Editorialby Charles F. Reynolds III, MD and Ellen Frank, PhDJAMA Psychiatry. 2016 73[3]:189-190.The US Preventive Services Task Force [USPSTF] has recommended screening for depression in the general adult population, including pregnant and postpartum women, with the use of brief, self-report instruments like the Patient Health Questionnaire 9 that typically take less than 5 minutes to complete. It further underscores the need for screening to be linked with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. The recommendation is silent, however, with respect to the ideal screening interval and the settings with highest potential yield. These are major shortcomings in our opinion.
In our view, this recommendation, while more limited in scope than is warranted by the available data, is nonetheless of first-rank importance, given the immense public health burden of depression across the life cycle and its downstream sequelae. The latter include recurrence of major depressive episodes and chronic illness course, emergence of treatment resistance, poor adherence to treatment for coexisting medical disorders, amplification of disability and of family caregiver burden, and increased risk for dementia, suicide, and early mortality from co-occurring medical disorders.
A central feature of the USPSTF recommendation, which we endorse whole-heartedly, is the need to integrate behavioral health services and primary care medicine. Most patients with major depression receive treatment in the general medical, not specialty mental health, sector. This state of affairs reflects patient preferences, issues of stigma that pose a barrier to help seeking [especially among racial and ethnic minorities], lack of an adequate mental health workforce, difficulties navigating the mental health care “system” and accessing expertise, and financial barriers to receiving mental health services…
Our view is that the risk architecture inherent in major depression should inform recommendations for screening intervals, especially in patients who have experienced episodes of major depression. In our opinion, annual screening for depression and its recurrence would be medically appropriate, given the liability of patients with previous episodes for recurrence and chronicity. There is now a strong evidence base for the efficacy of maintenance pharmacotherapy and psychotherapy to reduce the risks for recurrence and chronicity…
Another strong rationale for shorter screening intervals, on the order of 6 to 12 months, is the high prevalence of subsyndromal depression in primary care patients, especially in persons living with psychosocial and medical risk factors. Such patients can benefit from what has been termed by the Institute of Medicine indicated prevention of depression (and other associated common mental disorders) in order to prevent transitions to episodes of frank clinical (major) depression or to prevent chronicity of subthreshold symptoms and their disabling effects…
"Dr Frank receives royalties from the American Psychological Association and Guilford Press; she and her spouse serve on an advisory board to Servier International; she and her spouse have equity in HealthRhythms and Psychiatric Assessments, Inc. No other disclosures were reported."
11/20/2013 Failure to Report Financial Disclosure Information
by Gibbons, Weiss, Pilkonis, Frank, and Kupfer.
JAMA Psychiatry. 2013 71[1]:95.
"To the Editor We apologize to the editors and readers of JAMA Psychiatry for our failure to fully disclose our financial interests in an article that reported a diagnostic tool, the Computerized Adaptive Test for Depression [CAT-DI]… Lead author Robert D. Gibbons, PhD, is the president and founder of PAI, which was incorporated in Delaware in late 2011, then registered to do business in Illinois in January 2012. Dr Gibbons awarded “founder’s shares in PAI” to us, yet all 5 of us failed to report our financial interests in connection with our article and again in a Reply to Letters to the Editor regarding the article… Our submitted disclosure lacked transparency, and we regret our omission."
ADDENDUM: And if that’s not enough Screening/Measurement Conflict of Interest for you, check out HEALTHRHYTHMS…
Was looking for a recent post this would fit but can’t find one so will ask this here. Happened upon an older Real Psychiatry post and saw this (bolding mine):
“8. Neuroscience – This is the future of the field. There will be no demand for psychiatrists in the future who don’t know brain science and how it can be applied diagnostically or therapeutically. It is the logical basis to study human consciousness, complex decision making and psychiatric disorders and contrary to what you might read on many blogs there has already been considerable progress in this area. There are many excellent psychiatrist-researchers in this area already and I encourage reading their research and some of their popular works as a starting point. There are any number of Luddites out there who seem to think that psychiatry needs to remain stagnated in the 1950s to provide any value. I don’t think there is a shred of evidence to support that contention or that neuroscience will never be of value to psychiatrists. A good starting point would be to read Kandel’s 1979 article on plasticity, his recent article on nicotine as as a gateway drug, and everything that he has written in between. If your department has a neuroscience section, asking them to compile a reading list of what they consider to be the top neuroscience papers that apply to the field would be an added bonus.”
http://1boringoldman.com/index.php/2015/06/01/the-talk-that-matters/
http://1boringoldman.com/index.php/2015/03/13/yellow-brick-roads/
http://1boringoldman.com/index.php/2015/05/31/lets-pretend/
1bom is clearly one of “many blogs”
Interestingly I suspect that both of you would agree with the last paragraph of this blog:
http://www.psycritic.com/2015/04/psychiatry-as-clinical-neuroscience-why.html
So if we aren’t defining the application of brain science (neuroscience?) diagnostically or therapeutically in Insellian terms, I would love to see what a 1bom and/or Bernard Carroll version of “there has already been considerable progress in this area” would be. NOT as defined by the Insels and Nemeroffs, but from a grassroots level up?
