The U.S. government has recommended all American adults undergo depression screening. But how will that work, and what are the most pragmatic ways to aid the public health?
The Agency for Healthcare Research and Quality’s US Preventive Services Task Force (someone has to come up with better names) suggested every primary care physician use on every adult American patient one of a group of screening scales, particularly the Edinburgh PostNatal Clinical Depression scale in pregnant women. They also endorsed two forms of treatment – cognitive behavioral therapy and antidepressants – with a lot of caveats regarding antidepressants, especially in pregnant women.
Will This Work?
Only in part. In the era of checklist medicine, you may soon see physicians “monitored” for depression checklists and scales – especially if extra codes are used to pay for it. “Evidence based medicine” loves numbers and scales – it’s the people aspect it has real trouble with. The USPSTF also recommends that all adults be screened for alcohol use, sensible advice, but another area in which folks routinely lie and ultimately refuse treatment.
So with lots of extra screening, people who are now told they are depressed will probably be offered pills. Cognitive behavioral treatment generally demands people see themselves as ill, visit therapists regularly – often without insurance reimbursement – and are willing to do cognitive homework. Many will not do all this – nor will government recommendations for extra workshops, extra training and monthly seminars be followed. Besides, many therapists who declare themselves CBT trained do not do much actual CBT, and many regions lack enough trained people to do the job.
Few of the public – and that includes sadly many physicians – are aware that in the treatment of depression itself, anti-depressants are only marginally more successful than placebo. But patients and doctors will both be assured “they’re doing something” by taking pills. Clinicians will add another item to the “problem list” that governs their reimbursement. Big Pharma should also be gratified by the “increase in market.”
What Else Should Be Done?
Lots. Depression is a huge economic problem. It hits about 30% of the population lifetime, 10% on any given day. Unlike many other chronic illnesses, it strikes many working younger people. The effects on pregnant women are particularly important; not only are mothers affected, but their children – often for the rest of their lives. Many researchers describe depression as economically the most expensive chronic illness out there. So public health recommendations need to be a lot more comprehensive than business as usual; the USPSTF has little to say about combining medications with CBT, and virtually nothing about “everything else.” So here are some suggestions of what else could be done to treat a large number of fellow citizens, including many without major income and social means:
- Light. Sunlight is cheap. Electric light boxes are also cheap – you can get decent ones from Amazon for about 60 bucks. Recent data argues morning light is superior to antidepressants in many cases of depression, and adds to the effects of antidepressants. Sunlight – direct or artificial – can easily be used in one’s home. It resets biological clocks. It alerts people, wakes them up and makes them feel more productive. Some data argues it produces more muscle mass when exercising. As we say in Brooklyn, what’s not to like? And light exposure doesn’t require lots of clinician time.
- Physical Activity. Morning walks, treadmills runs, and bicycling seem to do well with “minor depression” of the sort screening picks up. Better, exercise seems to have preventive effects on depression – and on heart disease, stroke, tumors, diabetes, and most of the main scourges of American public health. Yet people generally do not think of walking as a treatment or preventive aid for depression.
- Online CBT. If there were ever time for a proper clinical trial of online CBT, this is it. Lots of different outfits, private and public, are trying to push the net as a psychiatric treatment center. How to combine it with clinical work is key. Screening represents a terrific opportunity to see how CBT might be applied across the population, rather than one by one, in ways that people can schedule as they please.
- Groups. Group therapies can effect changes individual treatments cannot. Community mental health centers can set up group depression treatments, particularly involving CBT, that might prove economically efficient in treating depression.
The Bottom Line
Depression costs people their lives, the economy hundreds of billions, families their heart and soul. If we are going to screen people for depression, we need better, cheaper, more effective ways to treat – and prevent it.
And that requires looking at a bigger picture than “standard clinical care.” We need to look at all aspects of health – physical, mental, social and spiritual, and apply them to populations, if we want to make people well. Work leave for fathers is something to consider when perhaps one out of seven pregnant and delivering mothers become depressed. It’s time we stood outside the ghetto of standard clinical practice with its narrow focus on a few elements of physical and mental health and near total neglect of social and spiritual health means, and look at what really works – for all of us.
We deserve better.