April 13, 2005 - New York Times
Depressed? New York City Screens for People at Risk
By MARC SANTORA and BENEDICT CAREY

Doctors in New York City have begun to use a simple questionnaire to determine if a patient is at risk for depression, a practice that health officials hope will become a routine part of primary care, much like a blood pressure test or cholesterol reading.

The new program is the first to carry out depression screening using a scored test on a wide scale. It comes amid a spirited national debate among psychiatrists, policy makers and patient-advocacy groups on the wisdom of screening for mental disorders, especially in children.

In 2003, an expert panel convened by President Bush recommended expanding mental health screening, and Congress budgeted $20 million in supporting money for state pilot programs for this year. Several states, including populous states like Florida and Illinois, have begun to investigate large-scale screening plans, and scores of schools and other youth centers throughout the country have used instruments to test youngsters for suicide risk.

But some politicians and advocates for patients argue that testing people broadly for mental conditions is an invitation to overdiagnosis, unnecessary treatment and lifelong stigmatization.

In New York, no federal money is being used for the program, which is under way in hospitals run by the city. The test, which is being given to adults only, derives a depression score from the answers to nine questions. It is not meant to yield a formal diagnosis, but a high score would lead a doctor to recommend a more thorough clinical screening.

The test includes questions about mood and behavior.

For instance, patients are asked if over the past two weeks they have felt "down, depressed or hopeless." They can answer by checking one of four categories: not at all, several days, more than half the days or nearly every day. Dr. Lloyd I. Sederer, who heads the mental health division of the Department of Health and Mental Hygiene, which is leading the New York effort, said he hoped the screening would set an example for other doctors in New York and around the country.

"It is our hope to have this become a standard practice," Dr. Sederer said.

Health officials in New York City are working with the Health and Hospitals Corporation to put their screening program into effect. So far, only about a dozen primary-care physicians are using the test, which was developed using research from the RAND Corporation. The goal is to have every primary-care physician in the city hospital system using the test within the next two or three years. One in every four New Yorkers uses city hospitals for basic health-care treatment, meaning the program could soon involve millions of patients.

Dr. Sederer said that a similar screening test could be developed for adolescents and that if the testing of adults gained acceptance, it would be easier for doctors to use a screening procedure for patients of any age.

Psychiatrists and other proponents say mental health screening is long overdue. They argue that millions of people with serious mental disorders never get help, and that heightened vigilance would not only allow doctors to head off much worse mental problems later, but would also reduce the tremendous costs of untreated illness.

Surveys have found that about 16 percent of Americans - or as many as 46 million people - suffer from depression at some point. And by some estimates, depression costs the nation $44 billion a year in lost work and disability - more than any other illness, including heart disease.

But opponents say that depression is not always easy for primary-care doctors to recognize, even in people who seek help, and they argue that a screening score of any kind could needlessly confuse or worry patients.

"When you label people as having a mental problem, such a label stays with them for their entire lives, whether or not it's accurate," said Vera Hassner Sharav, president of the Alliance for Human Research Protection, a patient-advocacy group that has been campaigning to block screening for mental health.

Critics like Ms. Sharav contend that screening tests will also increase the use of psychiatric drugs, including antidepressants like Zoloft and Prozac, whose use in children and adolescents has recently come under scrutiny by regulators.

Representative Ron Paul, a Texas Republican and a gynecologist, introduced an amendment last fall to block federal financing for screening programs, in part because of worries about overmedicating schoolchildren. The plan was rejected.

"We already have a tremendous number of kids being put on drugs like Ritalin and Prozac," Dr. Paul said, "and I think if these screening programs grow, you're going to see a lot of people pushed into medication programs for behavioral problems."

Dr. Sederer and psychiatrists, psychologists and administrators around the country who favor screening say these concerns are overblown and obscure a much larger problem: a dismissive public attitude toward mental illness.

Bill Emmet, coordinator for the Campaign for Mental Health Reform, a coalition of organizations working to build support for screening and other mental health programs, said: "Are people sometimes misdiagnosed? Of course. But the fact is that there are whole segments of the population that for a variety of reasons are not being diagnosed with problems they do have, and that is the far greater problem."

Dr. Sederer said that once doctors were convinced that a quantitative score worked in recognizing depression, they would be more open to using similar measures for other areas of mental health.

Still, he acknowledged that "nobody likes to be measured" and said that there had been some resistance from doctors who worried that this would take away from already limited time with patients and add to their workload. The science behind screening is mixed. In studies of patients who belong to health maintenance organizations in California and Washington, researchers have found that screening, when combined with programs that coordinate treatment, does help many adults who are struggling with depression and who would otherwise receive little or no care.

But in May, the Preventive Services Task Force, a federal panel of experts that advises doctors and the government on screening guidelines, concluded that there was not enough evidence to recommend a similar kind of screening for suicide risk. The controversy is not likely to be settled soon.

"I have been getting a lot of attention on this, and it runs across the political spectrum, from civil libertarians on the left to Christians on the right," Representative Paul said. "I think the idea of screening people, of asking these kinds of questions, rubs people the wrong way, and particularly when it's their children."

Officials in New York, however, defend their initiative.

"Depression is a leading illness in New York City, but it can be effectively treated," said Dr. Thomas R. Frieden, the city's health commissioner. "Our surveys show that there are an estimated 400,000 New Yorkers with depression; many have not been accurately diagnosed or effectively treated."