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Sometimes the noblest ambition can result in the worst unintended consequences.
The US Preventive Services Task Force is suggesting primary care doctors screen all adults for depression. The theory sounds great 鈥� identify those with depression early and treat them so as to reduce both the lifetime burden of illness and the risk of suicide.
The trouble is that this would be an absolute disaster in practice 鈥� worsening the existing paradox of overtreating people who are essentially well, while shamefully neglecting the really sick.
Fatal flaw
The fatal flaw of mass screening for depression is that the methods used, commonly a simple questionnaire, can鈥檛 distinguish between sadness 鈥� a completely normal emotion requiring no treatment 鈥� and clinical depression, which almost always does need to be treated, sometimes urgently.
Checking the general population in this way will result in even more overdiagnosis and over-medication 鈥� and we already have a lot.
The combination of loose diagnostic criteria in the DSM 鈥� the Diagnostic and Statistical Manual of Mental Disorders that guides the medical profession 鈥� and aggressive marketing by drug companies, means that 鈥� including 25 per cent of woman over 40. No wonder the use of these drugs has increased 400 per cent in the past 20 years.
Fat cats
Drug companies have grown rich selling the idea that everyday sadness is underdiagnosed depression, caused by a chemical imbalance in the brain, and best treated with a pill.
Routine screening will subject essentially normal people to senseless stigma and to medication they don鈥檛 need 鈥� a great gift to drug companies, but a terrible deal for those who are mislabelled.
It would also exacerbate our current tragic misallocation of resources. The needs of those who suffer from severe mental illness are very poorly met. The shift away from care in mental health institutions has resulted in the , without the much-needed accompanying investment in community services and housing.
Bridging the gap
In the US, more than 500,000 people with severe mental ill health are . Police are increasingly stepping into the breach because mental health services are so hard to access. And two-thirds of people with severe depression have not seen a mental health clinician in the previous year.
It makes no sense to create an army of new pseudo-patients when we are now so badly failing the people who desperately need our help. General screening for depression is an idea well before its time. We must first take much better care of those we already know are mentally ill.
And we must also have a much more accurate way to distinguish clinical depression from the everyday and inescapable sadness, disappointment, and grief that are an inevitable part of the human condition.
High-risk groups
Instead of screening everyone aged 18 and over, we should be identifying the high-risk groups that now slip through the cracks. Community mental health services should be easily accessible in emergency rooms, hospitals, jails, homeless shelters and via suicide hot lines. Continuity of care is also essential.
Don鈥檛 create new and questionable 鈥減atients鈥� until we finally provide adequate care for those we already have.
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