Tuesday, May 15, 2018

Unexamined assumptions and unintended consequences of routine screening for depression

Unexamined assumptions and unintended consequences of routine screening for depression. Lisa Cosgrove et al. Journal of Psychosomatic Research, Volume 109, June 2018, Pages 9-11. https://doi.org/10.1016/j.jpsychores.2018.03.007

1. Assumption 1: The condition has a detectable early asymptomatic stage, but is progressive and, without early treatment, there will be worse health outcomes

2. Assumption 2: In the absence of screening, patients will not be identified and treated

3. Assumption 3: Depression treatments are effective for patients who screen positive but have not reported symptoms

4. Unintended consequence 1: overdiagnosis and overtreatment

5. Unintended consequence 2: the nocebo effect

6. Unintended consequence 3: misuse of resources

7. Conclusion
The therapeutic imperative in medicine means that we are good at rushing to do things that might “save lives” but not good at not doing, or undoing [30] (p348).

Sensible health care policy should be congruent with evidence. As Mangin astutely noted, our goodhearted desire to “do something” often undermines our ability to interrogate our assumptions and accept empirical evidence. Before implementing any screening program there must be high-quality evidence from randomized controlled trials (RCTs) that the program will result in sufficiently large improvements in health to justify both the harms incurred and the use of scarce healthcare resources.

Helping people who struggle with depression is a critically important public health issue. But screening for depression, over and above clinical observation, active listening and questioning, will lead to over-diagnosis and over-treatment, unnecessarily create illness identities in some people, and exacerbate health disparities by reducing our capacity to care for those with more severe mental health problems—the ones, often from disadvantaged groups—who need the care the most.