagnosis and overtreatment of minor morbid mental states, and further overburden mental health services.
I wish there were more psychiatrists with common sense, I absolutely agree screening all people for depression is absolutely one of the dumbest ideas I’ve ever heard, for many of the reasons you list. But especially given the harm the antidepressants can cause, and our current medical industry’s delusion that the adverse effects of the antidepressants is “bipolar.” Adverse drug effects are not a genetic illness, as your industry claims “bipolar” to be, they are iatrogenic symptoms.
I would love it if the psychiatric industry would consider changing it’s current recommended treatment guidelines for “bipolar,” too. Since combining many of today’s recommended “bipolar” drugs is known to cause anticholinergic toxidrome, a syndrome which is known to make people “mad as a hatter.”
For example, adding a “bipolar” antipsychotic, to an existing antidepressant can create the following symptoms: “memory loss, disorientation, incoherence, hallucinations, psychosis, delirium, hyperactivity, twitching or jerking movements, stereotypy, and seizures.”
And psychiatrists misdiagnose these anticholinergic intoxication symptoms as “bipolar” or “schizophrenia.” No doubt, because they can not bill for creating “psychosis” via anticholinergic toxidrome, but they can bill for creating “psychosis” with drugs via “bipolar” and “schizophrenia.”
Do most the psychiatrists really not know your leaders have created an iatrogenic illness creation system, not a “mental health” system? “The Only Thing Necessary for the Triumph of Evil is that Good Men Do Nothing.” Thanks for speaking out against this very unwise recommendation by USPSTF.
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Thanks for the post. In my book, Neuroscience for Psychologists and Other Mental Health Professionals, I argue that we should screen for happiness. We could thus avoid the self-fulfilling prophecy with the diagnostic label. As you know under the Affordable Health Care Act, behavioral health is suppose to be integrated into primary care. For those in distress, the behavioral health provider could arrange support groups, yoga sessions, and coaching on an anti-inflammatory diet and more exercise.
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They could do that but that would be more complicated than writing a prescription. It also may empower people and change lives which would lead to the dreaded “R” word: recovery.
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I love that! Screen for happiness and reinforce it! What a paradigm shift THAT would be!
We could also screen for righteous indignation over real wrongs that exist in the world. We could validate the indignation instead of finding it a “disease state.” We could make the person RIGHT for feeling angry at injustice and cruelty. How would that impact our “mental health” system?
—- Steve
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Screening everyone for Diabetes would be a good idea as it is both a medical matter and their is science to a treatment based on valid chemistry.
Screening everyone for depression like Vivek Datta, MD, MPH writes is not a “thing” that that simply exists in a vacuum. Depression is an idea . There is no science to confirm near 100% reliability. The treatment after a diagnosis of depression is not 100% successful, as there are no chemicals to correct.
To myself this looks like mandatory religion. Everyone must worship the magical chemicals of psychiatry that “treat” depression.
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Sorry for the spelling errors.
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I would disagree with this. Screening in itself is inherently fraught once you begin screening “everyone” as you are more likely to have false positives and false negatives which has its own inherent risks. Also screening is not necessary as benign or helpful as you may think. For example, as I discussed in a previous post mammography screening for breast cancer led 1.3 million women over 30 years to be overdiagnosed with breast cancer – often leading to unnecessary mastectomy, whereas the PSA screening for prostate cancer leads to overdiagnosis of prostate cancer in 50% of cases and you had to unnecessarily treat 48 men to save one life. This leads to complications like impotence, incontinence and radiation proctitis. The perfect screening tool would identify 100% of cases of the problem at hand, and would have no false positives. But no such screening exists. This is why screening should be targeted to those most at risk of a particular outcome regardless of what you are screening for.
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I think screening everyone for depression is a terrible idea because it is obviously ‘a racket’.
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I agree. Another great example is “continuous fetal monitoring” of women in labor. It ties a person to the bed, usually means having to lie on their backs, and creates anxiety when the baby moves and suddenly the monitor flatlines and there’s no one there to intervene or interpret. This became 100% standard practice back in the ’80s, the idea being that this heart rate monitoring would lead to improved outcomes. But it was already known that these devices did not provide any better outcomes than intermittent checks with a fetoscope or stethoscope! They did, however, change one outcome – they dramatically increased the rate of Caesarian section. And yet they became standard practice, and may yet be today.
Tests are fine when there is an identified problem that needs to be further analyzed, but universal screening tests often have unintended consequences for the patient. I suppose in this case, they also have intended consequences for the industry, aka more patients, but the health and welfare of the patients themselves appear to be a secondary consideration, if they’re even a consideration at all.
