In a recent article published in the journal Current Medical Research and Opinion, researchers funded by AbbVie (a pharmaceutical company that sells several medications for depression and bipolar disorder) stated that they had developed a six-question “Rapid Screening Tool” for diagnosing bipolar I.
This screening tool is now being promoted in outlets such as Psychiatric Times, which features a slideshow titled “How to Screen for Bipolar Disorder in 2 Minutes.” The subtitle: “A new test screens for bipolar disorder with respectable accuracy.”
Yet, as even a quick look at the research paper reveals, this questionnaire wasn’t even tested as a screening tool, and it relies on questions that mistake adverse reactions to antidepressants and other psychiatric drugs as symptoms of bipolar disorder.
But this publication also suggests a larger subject: Is there any evidence for “screening” for psychiatric disorders? And what are the potential harms?
The Pharmaceutical Company Connection
According to the declaration of funding published with the article in Current Medical Research and Opinion, the pharmaceutical company Allergan funded the development and testing of the screening tool. Allergan is now owned by pharma giant AbbVie.
Among Allergan’s top products are the antidepressant drugs citalopram (Celexa) and escitalopram (Lexapro); AbbVie is the producer of Depakote (divalproex sodium), an anti-epileptic whose first indication is the “treatment of manic episodes associated with bipolar disorder.” They also market the antipsychotic drug cariprazine (Vrylar) for bipolar disorder.
The authors of the publication on the screening tool are Roger S. McIntyre, Mehul D. Patel, Prakash S. Masand, Amanda Harrington, Patrick Gillard, Susan L. McElroy, Kate Sullivan, C. Brendan Montano, T. Michelle Brown, Lauren Nelson, and Rakesh Jain.
Three of the listed authors—Patel, Harrington, and Gillard—are listed as employees of AbbVie.
Two other authors—Brown and Nelson—are employees of RTI Health Solutions, a company that the pharmaceutical industry uses to analyze data and then write and publish their research so that it appears not to come from the industry itself.
All of the listed authors report extensive conflicts of interest with the pharmaceutical industry, except for the employees of RTI. Masand, McElroy, Sullivan, and Jain report receiving speaker’s bureau or consulting payments from Allergan or Abbvie specifically.
The top earners were Masand and Jain: In 2019, Allergan paid Masand $152,000 for promoting Vraylar. Jain earned $862,000 from the pharmaceutical industry in 2019, with $131,000 of that from Allergan.
The authors also acknowledge the work of AbbVie’s contracted ghostwriting firm as follows: “Writing and editorial assistance was provided to the authors by Carol Brown, MS, of Prescott Medical Communications Group (Chicago, IL), a contractor of AbbVie.” Brown is not a listed author on the paper.
Even the peer reviewer hired by the journal to ensure an unbiased review of the manuscript lists 22 different conflicts of interest with the pharmaceutical industry, although none were with Allergan or AbbVie specifically.
Conducting the Study
The researchers call their tool for detecting bipolar disorder the RMS—Rapid Mood Screener. So how did they develop and test this measure?
First, the researchers scanned the existing literature for symptoms that were different between depression and bipolar I disorder. Next, they drafted a questionnaire based on these concepts. They interviewed 12 people with a diagnosis of either depression or bipolar I to see how well these concepts fit. Finally, they tested their questionnaire in 67 people with a bipolar I diagnosis and 72 people with a diagnosis of major depressive disorder. (All participants were already being treated with psychiatric drugs.)
The researchers did not test whether the tool could be used to spot “bipolar I” or “depression” in people who presented without symptoms or whether it could differentiate between healthy or “normal” controls and people with a diagnosis. Instead, they tested whether the RMS could differentiate between people who were already diagnosed and being treated for either depression or bipolar I.
Thus, the tool does not actually meet the definition of a “screening” instrument.
“Screening,” in the medical field, is the act of using a test to detect people who are not showing symptoms (or showing very few symptoms), but who may have the early stages of an illness that will get progressively worse.
Even more concerning is that at least four of the six questions on the RMS essentially measure the adverse effects of psychiatric drugs. One of the questions specifically asks whether the patient has experienced mania induced by antidepressant use.