Where the translation is a genuine clinical value add in the present?
Our Feel Good War on Depression?
http://www.nytimes.com/2013/04/28/magazine/our-feel-good-war-on-breast-cancer.html
Are all psychiatric patient or professional organizations build on either the Susan Komen or the “anti/critical-psychiatry” models?
Any people with melancholia (or family members of people suffering from melancholia) who can start to call BS on the focus on awareness raising and mass screening? To parallel the metastatic breast cancer survivors who are questioning the setting of priorities?
Is what is being described in the paragraph below not a clear parallel to D.C.I.S.?
“Another strong rationale for shorter screening intervals, on the order of 6 to 12 months, is the high prevalence of subsyndromal depression in primary care patients, especially in persons living with psychosocial and medical risk factors. Such patients can benefit from what has been termed by the Institute of Medicine indicated prevention of depression (and other associated common mental disorders) in order to prevent transitions to episodes of frank clinical (major) depression or to prevent chronicity of subthreshold symptoms and their disabling effects…”
That particular mix that Orenstein voices is not being spoken by APA, AACAP, or NAMI. Nor is it being spoken at Mad in America nor necessarily through the Critical Psychiatry movement.
We need those kind of voices from the patient advocacy side for Depression. Depression with the big D.
http://undark.org/article/smartphone-apps-mental-health/
(the last paragraph here might be of particular interest)
http://medcitynews.com/2016/03/startup-healthrhythms-mental-health/
http://www.businesswire.com/news/home/20160310006359/en/HealthRhythms-Launches-Mission-Redefine-Mental-Health-Understood
https://healthrhythms.com/en/#home
http://imaginecare.com/
The point is NOT just conflict of interest. That term causes people’s eyes to glaze over. Or transform the term to confluence of interest. It is more the possibility of dereliction of duty (which happens in this instance to be based of COI, and it need not be financial). This is a subtle point, but an important one I think. This post happened to accidentally, but starkly, capture that dereliction:
http://psychiatrist-blog.blogspot.com/2012/07/dsm-5-more-dynamic.html
“But I don’t see how the DSM-5 captures the dynamic nature of mental illness.”
Right. Because the DSM-5 didn’t. But that was irrelevant. Because in retrospect the point perhaps wasn’t so much the DSM-5 itself as the “dynamic nature” pitch. And, as Allen Frances points out, whether Kupfer’s “interest” was driven by money or zealous belief or both, his actions made the evolution of the manual secondary.
The process of making the mood section of the DSM-5 more useful to practicing psychiatrists, or at the very least less likely to get in our way, seems of little import in the brave new world of HealthRhythms?
One could possibly conclude that Kupfer and Frank abandoned (they were present in body but not in spirit) the DSM-5 process at some point, assessing that it simply could not serve their main goals. Those goals might be driven by ideology as much as money.
It’s what led Costello to resign from the process in 2008
http://1boringoldman.com/index.php/2014/01/03/dsm-5-retrospective-ii/
http://1boringoldman.com/index.php/2014/01/11/top-down-problem/
http://1boringoldman.com/index.php/2014/03/31/the-summer-of-09-five-years-later/
Whether the eventual DSM-5 did little to no good for clinical psychiatrists, or whether it actually hampers their work, is secondary. Because we are an anachronism.
Strange how in the end many of these issues may still circle around to the availability of raw data:
‘”When private companies make claims for their apps, he said, “they don’t give the raw data” ? just summaries of proprietary data. “In order for the field to grow, researchers need to be able to replicate studies,” he went on. “This lack of transparency is an obstacle which must eventually be addressed.”‘
“Proprietary Data”
Neuroskeptic looked at this aspect in one of his posts:
http://blogs.discovermagazine.com/neuroskeptic/2014/01/25/psychiatrists-another-dimension-part-2/
It’s interesting. You’re more worried about the “Proprietary Data” part, and Big Pharma has been the most obsessed with enshrining that aspect. Dawson is more focused on the devaluing and marginalization of the psychiatrist, and Managed Care has been the bigger driver of that.
The mixture of the two is particularly toxic.
Am struck by a line from neuroskeptic’s post: “from the perspective of you, the doctor using them (and by extension, the patients)”
Kupfer, Frank, et al seem far removed from that perspective. Of you, the doctor. “HealthRhythms customers include health insurance companies, health systems, and leading care providers focused on preventative approaches to health.” Yup.
Anyway, way too rambling, and my head is starting to swim because I don’t know in the end how this all comes together, but maybe the links will be of interest.
An argument could be made that Kupfer hijacked the DSM-5 creation process.
I love that term, Psy-borg Psychiatry! It is so appropriate, kudos to you for that one, Dr N!