—- Steve
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Do you screen for depression as part of your practice?
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Vivek,
Good post. I like this part:
“Firstly, this approach treats depression as a “thing” that that simply exists in a vacuum, rather than appreciating that feelings of depression occur within a context and ignoring this will lead to over-diagnosis and over-treatment.”
Also, I like the overarching theme of the post, e.g. that many life problems can be dealt with without professional intervention, and that for milder-to-moderate feelings of depression, psychiatric drugs may be useless.
I see you are doing the best you can from within your context to bridge the gap between your world and those who are against psychiatric practices. But let me quibble with you over a few things:
– Speaking of “overdiagnosis” is misleading, because psychiatric diagnosis is not reliable in the first place. It should be stated again that labeling someone Major Depression or not in the DSM 5 field trials had a kappa rating of an abysmal 0.32. In other words, whether or not someone is determined to be “majorly depressed” or not by the “experts” is like flipping a coin. Further, you spoke of “major” versus “minor” states of depression as if they could be reliably distinguished, but even drawing a line between these (illusory) two subjectively assessed states is problematic since they exist on an unbroken continuum.
– Sometimes you correctly spoke of “feelings of depression”, then at other times you lapse into talking about “depressive illness”. But there is no evidence that depression is an illness, a term which implies a physical or biological origin. So, stop talking about it that way!
– “This might require treatment or it might be a normal reaction to life’s vicissitudes.” – I don’t think it’s Either-Or. A normal reaction to life’s vicissitudes can even, occasionally, require psychotherapy if a person doesn’t have enough support from family or friends. Or, life’s vicissitudes may be so severe that the reaction of severe depression is a normal reaction to an abnormal situation. Your statement implies that some reactions to life’s vicissitudes are “abnormal”. But that is not the case. Everything makes sense in its context, as you implied earlier in the article. So again here you are wavering back and forth between the medical and non-medical model. Try to be consistent!
Again, despite these criticism, good post! I enjoyed reading it and respect your courage for writing in this way from where you are.
–
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The even bigger reason why screening everyone for depression is a terrible idea is that there simply is no reliable test for depression. It’s totally subjective and arbitrary.
Here’s yet another article going over how diagnosing depression is almost like flipping a coin: psychiatrists simply cannot agree on who has it and who doesn’t –
http://www.maartensz.org/log/2012/NL120508a.html
Here are a few choice excerpts:
“When the kappa is between 0.2 and 0.4 (as with Major Depression, at 0.32) – which means that there is more disagreement than there is agreement, dr. Frances, quite reasonably, it seems to me, chooses a term that adequately represents that fact: The term “~ no agreement”, while doctors Regier and Kupfer, who must care fuck all for misdiagnosing patients, especially if the misdiagnosing psychiatrist has been paid, find that lack of agreement.. “acceptable”.”
“In the very terms the various editors of the DSMs since DSM-III have insisted are of fundamental importance, namely what they call “reliability” and measure by kappa, the result is that the DSM-5 is about twice worse than any other psychiatric diagnostic manual: It is not reliable at all, other than reliably unreliable, for which reason it should NOT be unloosened on patients, who will be reliably more often misdiagnosed than correctly diagnosed, all in the very terms, namely “reliability” as measured by kappa, that all editors of these psychiatric diagnostic manuals insist are of prime importance.”
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I know you often cite the poor interrater reliability of DSM 5, but just wanted to point out that when using several other commonly used measures of depression, the interrater reliability of the construct of depression is overall pretty good. My impression is that these are what clinicians tend to use, instead of whatever is in the latest version of the DSM. Here’s a review (read about the Hamilton and the Inventory of Depressive Symptomatology). https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0ahUKEwjG-ISU9tHKAhUENT4KHQoZBUgQFgggMAA&url=http%3A%2F%2Fwww.springer.com%2Fcda%2Fcontent%2Fdocument%2Fcda_downloaddocument%2F9781588299666-c1.pdf&usg=AFQjCNHBUBb0QURFFcx3clXuUmVnfRKueQ&sig2=P7nNuHFMW54au4OVWEyiKA
As you noted, in DSM 5 the kappa for depression is considerably lower than in previous editions. Not sure why that is, though I do have some stats training and know that Kappa is influenced heavily by things like how common depression (or whatever it is you are assessing) is in the study population. In other words, it can be difficult to make comparisons across studies and I know some people choose to use other statistics for that very reason. Maybe that’s not the reason for the difference, but just thought I’d mention it.