Answering four of the six questions “yes” results in a positive “screen” for bipolar I disorder. In total, the RMS consists of two questions about depression and four questions about the adverse effects of antidepressant drugs.
That is, a clinician using the RMS will almost always conclude that people who experience the mania-inducing effects of antidepressant drugs should be diagnosed with bipolar I disorder.
The six questions on the RMS are:
- Have there been at least 6 different periods of time (at least 2 weeks) when you felt deeply depressed?
- Did you have problems with depression before the age of 18?
- Have you ever had to stop or change your antidepressant because it made you highly irritable or hyper?
- Have you ever had a period of at least 1 week during which you were more talkative than normal with thoughts racing in your head?
- Have you ever had a period of at least 1 week during which you felt any of the following: unusually happy; unusually outgoing; or unusually energetic?
- Have you ever had a period of at least 1 week during which you needed much less sleep than usual?
Notably, if a patient answers “yes” to question 3—indicating that they experienced the mania-inducing effects of antidepressant drugs—they will likely also meet criteria for questions 4, 5, and 6, which are the symptoms of (hypo)mania.
Thus, after experiencing just one week of adverse effects from an antidepressant, the patient will screen positive for a diagnosis of bipolar I.
It is likely that in the general population, this measure could lead to further increases in the bipolar disorder diagnosis, since the criteria for these six questions would be remarkably easy to meet.
For instance, ask anyone you know: “Have you ever felt happier than usual for one week?” or “Have you ever slept less than usual for a week?”
What’s the Harm of Screening?
Screening is a debated procedure even for many physical illnesses. For instance, screening for cancer can help detect the illness before a person experiences symptoms, but it also leads to overdiagnosis and overtreatment. Low-risk abnormalities (which might never turn dangerous) may end up being treated with procedures like chemotherapy, which are themselves harmful to the body. In some cases, it is unclear whether the benefit exceeds the risk.
The risk/benefit ratio is even more unclear in psychiatric diagnoses. In fact, there has not been a single study that provides direct evidence of a benefit for screening for psychiatric disorders.
In 2016, I was part of a research team that investigated the evidence for screening for psychiatric disorders. Guidelines from the US had very different opinions from guidelines from Canada and the UK on when screening would be helpful—and even whether there was any evidence for it.
We found that the US guidelines promoted screening for alcohol misuse, adolescent depression, adult depression, and intimate partner violence—but the Canadian and UK guidelines did not.
Why the discrepancy? The US guidelines pointed to indirect evidence—particularly studies that showed that screening could be implemented but didn’t appropriately compare outcomes, or studies that provided extra care to the screened group but not the non-screened group (that is, these studies didn’t compare “apples to apples”).
In contrast, the Canadian and UK guidelines looked for direct evidence. They found that there was not one study focused on any of these issues that directly compared screening to non-screening and found better outcomes.
We were able to find six studies that compared screening to non-screening in an appropriate fashion. Five of those studies found no statistically significant benefit to screening. The final study reported ambiguous results that also didn’t strongly support benefit.
Screening for depression, specifically, has long been lambasted in the research literature as useless at best, and dangerous at worst:
- A Cochrane review: “Screening questionnaires for depression appear to have little or no impact on the detection and management of depression by clinicians.”
- An article in the Canadian Journal of Psychiatry: “Depression screening, even with collaborative depression care, may not be beneficial for patients […] Routine screening would expose some patients to avoidable risks and would pose a significant cost burden.”
- An article in BMJ: “Rates of depression six months after screening were not different in the screening (15.0%) and non-screening (15.8%) trial arms.”
- Also in BMJ: “Screening for depression is unlikely to be a clinically effective or cost effective way to improve the mental wellbeing of the population.”
- An article in BMC Med: “Over-diagnosis and over-treatment of depression are common in community and primary care settings in the US, and there is a real risk that depression screening could exacerbate this problem without contributing to better mental health.”
- An article in the Canadian Journal of Psychiatry: “There is no direct RCT evidence that supports depression screening among children and adolescents.”
