{"id":43764,"date":"2014-02-07T19:21:09","date_gmt":"2014-02-08T00:21:09","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=43764"},"modified":"2014-02-07T19:21:09","modified_gmt":"2014-02-08T00:21:09","slug":"feels-wrong","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2014\/02\/07\/feels-wrong\/","title":{"rendered":"feels wrong…"},"content":{"rendered":"
I’ve recently waded into unfamiliar territory – screening for depression [beyond symptoms…<\/a>, the proposed study…<\/a>]. It’s an area that I don’t know a lot about. There’s no question that my sudden interest in the topic is a reaction to the Gibbons\/Kupfer CAT tests [open letter to the APA…<\/a>]. My anger at their undeclared Conflict of Interest is matched equally by a fear that this test is aimed at the waiting rooms of Primary Care Physicians. That doesn’t feel intuitively sound – more something that will up the general medication burden rather than improve health care. But I have no evidence other than the pregnancy\/post-partum studies I already posted [the proposed study…<\/a>]. But fortune shone through the clouds when this article showed up this week on the BMJ site, selected for the UNCERTAINTIES PAGE by David Tovey, editor in chief of the Cochrane Library<\/em>: <\/div>\n


<\/font><\/p>\n

[Note: I’ve chopped this article up in the service of space. If it’s something you’re interested in, you probably want to read it all on-line]<\/font><\/div>\n
\n
Does depression screening improve depression outcomes in primary care?<\/a><\/div>\n
by Brett D Thombs, Roy C Ziegelstein<\/div>\n
British Medical Journal<\/font><\/strong>. 2014 348:g1253.<\/div>\n
[full text on-line<\/a>]<\/div>\n

Major depression is present in 5-10% of patients in primary care, including 10-20% of patients with chronic medical conditions. Based on the prevalence and burden of depression, the availability of screening tools, and access to potentially effective treatments, routine depression screening has been proposed as a way to improve depression care. Depression screening involves the use of self administered questionnaires or small sets of questions to identify patients who may have depression but who are not already diagnosed or being treated for depression. Clinical practice guidelines do not agree on whether health professionals should screen for depression in primary care. The US Preventive Services Task Force [USPSTF] recommends screening for depression when enhanced, staff assisted, depression care programmes are in place to ensure accurate diagnosis and effective treatment and follow-up. The Canadian Task Force on Preventive Health Care previously endorsed a similar recommendation, but in 2013 recommended against depression screening in primary care, citing a lack of evidence of benefit from randomised controlled trials and concern that a high proportion of positive screens would be false positives.<\/p>\n

In the UK, the National Screening Committee has determined that there is no evidence of benefit from depression screening to justify costs and potential harms and has recommended against it. A 2010 guideline from the National Institute for Health and Care Excellence [NICE] did not recommend routine depression screening, but suggested that clinicians be alert to possible depression, particularly among patients with a history of depression or with a chronic medical condition… In contrast to these recommendations, between 2006 and 2013, the UK Quality and Outcomes Framework [QOF] financially rewarded routine depression screening of patients with coronary heart disease and diabetes in primary care. By 2007, 90% of eligible Scottish primary care patients had been screened, but outcomes were disappointing: 976 patients had to be screened for each new diagnosis of depression, and 687 for each new antidepressant prescription. The 2013-14 QOF no longer included depression screening as a quality indicator.<\/p>\n

Thus, screening for depression is sometimes encouraged in primary care guidelines and is often encouraged via other mechanisms, such as expert opinion articles in the medical literature. It is not clear, however, that screening would benefit patients…<\/p>\n

What is the evidence of uncertainty?<\/font><\/strong> <\/strong><\/font>A depression screening programme can be successful only if patients not already known to have depression agree to be screened, if a substantial number of new cases are identified with relatively few false positive screens, and if newly identified patients engage in treatment with successful outcomes. An assessment of the effect of a screening programme on depression outcomes must separate the effect of screening from the effect of providing additional depression treatment resources not otherwise available, such as staffing for collaborative depression care. Thus, randomised controlled trials of depression screening must fulfil at least three key criteria: [1] determining eligibility and randomising patients before screening; [2] excluding patients already known to have depression or already being treated for depression; and [3] providing similar depression care options to patients in both trial arms, whether they are identified as depressed by screening or via other methods, such as self report or unaided clinician diagnosis.<\/p>\n