I agree with your other points (and Vivek, great post, this is a terrible idea). Of course its important to remember that reliability is not the same thing as validity. Just because we can reliably measure the construct of depression, doesn’t mean that it is a disease just like diabetes, blah, blah, blah.
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While I totally agree with your belief that mass screening is a bad idea, and that depression isn’t an illness, your reference to the reliability of the Hamilton Scale concerns me.
Question 17 Hamilton Inventory is perhaps one of my favourites (although I confess to having several)
17. INSIGHT
0=Acknowledges being depressed and ill
1=Acknowledges illness but attributes cause to bad food, climate, over
work, virus, need for rest, etc.
2=Denies being ill at all.
Gotta love HamD…doesn’t include any tests to ascertain whether the patient has an actual physical illness and if you think you might have a physical illness or are under too much pressure and/or disagree with the tester about being depressed, then you get extra points!
Read the questions in this scale….how someone can be judged to be “ill” with “depression” and requiring medical treatment (usually psychoactive drugs) by a 12 minute run through these questions is totally beyond belief!
Whether the stats say it is consistent/reliable is really quite irrelevant when the questions are so subjective and/or general and could be a result of so many factors other than “depression”, which is an “illness” that has never been proven to exist in any physical sense what so ever.
Anyone can reverse engineer a list of questions to provide the desired result. Reading the questions from a critical perspective is really quite amusing and reveals far more about the basis of psychiatry than it does about the “patient”.
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One must acknowledge being depressed AND ill, not just one of the two, to be considered anosognosia-free?
Another perspective of course is that recognizing you don’t have a disease IS insight.
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To clarify my earlier comments, I completely agree that the VALIDITY of depression as some sort of medical illness is bunk. I also agree reliability is a secondary point, and validity is the main thing to be concerned about Just wanted to bring this up because reliability seems to be mentioned a lot here and it really isn’t the best way to criticize the use of these assessments. Because you can be reliable, but reliably wrong, as I like to think of it.
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Kim,
Forgive me, it’s been too long since I took one of these tests. Regarding,
“17. INSIGHT
0=Acknowledges being depressed and ill
1=Acknowledges illness but attributes cause to bad food, climate, over
work, virus, need for rest, etc. 2=Denies being ill at all.”
So if you deny being depressed, thus claim you’re well, this is this proof of “lack of insight”? And if you claim your problems are do to psycho / social issues, this means you only have moderate insight? And if you belief you have a “chemical imbalance” in your brain that requires psychoactive drugs to cure, then you have stellar insight?
Is this how this test works? Or did I get it backwards?
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the Hamilton isn’t a screening tool and doesn’t include anything to discern physical illnesses because it was designed to measure response to treatment. It shouldn’t be used to diagnose depression and is too cumbersome and not designed for screening.
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Someone Else
yep…I think that’s how it works.
Say you’re OK and it means you’re sick ‘cos you lack insight.
Say you’re sick, and it means you’re OK ‘cos you got insight.
Say you’re sick but attribute it to the fact that your mother died, you lost your job, lost your house, caught the flu because you were sleeping rough winter and have to shovel snow 12 hours a day to feed yourself and your kids and that might be indicative that you some lack of insight into your condition.
CUTE…not.
But maybe I have misunderstood…..
Quite interesting, really.
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It’s Saturday night and maybe time for me to repost this link to “Asymptomatic Depression: Hidden Epidemic and Huge Untapped Market,” which addresses the problem that “nearly a third of American adults have never been diagnosed with any mental disorder” and “explores the novel hypothesis that patients who feel well are, in fact, patients who need treatment.”
http://www.bonkersinstitute.org/asymptomatic.html
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Well, that explains why, in the medical records, of my first appointment with my psychiatrist, it states I “lacked insight.” (Although, I don’t recall taking the test that day.)
I’d paid to get a forth opinion, outside my medical insurance group, because I was suffering from the common symptoms of antidepressant discontinuation syndrome. My PCP had prescribed Wellbutrin as a “safe smoking cessation med,” and abruptly took me off it, since it didn’t help me quit smoking. And these symptoms were worsened by the common mind altering effects of an occasionally taken “safe pain killer” / actually a mind altering synthetic opioid, and a NSAI. I was quite certain my symptoms were due to adverse drug effects, but all my doctors claimed that absolutely impossible, including this psychiatrist. Who, then, created anticholinergic intoxication syndrome symptoms in me, for years.
Unfortunately, it took over three years for some decent nurses, who finally realized how disgusting my drug pushing PCP was, to hand over my family’s medical records and tell me to find another doctor.
I then picked up my other medical records, from a “bad fix” on a broken bone, and realized my PCP was pushing mind altering drugs on me because she was paranoid of a non-existent malpractice suit, since her husband had been the “attending physician” at the “bad fix.”