- An article in the Journal of Psychosomatic Research: “Screening in itself is unlikely to improve patient outcomes. Further, we identify costs to screening that are not readily apparent and that may negatively affect both patient outcomes and health-care delivery systems.”
- An article in Psychiatric Services: “In the absence of evidence of clinical benefit, there are concerns that wide adoption of the USPSTF recommendation for universal depression screening would lead to overdiagnosis of depression and an increase in inappropriate prescription of antidepressant medications.”
What Happens in the Real World?
But sometimes the data from clinical trials and meta-analyses don’t tell the full story. Doctors may dismiss this data, preferring to rely on “clinical judgment” to do their job. So what happens in the real world?
A new article by trauma survivor Anna Austin, published in JAMA Internal Medicine, may help tell that story. She explains how she has answered “yes” on the trauma screening she’s given every time she seeks medical care—and how she has never received any follow-up or even acknowledgment of that disclosure.
She describes the feelings of shame that accompany trauma, and how this can be exacerbated when disclosure is ignored, especially repeatedly, and especially by someone in a helping profession. She describes how she was left questioning whether she should ever disclose something like this and whether her medical professionals even cared.
“Questions about traumatic experiences are deeply personal,” she writes. “And while perhaps well intentioned, asking patients to disclose potentially painful and distressing experiences with no follow-up can cause more harm. A key tenet of public health and medical ethics is that screening without readily available and accessible evidence-based interventions, let alone a compassionate conversation, is unethical.”
The Human Cost
As demonstrated by Anna Austin’s experience, there is a real-world, human cost to people exposed to screening. Screening for trauma can leave a person feeling worse than if they had never disclosed it.
But another harm of screening is overtreatment, and the Rapid Mood Screener (RMS) for bipolar disorder is the quintessential example of such harm. People who are taking antidepressants for mild depression or anxiety may experience adverse effects of these drugs, such as (hypo)mania. Research has demonstrated that a person taking antidepressants is three times as likely to experience mania after taking the drug.
And the RMS “screening” tool makes it very easy for someone experiencing that side effect to now be given the much more serious diagnosis of bipolar disorder.
So what happens then? The person’s life may be upended. They will likely be told they have a lifelong chronic illness. They may be prescribed lithium or—just as likely—an antipsychotic such as those marketed by AbbVie/Allergan. These drugs have many adverse effects, which could negatively impact their physical and mental health.
Common side effects of lithium include headache, nausea, tremors, dizziness, and drowsiness—and the person must be monitored for lithium toxicity, which is deadly if not treated immediately. Common side effects of antipsychotics include drowsiness, dizziness, nausea, seizures, and tardive dyskinesia, as well as adverse effects on heart health and metabolism problems that can lead to extreme weight gain and diabetes. Antipsychotics have also been found to shrink brain volumes.
Such is the potential for harm. And, in terms of the use of the RMS, this turn in a person’s life could all be due to a side effect of a drug they were on for a milder condition—a side effect that could have been resolved just by tapering off the antidepressant. But instead, with the use of this bipolar “screening tool,” they end up with a more serious diagnosis, on more drugs, and experiencing all the harms of those drugs too.
So think about it. Have you ever been especially happy for a week? Have you ever had trouble sleeping for a week? If you tell your doctor, you just might end up diagnosed with bipolar disorder.
Reference to Wilson – Junger Criteria for valid Medical Screening Programs recommended.
What is ‘Respectable Accuracy’?
As one of the millions of people who’ve already had the common adverse and withdrawal symptoms of an antidepressant misdiagnosed as “bipolar.” I will point out that the psychiatrists supposedly USED to know such iatrogenic illness creation was morally repugnant behavior. From their DSM-IV-TR “bipolar” definition:
“Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.”
But apparently they believe the mere fact of taking that disclaimer out of their “bipolar” definition, now makes it okay to create “bipolar” in millions more people? Truly, the lack of ethics of the “mental health” workers and big Pharma are out of control.
Thanks for speaking the truth, Peter.
