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Occam’s razor<\/a>, also known as Ockham’s razor, and sometimes expressed in Latin as lex parsimoniae [the law of parsimony, economy or succinctness], is a principle that generally recommends selecting from among competing hypotheses the one that makes the fewest new assumptions. The strict translation is "Plurality is not to be posited without necessity."<\/em><\/font><\/sup><\/p>\n <\/p>\n …<\/font><\/strong><\/p>\n Conclusion<\/font><\/strong><\/em>: We hope that a rigorous review of current evidence will encourage the developers of future guidelines, including members of the Canadian Task Force on Preventive Health Care, to carefully consider their stance on screening for depression. We also hope that, consistent with the 2010 guidelines of the National Institute for Health and Clinical Excellence, such developers will conclude that evidence from well-conducted, randomized, controlled trials of the benefit of screening, in excess of its likely harms and costs, is needed before it can be recommended in primary care settings. Specifically, the benefits and harms of screening should be tested in a trial in which all patients identified as having depression should have access to the same integrated care for their condition, regardless of whether they are identified through screening in the intervention group or via physician recognition and referral in a control group. It is possible that such a trial would find that screening benefits patients to a degree that would justify the cost and the harms associated with the process. Until then, however, given the lack of evidence of benefit from screening and the concerns that we have described, it is not reasonable to simply assume that depression screening is good policy.<\/p>\n …<\/font><\/strong><\/p>\n Conclusion<\/font><\/strong>: …<\/font><\/strong><\/p>\n Screening is not recommended. In the US, it says don’t screen unless<\/u> you are in a system that can offer full services to evaluate, treat, and follow-up the results. <\/p>\nIn a reflection…<\/a> I was talking about screening for depression [waiting room screening], having encountered it as both patient and doctor at the beginning of the week of Thanksgiving. I ended by saying:<\/div>\n\n
But I did decide that chasing this down would be worth the effort. It might take a while because this has obviously worked its way into government guidelines. So I’m going to table it for a time when I run out of other things to look into. In the meanwhile, I’m going to see how it worked its way into my clinic.<\/div>\n<\/blockquote>\n…thinking that with all the references that appeared when I looked into the why of things, there was a lot of reading between where I was and where I needed to be to understand why both my personal doctor and the clinic I work in were screening people for depression in the waiting room with questionnaires. So I started looking for meta-analyses and studies to figure it all out. Finding the answer to the why of this business of screening for depression had suddenly come into my life turned out to be much simpler than I thought it might be. Occam’s Razor<\/font><\/em> proposes that the simplest explanation is usually right. And this is a prime example.<\/div>\nIt takes just a couple of representative articles to summarize essence of this story. So let’s start with Canada. Back in 2005, the Canadian Task Force on Preventive Health Care<\/a> had recommended depression screening. In 2012, there was a strong review article summarizing the available information in the interim. Like the Cochrane Review in a reflection…<\/a>, they concluded that the Task Force should reconsider that recommendation:<\/div>\n\n
Rethinking recommendations for screening for depression in primary care<\/a><\/div>\nby Brett D. Thombs, PhD, James C. Coyne, PhD, Pim Cuijpers, PhD, Peter de Jonge, PhD, Simon Gilbody, DPhil, John P. A. Ioannidis, MD DSc, Blair T. Johnson, PhD, Scott B. Patten, MD PhD, Erick H. Turner, MD, and Roy C. Ziegelstein, MD<\/div>\nCanadian Medical Association Journal<\/font><\/strong>. 2012 184[4]:413-418.<\/div>\n[full text online<\/a>]<\/div>\n
The prevalence of depression and the availability of easy-to-use screening instruments make it tempting to endorse widespread screening for the disease. However, screening in primary care is a resource-intensive endeavour, does not yet show evidence of benefit and would have unintended negative effects for some patients. Evidence from one simulation study using Canadian national data found that the overall burden of depression could be reduced by providing more consistent treatment to reduce symptoms and prevent relapse among people with recurrent disorders, but not by increasing treatment through screening.<\/p>\nKey points<\/font><\/strong><\/div>\n\n
