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.