I would like to thank the author for this article. It is very well done, even if some of the statistics elude me. But, what doesn’t elude me is this: in my experience, some form of bipolar disorder is like a throw-away diagnosis— why there must be something wrong with you; so we’ll diagnose you as bipolar. This article, sort of verifies, this. The first give-away point–“how to diagnose bi-polar disorder in two minutes?” If there is something wrong with you, even the “common cold” do you want it to be diagnosed in two minutes? (But, then, may be the going diagnostic procedure these days.) All of these questions are misleading and can be used against the patient; especially if there’s is hesitancy in answering them. Someone else pointed out specifically how they were denying their own diagnostic criteria on the anti-depressant drug question. Additionally, it seems they are trying to rationalize their anti-depressant drug prescriptions and codifying into saying “look how useful it is to us that we prescribe these drugs; now from the patient’s reaction, we can determine the sickness of the patient or how sick the patient is.” Like I said for these psychiatric diagnosis people; if they can’t find something wrong with you; they’ll say you have bipolar disorder. Finally, on lithium toxicity. Of all the drugs, I spent more time on that drug than any of the others. Lithium Toxicity can creep up on you, silently and stealthily, like a snake in your sleeping bag. The odd thing, at least for me, is that even as it crept up on me, my lithium levels showed within the acceptable range. But, I was getting sicker and sicker and much of my symptoms met the lithium toxicity criteria. I also developed extreme bodily restlessness and inability to control bodily movements. The prescriber was confused if this was something that had to do with lithium or was a symptom before the lithium. A-ah! When I stopped the lithium, that bodily stuff went away, too. Thank you.
If I was to be named on this list of “authorities”, I’d want the creators of said list to use an alias instead of my real name.
And, instead, it’s us truth tellers, and “one in a million” psychopharmacological researchers – according to the head of family medicine, at one of the US’s most well respected hospitals – speaking out against big Pharma and its ignorant psychiatric and psychological misinformed minion liars, who have choosen to speak under aliases.
But those of us who do speak out against the systemic big Pharma industry crimes, have good reason to use aliases. Since when we do show our work, which “too truthfully” exposes these systemic industrial crimes. We are attacked, by the misinformed minion and liars of the ignorant, psychological and religious industries.
How does one learn, with the Hippa Regs that “protect” the individual also shelter truths from being told? For to understand the enchanced ability to list/categorize information, may obscure the Art and the Practice of learning how to read the integration of Body? To have been a patient in a State Mental Hospital, to attempt to become well without the medications, to taper off, while being aware of feeling better or feeling worse, beyond the norms of my internal biology when one has difficulty to hold at bay, “the misinformed minion and liars of the ignorant, psychological and religious industries” seemingly requires a language that speaks from the inner eye to the public eye? But how does one get to “the truth” in a knowledge producing economy? That becomes being authentic?
I have discovered that the relapsing/remitting nature of late-Lyme Disease flares looks an awful lot like the criteria for “bipolar disorder”. When I am in a flare – which is usually brought on by stress depressing my immune system – I become “depressed” from a combination of severe pain and exhaustion because my body is fighting an inflammatory infectious illness. After years of fighting this process, trying to medicate my way out of it with both OTC and Rx painkillers, sleep aids and energy boosters, I have learned to instead work with my body during these times. I give myself permission to rest and be sick when I’m sick. I stay in bed when I need to. I boost my immune system with natural anti-inflammatory substances like curcumin, ginger, vitamins c and d, vegetables, berries and cold water omega rich fish. I don’t judge myself for being unable to do things I “should” be able to do. I cry, releasing emotion as needed.
Then when I’m better, I play catch up. I feel good, my energy level returns, the pain recedes to a manageable level, my emotions stabilize and I get done the things I need to get done.
This works for me. Judging myself as disabled, deficient, abnormal, disordered and the like didn’t work for me. Following the route of western medicine and American style rugged independence didn’t work for me. I need supports around me when I’m ill and I need agency and independence and freedom when I’m well.