Screening for depression in primary care is recommended in the United States and Canada under certain conditions, but not in the United Kingdom.<\/div>\n<\/li>\nNo trials have found that patients who undergo screening have better outcomes than patients who do not when the same treatments are available to both groups.<\/div>\n<\/li>\nExisting rates of treatment, high rates of false-positive results, small treatment effects and the poor quality of routine care may explain the lack of effect seen with screening.<\/div>\n<\/li>\nDevelopers of future guidelines should require evidence of benefit from randomized controlled trials of screening, in excess of harms and costs, before recommending screening.<\/font><\/strong><\/div>\n<\/li>\n<\/ul>\n<\/blockquote>\nAnd that is, in fact, exactly what the Canadian Task Force on Preventive Health Care<\/font><\/strong> recommended the next year:<\/div>\n\n
Recommendations on screening for depression in adults<\/a><\/div>\nCanadian Task Force on Preventive Health Care<\/font><\/strong><\/div>\nCanadian Medical Association Journal.<\/font><\/strong> 2013 185[9]:775-782.<\/div>\n[full text online<\/a>]<\/div>\n
Our recommendations highlight the lack of evidence about the benefits and harms of routinely screening for depression in adults. In the absence of a demonstrated benefit of screening, and in consideration of the potential harms, we recommend not routinely screening for depression in primary care settings, either in adults at average risk or in those with characteristics that may increase their risk of depression. However, clinicians should be alert to the possibility of depression, especially in patients with characteristics that may increase their risk of depression, and should look for it when there are clinical clues, such as insomnia, low mood, anhedonia and suicidal thoughts.<\/p>\nSummary of recommendations for clinicians and policy-makers<\/font><\/strong>:
Recommendations on screening for depression in primary care settings are provided for people 18 years of age or older who present at a primary care setting with no apparent symptoms of depression. These recommendations do not apply to people with known depression, with a history of depression or who are receiving treatment for depression.<\/div>\n\n
For adults at average risk of depression, we recommend not<\/u> routinely screening for depression. [Weak recommendation; very-low-quality evidence]<\/div>\n<\/li>\nFor adults in subgroups of the population who may be at increased risk of depression, we recommend not<\/u> routinely screening for depression. [Weak recommendation; very-low-quality evidence]<\/div>\n<\/li>\n<\/ul>\n<\/blockquote>\nTheir report is accompanied by a sensible Commentary<\/font><\/em>:<\/div>\n\n
Why screening for depression in primary care is impractical<\/a><\/div>\nby Roger C. Bland CM MB ChB, David L. Streiner PhD<\/div>\nCanadian Medical Association Journal<\/font><\/strong>. 2013 185[9]:753-754.<\/div>\n[full text online<\/a>]<\/div>\nKey points<\/font><\/strong><\/div>\n\n
There is little evidence of sufficient quality to guide practitioners about what type of screening, if any, to use to detect depression in adults in primary care settings.<\/div>\n<\/li>\nThe number of false-positive screens with current assessment tools is too high, and the follow-up required to rule them out too time-consuming, to justify routine screening for depression in primary care practices.<\/div>\n<\/li>\nIf false-positive screens are not ruled out. patients are at increased risk of receiving the wrong diagnosis and inappropriate treatment.<\/div>\n<\/li>\n<\/ul>\n<\/blockquote>\n![](\"http:\/\/1boringoldman.com\/images\/cmaj.gif\")
Summary for Canada, US, UK
table from the Canadian Task Force on Preventive Health Care 2013<\/em><\/sup><\/p>\nSo you might be asking at this point, "How this is a post to explain why 1boringoldman’s doctor and 1boringoldman’s clinic are both doing routine waiting room depression screening?" But that’s because you’re not thinking about the right thing – that Occam’s Razor proposes that the simplest explanation is usually right. And the answer is pretty simple. They’re doing waiting room<\/font><\/strong><\/em> depression<\/font><\/strong><\/em> screening because they’re getting paid to do waiting room<\/font><\/strong><\/em> depression<\/font><\/strong><\/em> screening.<\/font><\/strong><\/em><\/div>\n\n