And, it took several years of medical research on my part, and asking my pastor about the situation, for me to learn that historically, and still today, two of the primary functions of the psychiatric industry are covering up child abuse for the religions and covering up easily recognized iatrogenesis for the incompetent mainstream medical doctors. My pastor called this, “the dirty little secret of the two original educated professions.”
Hope the psychiatrists will some day get out of the business of proactively preventing non-existent malpractice suits for the paranoid and incompetent doctors (the one I dealt with did subsequently kill another patient, relating also to an ankle problem, according a lawsuit I found on the internet). The incompetent doctors really should be sued, to prevent subsequent deaths.
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Not to mention, psychiatric cover ups of child abuse for the religions, results in the bishops of those religions turning into “psychopathic” non-Christians.
https://books.google.com/books?id=xI01AlxH1uAC&printsec=frontcover#v=onepage&q&f=false
“Oh what a tangled web we weave when first we practice to deceive.” Gas lighting the daughter of the head of the investment committee of the board of pensions for the ELCA religion may have been a choice that lacked “insight.” Since it’s likely she has good enough genetics, intellect, to figure out “the dirty little secret of the two original educated professions.”
Shame 2/3s of all so called “schizophrenics” today, are actually child abuse / ACEs victims. Especially, given the reality that the neuroleptics can create the negative symptoms of “schizophrenia,” via neuroleptic induced deficit syndrome. And the positive symptoms of “schizophrenia,” via anticholinergic toxidrome.
So I also hope the psychiatrists get out of the business of profiteering off of covering up child abuse, by turning child abuse victims into “schizophrenics” with the neuroleptic drugs.
“Concerns of child abuse are not cured with antipsychotics.” Shocking none of the mainstream medical doctors knows this, and it took an oral surgeon to confess this.
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Is the HAMD the one that counts cessation of weight loss as improvement? (Today’s MDD diagnosee isn’t so low s/he can’t eat.)
The scale with that question is a gift to clinical trialists, because drug-induced weight gain contributes to the desired trial outcome.
Weight gain is probably the real reason the studies are of short duration. By week 8 no one can zip their trousers and good moods are turning dark.
I appreciated this article. The New York Times ought to run it.
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Thanks for your thoughts Surviving; I found them interesting.
I know it is true that in some studies reliability appears quite high. However, the deeper problem is that no matter how high the reliability, there is still no validity to psychiatric diagnoses. I.e., they do not describe a discrete clear phenomenon in the way that true physical-medical diagnoses like diabetes or influenza do.
The biggest difference is that true medical diagnoses have one or a few clear known etiological pathways/causes. But psychiatric diagnoses on the other hand are attempts to “categorize” vague spectrums or continuums of related problems which are much more heavily affected by a whole multitude of factors than purely physical diseases – factors including the person’s relationship stresses, job problems, past history, feelings/thoughts, poor nutrition, illegal drugs, and hundreds of other causes.
The lack of validity is a core reason why reliability is never perfect for psychiatric diagnoses, and is often very poor (but not always poor as you correctly pointed out).
Lastly, it should be noted that reliability could be very high for a completely illusory fraudulent phenomenon. For example, scientists could agree with other at a very high rate that a bunch of people who are hopping around and singing rather than walking around quietly have bipolar disorder. But that wouldn’t mean bipolar disorder is at all valid or real or that hopping around represents a psychiatric illness with a known etiology…
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thank you for your comments. I think we mostly agree but for the sake of simplicity and parsimony I have avoided going into these important though thornier issues in this post. As for the “depressive illness” – this is mainly a semantic disagreement. I do use the term illness to describe morbid mental states not to imply disease or a medical problem, but to underscore the subjective experience of being unwell. Clearly larger social, political, and economic factors can make people feel unwell- this does not of course mean the solutions is medical, and I don’t think it necessarily pathologizes those feelings as individual ones, but rather emphasizes the larger toxic influences that may affect how we feel.
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Indiana NAMI Rep pushing mental illness screening, which will result in even more kids on drugs.
https://www.youtube.com/watch?v=Z6TapDyT-mI
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My favorite from the comment section of the video.
“This guy’s voice is just cracking and meek, I could be unable to speak english and still know that he has absolutely no conviction in what he says, by his body language and tones, what a slime, where do they find them?”
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NAMI is a front. If you ever doubted this look to:
http://ahrp.org/culling-the-evidence-national-alliance-for-mental-illness/
NAMI currently hides under the support of the health care industry in the form of hospitals and clinics that push the drugs that make the money. Look at their tax forms, the number of paid staff vs the number of exploited volunteers (who parrot their big pharma message). They are not anything they claim to be (grassroots, supporters if the mentally ill, etc).