I would fail this test without question. And I think it serves a far more insidious agenda than screening for any kind of illness. It serves as a sort of new rule. A new set of lines we must learn to stay within lest we risk losing agency and become pathologized as disordered instead. You can’t be too happy. You can’t be too sad. You can’t be any of these things for too long. The length of which creeps shorter and shorter as time goes on. If you have trouble sleeping, it can’t be an unrelated sleep disorder like the sleep apnea it took me seven years to get properly diagnosed and treated. Or it can’t be ongoing unavoidable stress in your life. It must be a disorder. And you should seek treatment for it.
And then you have to ask yourself, why are humans now treated like we’re supposed to be robots? Why is there such a strict definition of what it means to be properly functional?
When you peel the layers back, you realize we live in such a rigidly controlled system because what we are now is labor generators for the people we produce profit for. Our lives are designed around work. Around productivity. We are programmed from birth to prepare ourselves to be come part of the labor force and for most of us that will mean laboring for others. School is not because we have a right to education, it’s because we grow up into a world where a “right” to work really means a right to be fired for no reason and a right to be exploited.
This is not living. This is not freedom. We are human capital.
So then what happens to those of us without the ability to hold down a forty hour a week (or more) schedule of labor outside the home? We are throwaways. If we are lucky, we earned enough or we were disabled early enough and our parents earned enough that we won’t be thrust into poverty by our inability to be constant income generators for those above us. Or maybe we allied ourselves romantically with someone who earns enough to keep us out of the disability-poverty continuum. If we are lucky, we won’t be completely thrown away in the human trash pile. If we are lucky, we aren’t institutionalized, ordered to AOT, or placed in myriad forms of guardianship.
If we are lucky.
A screening tool can be a very dangerous thing indeed. Screening tools lead to “treatment”, which often leads to poly pharmacy, and then to increasing disability, increasing loss of rights and freedom.
Britney Spears apologized for lying to us and saying she was ok. But Britney was just doing what many of us have learned the hard way to do. Grin and bear it. Don’t burden others. Smile. Fake it. Not because we don’t need and deserve help but because control often arrives cheerfully masquerading itself as “help” and “care”.
Miranda Lambert wrote a very poignant line into one of her songs. “It doesn’t matter how you feel, it only matters how you look.”
Message received. Yes, doctor, I sleep great. No I’m never unusually happy for too long. No I’m not depressed. Pain levels are great. Thanks, see you next year.
What a shame it’s come to this in order to be free in our “free country”. And what a shame so many learn this the hard way. And what a shame so many “helpers” are so invested in the business of further disabling rather than supporting.
Finally, I’ve learned the answer isn’t to refuse the screening, which brings its own level of suspicion because now you’re not playing along and walking nicely into the trap set for you. The answer is to know you need to lie, to practice the lie, and pretend like your life depends on it.
Let freedom ring.
I, too, lie on those screening tools. You have to, or you’ll be put on a med that makes you non-functional while doing absolutely nothing to improve your “symptoms” of depression or anxiety.
I try to fight. I am scheduled to chat with our local disability rights advocacy group today about “diagnostic overshadowing.” I wanted to make it a more global issue: Those with mental health diagnoses (past or present) do not receive the same medical care as those without.
And we die earlier as a result. Years earlier.
It is a serious problem up here and I’ve experienced it for years. I’d like it to be addressed legislatively.
I have two recent referrals from my PCP’s office that very clearly show evidence of serious issues, one of which is a 4.8 cm ascending aortic aneurysm! I have imaging and everything and, still, that referral goes over in detail my psychological diagnosis history and my past alcohol use (Last detox 2016, thank you very much.). The one to hematology goes so far as to call me a “difficult patient” who makes too many demands on staff time.
The office’s administrative chaos really isn’t my fault. Nor is the imaging department’s sloppiness. Both of which, again, I’ve documented.
I feel pretty strongly that I can prove a pattern of abuse and neglect with this doc that may have set my care back a year or more. But most people in the midst of serious trauma do not have the kind of energy I’m having to expend to get anyone to give a flying hairy rat fart in space.
I’ve been there. And you accept whatever help is given, even if it’s actually making you worse in the long run. At least, someone is listening. Right?
So it is vital that these unhelpful “screening tools” go away. If there is no standard of care associated that results in measured positive outcomes, why are we doing it?
