Focusing on reducing suicide in pregnancy suggests a serious misdirection of scarce funds.
UK Prime Minister’s plans may make a dysfunctional system of depression care even more dysfunctional.
UK Prime Minister Cameron will pledge extra mental health support [http://www.bbc.com/news/uk-politics-35276854 ] with a call for a “more mature” conversation about mental health. The BBC News coverage of this forthcoming announcement gave a few details:
Specialist care for new mothers with mental health problems and support for anorexic teenagers will gain money allocated in the Autumn Statement.
The PM will also pledge more support in hospital A&E departments.
He will also announce new parenting support and plans to demolish some of England’s worst council estates.
He is expected to say mental illness is not contagious and is “nothing to be frightened of”.
“As a country, we need to be far more mature about this. Less hushed tones, less whispering; more frank and open discussion,” he will say.
“We need to take away that shame, that embarrassment, let people know that they’re not in this alone, that when the clouds descend, they don’t have to suffer silently.
“I want us to be able to say to anyone who is struggling, ‘talk to someone, ask your doctor for help and we will always be there to support you’.”
The specific measures expected, which will apply in England only, are:
- £290m up to 2020 to give 30,000 more women each year access to specialist mental health care before and after giving birth, including through classes
- £247m over the next five years so that every hospital has mental services in their Accident and Emergency unit
- A new waiting time target for teenagers with eating disorders, which will track the number of patients being seen within a month of being referred
- A target that at least half of people experiencing psychosis for the first time should be treated within two weeks
Who could take issue with this initiative? Well, the sparse details provided in the BBC article suggest a commitment to making popular, but ineffectual pitches that are counter to available evidence.
The BBC news coverage prominently features a photo which seems to indicate misdirection in Cameron’s efforts.
Cameron obviously did not consult with mental health consumer groups who strongly object to head-holding depictions of persons with mental disorders.
The statement that “women with serious psychiatric disorders during pregnancy are at an increased risk of suicide” will gain support from the uninformed, but skirts a wealth of contradictory evidence about suicide, mental disorder and pregnancy.
Compared to otherwise matched other women of childbearing age who are not giving birth, pregnant women have no more depression.
In terms of absolute risk, pregnancy and early motherhood are periods of low risk periods for suicide. Going back to the classic work of Emile Durkheim, there is the strong suggestion (and considerable subsequent evidence) that having responsibility for a young child actually reduces suicidality though it can be a source of considerable stress especially for economically disadvantaged mothers.
George Brown’s classic work suggests that having three children under the age of six at home puts women at risk for depression, but this work did not show that put them at risk for suicide.
Programs to reduce depression in pregnant women and women who have just delivered often focus on routinely screening them for depression. Although popular with policymakers, there is a lack of evidence that screening for depression improves depression outcomes in this population and certainly no evidence that reduces suicidality.
Screening programs result in more referrals to mental health services, but not uptake of services or improvement in depression outcomes. They are much better in generating employment for mental health professionals than improving the well-being of women.
Depression screening programs for young women, to the extent to which they have any effects at all, increase the mislabeling of personal and social problems as a clinical disorder. Why is that?
A self-report questionnaire or touchscreen screening instrument is not an adequate basis of diagnosis. An elevated score only suggests increased likelihood that the person is depressed. A questionnaire does not provide a valid diagnosis. This requires a structured conversation with a specific probing of symptoms. Evidence is that primary care physicians are unwilling or unable to follow-up the large number of women screening positive for depression, most of whom will prove to be false positives.
A heightened score on a depression screening instrument is a report of considerable distress, but not necessarily a clinical disorder, in terms of indicating number and severity of depressive symptoms. Everyone experiencing misery is not suitable for mental health care, the evidence base for which requires appropriate diagnosis.
Most heightened scores on a depression questionnaire do not indicate a need for specialty mental health services. Heightened scores may indicate a need for personal and social difficulties. Further conversation is required to determine precisely what is needed and how any needed services can be accessed. Having to deal with false positive screens takes personnel away from having these conversations.
I lacking interest of time or training to probe heightened scores, primary care personnel may simply accept a positive score on a screening instrument as indication of clinical disorder. This overidentification of patients as depressed is confusing to those who know that they are not clinically depressed, but directs others into treatment that they don’t need.
There is considerable controversy about the safety and relative efficacy of antidepressants during pregnancy and breast-feeding. Particularly with women who have a past history of severe depression and suicidality, continuation or initiation of antidepressant treatment may be warranted, but with extra monitoring. In general, however, decision-making about whether to accept antidepressants or psychotherapy is best undertaken in an extended conversation with a woman in which professionals provide information and address myths and misunderstandings.
Many women who screen positive and are found to have clinical depression have already been identified, but are receiving no or inadequate care.
The prospects for a newly screened and identified depressed women getting adequate and timely treatment are low.
In the UK, a woman identified by a screening program, properly diagnosed, and referred to psychotherapy can expect to wait 8 months before receiving treatment.
What would be a better use of scarce funds than programs for detecting and treating depression in pregnant women and new mothers? Improve the overall quality and access to primary care and specialty mental health depression treatment in this age range. Otherwise, scarce resources will be withdrawn from already poorly functioning services and women will simply be put on waiting list or offered unnecessary treatment with antidepressants after an inadequate discussion of treatment options.
So Prime Minister Cameron, what are you going to do to increase the opportunities for conversations with women at risk for depression to ensure that they get appropriate treatment when they need it? Your current system is quite dysfunctional and you may be about to make it more dysfunctional.