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Thanks for that link, very informative.
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Yes NAMI is a front for thousands of peer volunteers across the country that do good work every day to reduce the stigma associated with mental illness. As a volunteer, I have no connection to the pharma industry, I’m not exploited or parrot any message, other than my own personal experience of recovery. I invite you and any concerned person to visit your local NAMI office, meet the people there and make up your own mind. You will find people with many opinions and probably some that agree with you, if that is what you are looking for.
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It might be plausible if you could screen yourself using quantitative testing that would pick out items responding to certain (and sometimes simple) treatments. For instance, loss of taste and smell sometimes appears during the onset of depressions and is restored by a course of zinc salts, possibly obviating the need to go to the Twilight Zone of medication.
You could also reduce the likelihood of medication disasters. Although the good doctor won’t do it, for some reason psychiatrists seem to insist on medicating people with many simultaneous dysperceptions with antidepressants alone, if they present depressed at the exam. Forewarned, the potential patient has a chance to dump his doctor (I’m sure I’m never going to be an APA member patient saying that) before the incident with the police surrounding the house occurs, so that it never happens in the first place.
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If you are aware at all of the world around you, not being depressed would be more of a concern. You are correct that “depression” does not exist in a vacuum.
This is another “prevention” and “treatment” angle that will primarily benefit the health care industry (and I use that term to describe the current system in it’s various forms that provide ill health more often than not). Until they understand that this is not an issue that is based in the body but in the soul, there isn’t going to be change. Big pharmaceutical has a vested in keeping things as they are. Their existence depends on it.
I find it suspect that as more information becomes available regarding the ineffectiveness and the damage anti-depressants do, the government now pushes for a broader drag net. Hmmmm. Coincidence? Probably not.
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Squash, “I find it suspect that as more information becomes available regarding the ineffectiveness and the damage anti-depressants do, the government now pushes for a broader drag net.”
Exactly, our government’s been taken over by the wrong people. Specifically, “the banks and corporations that will grow up around them,” that Thomas Jefferson forewarned this country about.
The exact same evil bankers and corporations that brought us WWII, and the anti-Semetic “Protocols of the Learned Elders of Zion” manifesto. Which does, ironically, seem to be the playbook of our current leaders.
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Hey, we’re missing the forest for the trees. This is a dangerous totalitarian machination aimed at every single person, not an academic discussion, and this thrust of the article, and much of the response, misses the point.
The least of our problems is “lack of a mental health care provider”; in fact that would make us all safer. This looks like something that will be pushed as a mandatory part of mandatory Obamacare and then labeled “voluntary” since you aren’t actually “screened” at gunpoint.
There’s a lot of things to be unhappy about and fuck anyone who tells me I should feel content. Or that I shouldn’t feel good about something they disapprove of.
Dr. Breggin was on the late night national “Coast to Coast” talk radio program this week and was asked about this proposal. His response was that it was terrifying, and a ploy to put more & more people on pharmaceuticals. When asked if this screening could be forced on people he pointed out that de facto coercion is already being used. What we do have on our side will be more & more people affected by this who will resist, and we should do all we can to encourage this.
We need a bunch of sympathetic psychiatrists and other MH people to put together an official crib sheet of “correct” answers to all official “depression exams” that will help people avoid being diagnosed; this could render the whole process useless. Do I hear a second?
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I agree, but the problem is…you have to convince people the screening and treatment is dangerous rubbish before they’ll use the cheat sheet…and “screening” is often done in conjunction with a visit to a doctor or counsellor or other practitioner for an entirely unrelated issue and so may be totally unexpected….an ambush, in fact.
Need to get articles, interviews etc challenging this initiative into mainstream press, and it also needs to be presented as a potential threat to people’s rights to freedoms, privacy, self determination, etc rather than a a medical initiative.
It’s so good that Breggin is still doing his excellent work – we also need a chorus of mainstream doctors, politicians, human rights activists who can see the implications.
Some pieces on the nature of the questions (I assume here there’ll be a standardised questionnaire) highlighting their total lack of anything that could link them to evidence-based medicine could also help, as well as serve as somewhat of a cheat sheet.
From my experience here in Australia, though, primary care doctors already administer the HamD almost as a matter of course. Next time my doc administers it, I am going to have a bit of fun asking about the questions and pointing out their logical absurdities and inconsistencies!