Truthfully, I think is all tied up in systemic misogyny and the myth of “the hysterical female.” Women still do make up the majority of people prescribed psych drugs in the U.S. Bogus screening tools allow lazy doctors to ignore real issues, like autoimmune diseases, which often take years and a whole lot of dogged persistence to get diagnosed.
And you have to be willing to fight being routinely abused, gaslit, & diagnosed “crazy” the entire time.
Lying can work for you or against you on these various screening tools. Once, I lied or rather I made up something–a story answer–and I was described as hysterical and shallow. Well, no one had ever said before that I was shallow. I, honestly, think they set these screening quizzes up so that no matter how you answer, you are already deemed as needing some sort of diagnosis; which, of course follows with dangerous and harmful treatments; including drugs. Thank you.
The best plan, I think, is generally to refuse them politely. Remind them that you have a right to refuse medical treatment, and you’re choosing to decline. This would only be a problem if you are already on their “radar” as a “crazy person” (oops, I mean “Person suffering from mental illness!”), in which case, I think a very careful lying strategy would probably be safest. “Have you had difficulty sleeping?” “No, not at all. Sleeping great!” Etc. If you read up on the so-called “symptoms” of what they’re screening you for, it’s pretty easy to stay ahead of them.
When they run out of science, the go to is psych. Unless you ache and die like a stoic, you are defective.
It’s ALL BS. But they know they can, they know they got you overpowered. It’s totally a waste of time to say anything to them.
If ever one is in front of a shrink, say absolutely NOTHING. You will still get a label, but not based on your words. He will write whatever he wants to whether you look down, up, sideways, play with your fingers, yawn, stretch, move in your chair, or if you do nothing. SO? What does it matter. Miraculously, you will walk away with your little certificate of being defective, forever and ever, until you die.
You will have been known by everyone as being a mental case. The shrink or doc said so.
It is exactly the same as the powerful calling treason on someone. The courts were made up of all who agreed. And similarly, you lose your head over it and nothing you said could move the ignorant cold hearts.
Ha. If you say absolutely nothing, you may be labeled catatonic and given ECT!
The trick is to smile, nod, admit to some struggles here and there but assert you’re ordinarily happy and content with your life. No, you don’t hear things or see things. Of course you sleep great. You’re not too happy or too sad. You have reasonable goals like, you know, sewing up a pretty skirt or knitting a scarf. Nothing too fancy or outlandish. You appreciate the concern. Compliment the nice doctors and thank them for their time. Stay calm, don’t cry. Don’t fret. Walk out of the office. Don’t run.
And then you practice like you’re about to audition for a part in a play. Practice makes perfect. Throw fear out of your mind. Convince yourself it’s true. Play the part. This is how to survive.
The only I have ever been screened were when I went in for Vocational Rehabilitation Services which led me to mental health clinics which, of course, screened me there. When, I was put into the local mental illness hospital, they screened me there. They were attempting to make suggestions about things that never happened to me. Thus, the lesson I have learned about screening: stay away from agencies like Vocational Rehabilitation. They will not help you; but, only lead you to places that will make your situation so very worse. I know sometimes a GP, an Internist or OB-GYN Doctor might try to screen you. Or they might try to screen you in an emergency room visit or if you need to be admitted to a hospital for a “non-mental-health” reason. Those may be hard to handle; but, you can say no to referrals. I was referred to physical therapy; which is not psychiatry, etc. and I said no. Although, at times, it is very difficult, in the USA, we still have the right to refuse any medical treatment. Of course, lately, there have been times of increasing difficulty to retain this. This is important for us to have. It is our freedom as Americans. Medical Freedom is as important as all other freedoms. Thank you.
I do not think there is anything you can say to a doctor to change their mind about anything. I wouldn’t lose too much sleep trying.
Lies are hard to keep up. It’s probably safest to have a stock answer as to why you don’t participate in routine screenings. Something like, “Those screenings are a conflict of interest. The PHQ-9 & GAD 7 were written by Pfizer, which sells psychiatric pharmaceuticals. They did not provide those tools gratis out of the goodness of their hearts.”