Screening
I was idly scanning my Google News alerts this morning to see if there was something I wanted to write about when this caught my eye: Start year with mental health screening where readers are directed to a site, benignly called "Help Yourself, Help Others", where screening tools for alcoholism, depression, bipolar disorder, and PTSD are available to be taken online. That sounds benign, doesn't it?
So I took the one for depression -- and mind you my mental state is pretty normal. I answered questions fairly honestly which meant most got a not at all or some of the time, the two lowest frequency choices. I said I had never been treated for any of the disorders being screened for. And low and behold, the results suggested that I might be bi-polar! Now what might lead to that as a possibility?
Well consider this question: " Have you ever had a week or more of sustained, excessively irritable mood, with anger, arguments, or breaking things that led to difficulties with others?". I am almost 65 years old. Yes, I have had a week like that in my life. I raised kids!
The results, as I suspected, trigger a suggestion of a problem if one or more questions is answered at the to the lowest level.
So I decided to see who funds this screening? And surprise surprise surprise -- everyone on the board of Screening for Mental health receives funding from pharmaceutical companies and the screening tool itself is underwritten by them.
In a book I am reading, Against Health, by Jonathan Metzl and Anna Kirkland, the idea of what is health is considered in a series of essays. The book is well worth reading . In an article in The New Scientist, Metzl says:
"Suppose a patient is discussing test results that show borderline abnormality in bone density, cholesterol, or blood pressure. The usual presumption is that the test has detected some objective feature of the patient's body we can treat, just as if she or he had a burn or a broken bone. Perhaps there would be more tests, some drugs, and eventually a label, such as "osteopenia" or "pre-diabetes".
Shared scepticism between doctor and the patient could be helpful in removing some of the mystery from what is bound to be a stressful encounter. What did the test really measure? Would the treatment regime require giving up something pleasurable or convenient, and if so, what would all the pros and cons look like?
Bringing these questions into the discussion would mean the measure of health (the test) had been "denaturalised" - that it would no longer be taken for granted and instead become something that could be critically examined. That way, alternative notions of life and health would have entered the conversation."
Let's take our screening test. If we do not assume that the test is actually measuring something wrong, then the results that I got would be subject to scrutiny and discussion and in the process, it would be discovered that these "symptoms" I endorsed had other and perfectly reasonable and ordinary explanations and are not indicative of any mental disorder.
But, consider this:
In an essay entitled "To Overhaul the System, ‘Health’ Needs Redefining", H. Gilbert Welch says:
"In the past, people sought health care because they were sick. Now the medical-industrial complex seeks patients. It encourages those with minor symptoms to be evaluated and urges those who feel well to get “checked” — just to make sure nothing is wrong.
So, if health is the absence of abnormality, the only way to know you are healthy is to become a customer.
But healthy people aren’t great customers; they’re like the people who pay off their entire credit card balance each month. The money is in those in whom an abnormality can be found.
The medical-industrial complex has made that relatively easy to do.
It develops diagnostic technologies able to find smaller and smaller abnormalities. So more and more of us are found to have damaged cartilage in our knees, bulging discs in our backs, and narrowed blood vessels throughout our bodies. And far too many are also found to have “spots” or “shadows” that are seldom significant but are said to be “worrisome.” So more and more of us have knee surgery, back surgery, angioplasty and more diagnostic investigation."
and
"Some believe that finding more abnormalities is the right strategy to improve the nation’s health, but how much it reduces death and disability is open to debate. The new abnormalities being found are generally not severe, but mild: they are not life-threatening, and in many patients they won’t ever produce symptoms. When the benefit of treatment is known, it is known to be small — so small that many people, sometimes hundreds, must be treated for one person to benefit. But more often than not, the value of treating these mild abnormalities is simply not known."
I have not seen any data on the benefit to patients of the mental health screening tool. The benefit to prescribers is obvious -- more patients. But is there any evidence that lives are saved? Are the side effects of SSRIs really worth treating mild depression, for which these drugs are least effective? Or is the benefit only to those who profit from them?
Has anyone seen any data about how many people end up receiving treatment because of these screenings? Or how many of them actually saw themselves as perhaps needing help before the screening?
Mental health screenings are being urged as part of health care. What do you think? Me -- I am profoundly skeptical.