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you have to convince people the screening and treatment is dangerous rubbish before they’ll use the cheat sheet
I don’t need to convince anybody of anything, I know I’D like a “cheat sheet” and I think lots of others will as well as soon as they understand what this is all about, which is labeling dissatisfaction with the system a de facto crime punishable by drugging and stigmatization. (And no the goal isn’t to “end stigma” but the system which invented it.)
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Apologies…of course you don’t!
…and I think we agree that once people actually understand what it is all about they too will find it offensive and will be seeking ways to manage it…a cheat sheet will be good.
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I definitely agree about the need for a crib sheet. Meanwhile, folks might want to go to this site, sponsored by Pfizer (I am shocked), to see what the various versions of these questionnaires look like in case they get hit with one unexpectedly at a PCP’s office.
http://www.phqscreeners.com/select-screener/31
I am wondering if there is a way to refuse to take. For example, one time before a visit to my former PCP, I noticed a depression questionnaire was online and of course avoided it. But when she surprised me by giving it as part of their routine screening, I was caught off guard and didn’t know how to politely refuse it without coming across in a negative manner.
I know some people would say just cooperate and answer no to the questions but for me, that solutions falls way short.
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Take responsibility for your own mental health. Are you really worried about being polite and negative? Wonder no longer and have the courage to take action.
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If they ever create a drug that really does get rid of depression it will be devastating to humanity.
My toilet broke I went to flush but it won’t go down. Oh well that doesn’t bother me so I have no motivation to fix it or do much of anything. Nothing makes me feel sad. I have no dog food, well if the dog dies I won’t feel sad and even the thought of it doesn’t make me sad, I took that drug that rids me of depression. I am so happy that I am happy I think I will just sit here and be happy, no sense doing anything.
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Here’s another tidbit from the aforementioned study:
The USPSTF found that second-generation antidepressants (mostly selective serotonin reuptake inhibitors [SSRIs]) are associated with some harms, such as an increase in suicidal behaviors in adults aged 18 to 29 years and an increased risk of upper gastrointestinal bleeding in adults older than 70 with risk increasing with age; however, the magnitude of these risks is, on average, small.
and
Depression also imposes a significant economic burden through direct and indirect costs. In the United States, an estimated $22.8 billion was spent on depression treatment in 2009, and lost productivity cost an additional estimated $23 billion in 2011.5
Gotta love it. They make unhappiness a “disease” requiring billions of dollars to “treat,” hook people on drugs then whine about “lost productivity” and the toll of their self-created “disease” on the economy. Rich.
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No matter how this turns out people need to be educated that they can refuse the screening just as you can refuse the PHQ9 (a Pfizer depression tool). No one is ever told that so most people fill them out without resistance. If you educate everyone you know about this and advocate for a truly voluntary screening, that gains some ground.
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Yeah, that plus the cheat sheet. 🙂 It should include a section on how to recognize when you’re being screened.
What makes you so sure it will be voluntary?
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Just tell your physician no. Refuse to answer his questions. If he has problems with that, get a new physician. Is any other kind of screening for medical conditions mandatory? I take responsibility for my own mental health and have no problem with depression screening.
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the PHQ-9 is the commonest screening tool that is used.
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Thanks, Vivek, for both the original excellent article and the clarification re the correct use of the HamD and PHQ – 9, the latter of which, on reading, isn’t quite as silly, but still has immense potential for abuse.
Both doctors (primary care, not psychiatrists) who used the HamD with me here in Australia described and used it as an initial screening tool, and so there might be some confusion around the correct use of the various tools, as numerous articles (incl academic studies conducted in places other than Oz) I have read have also referred to it in that way.
That said, the main point is not which tool should be used for mass screening, but whether mass screening is in any way wise or warranted.
It is wonderful to hear an emphatic “NO” from all camps for a whole range of reasons, as these reasons will form the basis of resistance to such a retrograde move.
Thanks again for yet another excellent piece!
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I think that having those around us who are able to listen to what we say without judgment, without disparaging remarks, could do a lot to help lower depression. Instead so many people go to psychiatrists in order to have a listening ear, then they’re sent home with antidepressants, benzo drugs, or other pills.
The depression screening raises a lot of red flags. Depression doesn’t stay forever, although we think it will. If someone went to the doctor, feeling depressed that day regarding a death or bad grade, for instance, and states on the form that they’re depressed, would that person then be given a prescription or would the doctor spend time asking about the source of the depression first? Would doctors even have time to do this? Unfortunately, the prescription pad has been much too handy for doctors. A person could end up being iatrogenically dependent on a drug simply by being depressed by a life event that anyone going through the same thing would be depressed about.