And in that vein, let’s look at the most popular example in entertainment, the Terminator series, and how the cyborg will stop at nothing to achieve his purpose, his agenda, and his mission.
Which really is equivalent to what the APA is about, their purpose, agenda, and mission. It is “we are more than relevant, we set the goals of mental health care, we dictate how our minions, er, colleagues will be trained to practice, and we are not wrong in our conclusions”. Oh, and those who dissent, “they are to be ignored and marginalized, and then ostracized”. I’ll give them credit for that last agenda, yes, inappropriateness must be marginalized and ostracized, but, for the APA, wow, projection at it’s finest.
Again, I will say and write this until I die, why do people belong to the APA who claim to be advocates and defenders for the mentally ill, when their organization is beyond complicit to agendas that do not consistently nor genuinely advocate and defend the mentally ill.
Hey, you want a parallel today? Why are there an entrenched 15% of this population who continue to support Donald Trump when his candidacy has serious flaws that need to be addressed by citizens who have a clue?
I end with this, that I will write a post later today in more depth, but, you need to look at the apologists and defenders and their rhetoric of “compassionate” tolerance of people and agendas that are just outwardly harmful to the public.
I have a YouTube snippet from a post a few weeks ago of when the character Loki in the first Avengers movie makes the crowd bow to him, and he says to humans “you were meant to be ruled”. When the old man rises and say, “there will always be men like you [of evil and nefarious agendas]”, that is not disputable. But, why are there always a sizeable crowd that validates we have to tolerate men like the Lokis, but in real life you know who to substitute as hideous examples?
Sad state of affairs, no matter who you are, where you live, what you do for a living, and what you strive to do, there will always be men, and women, who live to rule and be cruel.
Psy-borg Psychiatry, can I use that at my site, I will definitely give you credit for the term?!
Don’t worry, the APA was all over it and said back to business as usual:
http://1boringoldman.com/index.php/2014/01/19/why-again/
https://www.youtube.com/watch?v=9cWnubJ9CEw
First of all, thanks for the use of the term.
Now, sorry to vent here, but, I think the following relates a bit to your post, so bear with me, I will honestly do my best to keep it short and sweet, but really it is sour:
Who are these cretins who masquerade as alleged leaders and KOLs for the profession, really, do they think themselves so insulated and impervious to consequences from their flagrant profit gaining motivation from medication use to promote this BS cloaked as professional inroads???
I read Allan Tasman’s editorial column in the recent issue of Psych Times (which I have tried to link but for some reason I seem to have the issue before the Net does?) where he goes on some ramble about the RAISE study, but then in the last 1/4 on another page, he then goes off about screening for all women who are pregnant for depression.
I kid you not, this is what this moron writes, “Only recently, however, has psychiatric research revealed that depression during pregnancy is not only a a concern in its own right, but it also serves as a marker for those who might be at greater risk for postpartum depression.”
Fine, that so far has some credibility, but then,
“As important as this recommendation is, the media reports neglected to emphasize the more broadly important recommendation for the adult population. This means that not only should depression screening that ensures and accurate diagnosis be implemented for ALL adults, but that effective treatment and appropriate follow up must also be implemented. We in the psychiatric community have been advocating for this for decades, but now come the force of an expert panel from the federal government that recommends both screening and treatment availability with their second highest of 5 levels of certainty of positive population benefits.”
(note I had to type all of that above as no link to copy). What a jerk to just acquiesce to what the government says, are these idiots who claim to set precedence even thinking for a millisecond that there are not easy definitions for illness, much less giving the illusion that patients have to participate and accept treatment recommendations?
It is F—–g Obamination care, plain and simple, and for “colleagues” to write this septic laden deposit just really pisses me off !
I just want to say to colleagues who read here this simple point: advising women to be more accepting of medication in pregnancy while these jerks in ivory towers or tenured appointments of “emeritus” or other lifelong props as academic scions who think they are immune to prosecution, civil or felony in nature for perverse ideations that meds in pregnancy outweigh any risks, needs to be rectified.
Ironic I use that term in the end of that last sentence, eh !?!?!?!
Thank you for the opportunity to write this, maybe it will be read early next week, I have too much time this weekend for Net surfing…
I had no idea about computerized “adaptive testing” for depression (perhaps because I don’t read psych journals, knowing they contain little trustworthy info) and the involvement of some of the DSM V crowd. So great to have 1boringoldman pull all this context and history together.
I have to admit I was ambivalent about this recommendation—my gut said bad idea—but I do respect the USPSTF and have not reviewed all the evidence myself as they have. I appreciated their caveat that:
“screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment and appropriate followup.” I also liked the fact that they singled out CBT for treatment of depressed pregnant and postpartum women (not that some will not benefit from medication).
As I’ve thought further about it, it’s more likely that screening as it is practiced will simply add to the culture of check-box medicine, rather than actually looking at and listening to patients.