Depression affects millions of Americans. Many of them know it; many others don’t. In an effort to reveal — and treat — hidden depression, the United States Preventive Services Task Force has reaffirmed that doctors should screen all adults and adolescents for depression.
Screening means checking a seemingly healthy person for signs of hidden disease. It is done for all sorts of ailments, from high blood pressure and osteoporosis to breast and prostate cancer.
Although screening sounds like it is straightforward and completely beneficial, it can lead to overdiagnosis and overtreatment. STAT asked two experts to weigh in on the benefits and the possible hazards of screening for depression.
Karina W. Davidson: Screening can “open the door” for people with hidden depression
Allen Frances: Screening identifies many as depressed who really aren’t
By Karina W. Davidson: The US Preventive Services Task Force believes that screening all adults and adolescents for depression has several benefits.
Depression is common, affecting about 8 percent of adolescents and adults. It causes suffering for the patient as well as for his or her family. Depression in a pregnant woman or new mother can affect her children. This disease has a profound impact on individuals and our society. Screening for depression, and following that screening with effective treatment, can reduce the burden of depression.
The stigma associated with depression prevents some individuals from telling their health care providers they are feeling depressed. Asking clinicians to routinely screen their patients for depression can open the door and let patients describe their feelings and find ways to alleviate their suffering.
Depression can also have a ripple effect on an individual’s overall health. It can make it difficult to exercise, lose weight, quit smoking, or take medications to control high blood pressure, diabetes, and other chronic conditions. Identifying undiagnosed depression and treating it may help these patients better manage their health.
Although screening by clinicians is important, it doesn’t mean that individuals should wait to be asked about depression. If you are feeling inexplicably sad, or have lost interest in activities or people you used to enjoy, tell your health care provider. Depression can and should be treated.
Karina W. Davidson, PhD, a member of the US Preventive Services Task Force, is a clinical psychologist and professor of behavioral medicine at Columbia University Medical Center.
By Allen Frances: Routine screening for depression is wrong on several levels.
It perpetuates a huge mistake made in 1980 as part of the update of the Diagnostic and Statistical Manual of Mental Disorders, psychiatry’s “bible” for defining mental illness. It combined two distinct types of depression under the single label “major depressive disorder.” One type, known as melancholia, or endogenous depression, causes severe trouble eating, sleeping, feeling, moving, and talking, along with unbearable sadness worse than losing a loved one, severe agitation, and sometimes delusions. The other type, known as reactive depression, is more common and much milder, on a continuum with the normal sadness that comes with daily life.
In lumping together these two very different severities of depression, “major depressive disorder” was often no longer really major, or depressive, or even a real disorder. This helped medicalize the inevitable disappointments, stresses, and losses that are part of everyday life. The pharmaceutical industry exploited the loose definition with misleading marketing claims that all depression is due to a chemical imbalance in the brain that requires treatment with a pill. Today, 11 percent of Americans take an antidepressant; among women over 40, the rate is 25 percent.
Screening tests — especially the brief ones used by primary care clinicians — can’t judge clinical significance. They aren’t specific, meaning they identify as depressed a large number of people who really aren’t and who would do just fine with the simple passage of time, natural resilience, family support, and/or brief counseling. But far too often they won’t be given a chance to get well on their own. Instead, harried clinicians prescribe pills as the easiest way to get the patient out of the office. Insurance companies make things worse by not paying for careful diagnosis and further encourage a rush to medication.
Routine screening of all adults and adolescents would ramp up this already excessive treatment of the mildly ill and worried well. It would also further burden primary care clinicians, giving them yet another box to tick off and reducing precious quality time spent caring for their patients.
Instead of screening all adults and adolescents for depression, our efforts would be better spent identifying and helping those with true clinical depression. It doesn’t make sense to create an army of fake “patients” when hundreds of thousands of Americans with serious depression and other mental health issues slip through wide cracks in our broken health care system and receive minimal or no treatment.
Allen Frances, MD, is professor emeritus of psychiatry and behavioral sciences at Duke University School of Medicine and author of “Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life.”