Another thought is that a person could be depressed due to a drug that person was prescribed previously. What then? Doctors frequently overlook this fact. Would the person then be prescribed another pill on top of the one that was causing depression? Polypharmacy could result, further exacerbating depression and adding even more symptoms to the mix.
I tend to think that depression screening is yet another ploy by big pharma to gain more customers. I have little trust in the medical system after what I’ve been through. The time it takes to taper off antidepressants and benzo pills, for instance, plus the added years for additional withdrawal, can last far, far longer than the initial depression that a patient originally had.
In the U.S. there tends to be the notion that the more busy and productive a person is, the more that person is looked up to and admired by others. I wish that there were more people trained – in volunteer or stipend positions – to simply listen to what people have to say, maybe a cell phone/telephone service if the person calling would want to remain anonymous. Not a suicide-type service, but way before it gets to that. Someone on the other end of the phone who would listen, offer tips, and be genuinely interested in what the caller says, no matter how long it takes the caller to explain. There is too little of that in the world.
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The 3 Reports that the USPSTF have published are so disturbing to me that I don’t understand the direction that our current Mental Health System is going. Although, what I do understand is that it’s Greed in it’s finest form coming directly from Big Pharma. “ALL members of the general population should be screened for depression.” ALL is a pretty big word. In which, ALL will qualify. The other two reports are just as horrifying, as they want to now include more than ALL. Now they are targeting pregnant and postpartum women – http://jama.jamanetwork.com/article.aspx?articleid=2484344, and then on September 8, 2015 – “12 to 18 year olds should be screened for MDD – and with MDD, these feelings last more than 2 weeks – USPSTF”. Isn’t it natural for most teenagers to be this depressed after a boy/girlfriend breakup, or they just got beat the night before, or sexually abused by a relative, or they’re living in extreme poverty, ect, ect, ect. And now our Society, our Country, and our Mental Healthcare System would rather quickly diagnose and drug them using drugs that will most likely ruin them for life, and that’s only if they’re able to live through all the iatrogenic illness the drugs are going to induce. And this doesn’t even cover all the mentally torturous withdrawal symptoms. I’m so glad that I’m old and I won’t be around much longer because what’s happening to every man, woman & child in this country by first, convincing them they have a mental disease, secondly, by over drugging them is so horrifying to me since I know full well what multiple psychiatric drugs do to a persons life. As a psychiatric survivor of over thirty-five years, the drugs completely destroy lives not improve them.
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Something rather interesting about this “task force”. There are VERY few people with a mental health background on it…I didn’t google all the names, but of the 10 i did, they were all in primary care. Maybe there’s a psychiatrist or two on there, but it’s definitely a minority. I looked at their bios and the ones I looked at didn’t even have interests in mental health. I only see one psychologist. If anyone wants to look through the names/directly criticize them, heres the list (the guy in charge has a background in Geriatrics and Palliative Medicine…let’s see if his next article is justifying the use of Haldol in nursing homes):
Corresponding Author: Albert L. Siu, MD, MSPH ([email protected]).
Authors/US Preventive Services Task Force (USPSTF) members include the following individuals: Kirsten Bibbins-Domingo, PhD, MD, MAS; David C. Grossman, MD, MPH; Linda Ciofu Baumann, PhD, RN, APRN; Karina W. Davidson, PhD, MASc; Mark Ebell, MD, MS; Francisco A. R. GarcĂa, MD, MPH; Matthew Gillman, MD, SM; Jessica Herzstein, MD, MPH; Alex R. Kemper, MD, MPH, MS; Alex H. Krist, MD, MPH; Ann E. Kurth, PhD, RN, MSN, MPH; Douglas K. Owens, MD, MS; William R. Phillips, MD, MPH; Maureen G. Phipps, MD, MPH; Michael P. Pignone, MD, MPH.
Some are probably going to disagree with this, but I think if they had more psychologists and even more psychiatrists (especially if they had someone like Vivek), they wouldn’t be recommending screening everyone. Primary care physicians probably don’t see what happens to someone who has a bad reaction to antidepressants. If they become manic, they likely are shipped off to a psychiatrist. Or if their life crumbles and they lose health insurance/become poor, they might not be able to afford a trip back to the doctor. If they had psychologists/therapists on this panel, they might have some idea that psychotherapy isn’t financially feasible for a lot people, so the poor will probably get pushed on to antidepressants right off the bat. Especially those on Medicare/Medicaid, since there aren’t many providers who even accept it (often only the crappy ones), and someone poor can’t afford to pay out of pocket for the many therapists who don’t take insurance.
These people are clueless.