We searched Embase, PubMed, PsycINFO, Scopus, and the Cochrane Library for systematic reviews on the effect of depression screening on depression outcomes and for randomised controlled trials conducted in primary care settings that fulfilled the three criteria we have described for tests of depression screening. This search was partly based on that for our own systematic review.<\/p>\n

We identified three systematic reviews. A systematic review done in conjunction with the recent Canadian guideline did not identify any randomised controlled trials of depression screening. A 2008 Cochrane systematic review, on the other hand, assessed five randomised controlled trials and reported that depression screening did not reduce depressive symptoms [standardised mean difference −0.02 (95% confidence interval −0.25 to 0.20)]. In contrast to this, a systematic review done in conjunction with the 2009 USPSTF depression screening guideline included nine randomised controlled trials and concluded that depression screening benefitted patients when done in the context of staff assisted collaborative care but not in the context of usual care without these services…<\/p>\n

Overall, no trials in the Cochrane review or USPSTF review fulfilled all three criteria for a test of depression screening…<\/p>\n

We did not identify any randomised controlled trial that tested whether screening with collaborative depression care would be more effective than collaborative care without screening…<\/p>\n

We did not find any studies that reported the degree to which administering depression symptom questionnaires improved diagnostic accuracy for depression among patients suspected by healthcare providers of having depression.<\/p>\n

Is ongoing research likely to provide relevant evidence?<\/font><\/strong> We searched ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform for ongoing trials intended to evaluate the effects of depression screening, but did not find any studies that fulfilled the criteria for tests of depression screening…<\/p>\n

What should we do in the light of the uncertainty?<\/font><\/strong> The absence of evidence that routine screening of all primary care patients or even screening of only high risk patients improves depression outcomes does not take away from the importance of depression as a condition that negatively affects quality of life and may respond to treatment. It only means that there is insufficient evidence to recommend screening as a strategy to identify the condition…<\/div>\n<\/blockquote>\n
Like with the WHO criteria and the findings of that Canadian Review of screening pregnant and postpartum women [mentioned in the proposed study…<\/a>], there are recommendations for depression screening, but there’s little or no evidence that it’s of use from a public health perspective. My objections go further than that. I don’t really think depression is usually a thing. It’s an emotion. And there’s a downside to seeing it as a thing [unless it is, like Melancholia]. In the little clinic where I volunteer, I see an occasional person with what I would call a Depression, a thing, but most people use the term as a synonym for unhappy, or sad, or frustrated, or any number of negative experiences. I don’t mind the imprecise grammar, but I do mind that they think it’s a thing they have – a thing they think should be amenable to medication. We’ve taught them that with our television ads and our DSMs and the way we act in our offices. It hasn’t been a good lesson and I worry that screening will be more of the same – and worse than seeing emotional pain as a thing is the notion that we need a psychometric to ferret it out.<\/div>\n

At the risk of being preachy, being attuned to the emotional state of a patient is no different than noticing that they’re covered with a rash, or jaundiced, or gasping for breath, or have a knife sticking out of the middle of their forehead. To my mind, the results of a depression screening test are just something else to put on the ubiquitous computer screens that medical personnel look at rather than their patients [that’s a preachy part]. They finally took the computer out of my office because I didn’t use it, even for prescriptions [even though I’m something of a computer guy]. The point is that no matter what the tenets of modern psychiatry or medicine teach, emotional discomfort is best evaluated in inter·<\/font><\/strong>subjective space. If we’re missing a lot of emotional illness, it says something about us, not our tools. We’re not properly inhabiting the offices where we meet our patients [preaching again].<\/p>\n

I have had kind of a rule not to talk like this here. The point of this blog is to focus on areas where medicine has been corrupted by commercial or ideological influences, and this may be my own ideology peeking out. I just can’t think of another way to talk about my actual objection to screening for mental health. It just feels wrong. And I think my attraction to this review is that it confirms what I already thought…<\/div>\n","protected":false},"excerpt":{"rendered":"

I’ve recently waded into unfamiliar territory – screening for depression [beyond symptoms…, the proposed study…]. It’s an area that I don’t know a lot about. There’s no question that my sudden interest in the topic is a reaction to the Gibbons\/Kupfer CAT tests [open letter to the APA…]. My anger at their undeclared Conflict of […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-43764","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/43764","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=43764"}],"version-history":[{"count":19,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/43764\/revisions"}],"predecessor-version":[{"id":43783,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/43764\/revisions\/43783"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=43764"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=43764"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=43764"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}