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Unfortunately, in my situation, primary care doctors have been clueless when it comes to understanding pills. I’ve been told some very incorrect information regarding getting off a blood pressure pill, for instance: “Just quit taking it and updose on the blood pressure pill you’re already on.” Well, that turned out to be rubbish, as I went through hellish dizziness, housebound, for a few days before figuring out my own slow tapering plan. Doctors say that patients need to taper slowly off drugs, yet the tapering plans they recommend are extremely fast in many instances (especially in the case of benzodiazepines) and can contribute to years of torturous withdrawal.
Why are primary care doctors even allowed to prescribe drugs? I’ve read that they get very little information about drugs in medical school, yet they seem to be doing most of the prescribing these days. In fact, prescribing drugs appears to be one of the fundamental aspects of their practice. Please correct me if this is wrong. Their continuing cluelessness about drugs, their side effects, interactions with other drugs a patient is taking, and poor knowledge about how very toxic drugs can be to the CNS continue to floor me.
If doctors are listening to, and believing, what pharma reps are telling them about drugs, that is another very dangerous slippery slope. From what I’ve read, pharma reps usually have little knowledge about pills except through information they’ve received and have duly parroted to doctors. And the information they impart is skewed to benefit big pharma and not the health of a patient. Of course they’re going to tout the benefits of the pills and discount the dangerous side effects. That’s their job – to push the drug!
When will the insanity and stupidity end?
Something has got to be done about this, and soon. And God help us, as even more prescribing will be done, due to depression screening, by primary care doctors who, for the most part, know next to nothing about drugs. There are those doctors who are very wise regarding pills, but there are too few of them.
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good points. I am starting to think that perhaps we should be more worried about primary care than psychiatry. this is the new trend, for clueless primary care physicians to act as mental health providers and this recommendation is likely to further the trend towards dangerous medicalization of depression.
I went through the whole list and there are ZERO psychiatrists on that task force. As much as we criticize psychiatry, my suspicion is that psychiatrists would raise more concerns about screening the entire population.
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The insanity and stupidity ends with you. The amount of information on health issues available to the public is incredible. This includes not only information of medications but reviews of physicians. So you can know more than your physician, who is busy seeing patients to make a living. “And God help us” – maybe she already is.
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Not surprising from “Panel Calls for Depression Screenings During and After Pregnancy” which appeared in the January 26, 2016 NY Times, “The only state that requires screening, New Jersey, has had mixed results because too few treatment options have been available.” [I emphasize “…. mixed results because too few treatment options have been available.”]
I continue to wonder what outcomes persons screened positive for depression experience given the nature, timing, extent and quality of available treatment. In 2004 I contacted TeenScreen. My inquiry included a request for information about treatment outcomes for those screened positive for depression. Their reply included, “We do not at this time have any data to show what happens to these youth once they are engaged in treatment.”
In general, do post screening outcomes for individuals who engage in treatment reflect those found in Minnesota’s “2014 Health Care Quality Report” on page 158 or Ed Pigott’s analysis of STAR*D? If so, do many of the individuals screened positive for depression experience little more then a label when the pain of depression can be so great?
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Anyone thought about telling the US Task Force directly what they think about this? Apparently you can, and you don’t have to leave a name/email address. http://www.uspreventiveservicestaskforce.org/Page/Name/contact-us
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Thanks so much, Surviving and Thriving! I’ll write to them. Great idea!
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Why is depression screening any different than cancer, diabetes or heart disease screening? Depression screening gives me the information I need to make good health decisions for myself. Its a start and what it leads to is my responsibility, not any healthcare professional. The lack of quality care argument reminds me of the saying “cut off your nose off to spite your face.” Should I ignore the symptoms of depression because I might not be able to get quality care? Maybe depression screening will help to reduce the stigma associated with mental illness and help get the suffering the care they deserve. I’m interested to know if the author provides depression screening as part of his practice.
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Depression is not a “disease.”
http://www.behaviorismandmentalhealth.com/2009/07/28/depression/
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Well screening is problematic in general because it leads to false positives, and can generate unnecessary intervention, misdiagnosis, and cause anxiety and actual harm. Some cancer screening programs such as breast cancer and prostate cancer have been shown to do more harm than good. If you can’t provide care to people, or interpret the results of a positive screen for depression, that is in my view, unethical. That is also the position of the World Health Organization. I do not screen for depression in my practice, but I’m not a primary care doc, but a specialist, so if someone is coming to see me it is because they already have a neuropsychiatric problem like memory loss etc. And I am able to provide a comprehensive assessment of problems unlike the average PCP office because I see patients for 2-3hrs at a time, not 10 minutes.
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