Overdiagnosis in depression: there are doors better left closed

Andrés Fontalba

A young Cecilia, aged 13, in Sofia Coppola's brilliant film based on the homonymous novel, "The suicide virgins" advised:

-Obviously doctor, you were never a 13-year-old girl.

It’s obvious that depression in children and adolescents is an important cause of disability and generates great suffering for the person and his or her environment, requiring specific management adapted to the needs of that peculiar age. Based on the severity of this pathology, the availability of effective screening tools in the detection of depression, and a treatment that improves prognosis, the United States Preventive Task Force in 2009 recommended the screening for depression in all adolescents in a medical and integrated with mental health services setting, despite not having any previous trials that would justify this intervention.

The objective was to ensure that it was carried out in a situation that guaranteed a correct diagnosis, an intervention on detected cases with demonstrated efficacy (cognitive or interpersonal behavioural psychotherapy) and a follow-up of them. This recommendation is currently inactive and archived. Projects derived from this perspective, such as TeenScreen, developed by Columbia University emerged in more than 2,800 centres, which was closed without explanation in 2012.

Depressive symptoms are more easily recognizable in an adult, while psychopathological exploration in adolescents requires special considerations. It must start from the understanding of the adolescent as a being whose personality has very specific characteristics and who has in his psychic suffering, an expression of his own that essentially differentiates him from the adult person. Depressive disorder can manifest as oppositional, negativist or dissocial behaviours, initiation in the consumption of toxins, irritability or loss of interest in normal activities, running away from home, hypersensitivity in dealing with adults and even suicide attempts.

There is, as with any screening instrument, a risk of false positives. The mere characterization of a person as "depressed", without being so, can enhance the character of illness and place it in a passive position, which moves away from adopting coping strategies more appropriate to a possible emotional conflict. It’s necessary to contemplate even the possibility that adolescents who undergo normal changes of adaptive type as part of their life cycle are characterized as pathological and submitted to therapeutic attempts that they don’t need and probably are not effective, although this can be counteracted with a more diagnostic evaluation that is more complete and goes to a greater depth.

Special consideration should be given to the complications caused by overdiagnosis and overtreatment, which would lead to an increased risk of iatrogenesis. There may also be possible adverse effects of the treatment of an adolescent who might be able to overcome a difficult situation with support from his environment and his own resources and who would not need this therapeutic overactivity.

In depression, the emotional burden is especially sensitive, simply because it is labelled as "sick" and associated with an increase in the vulnerability of the individual. We are aware of the insufficient evidence of this type of actions in rigorous systematic reviews and their potential harm (Thombs et al 2012, Roseman et al 2016). The risk really lies in the intentionality of spending health and psycho-social resources in finding new cases, instead of using them in already diagnosed adolescents with treatment needs that are not fully covered.

As some of the child and adolescent mental health care plans, such as the Mental Health Care Program for Children and Adolescents, indicate that prevention actions in adolescence from the health point of view should be developed through a series of very defined actions and risk groups. It’s necessary to consider that the object of prevention is not limited to adolescents, but also includes support for their life contexts. Thus, any preventive action in juvenile mental health should prioritize relational, family and educational aspects.

In cases where families are especially affected by poverty, conflict and forced migration, the support that the adolescent needs for a good intellectual and social development can be altered. These barriers have long-term consequences for the well-being of the adolescent, and for the health of the communities as a whole, so we must act on them.

The key to not leaving treatment for depression for any person who needs it is in the accessibility to health services, beyond developing intensive population screening plans without previous evidence to support them. Another difficulty to point out is the prejudices and taboos within the general population to people who use  mental health services, being the adolescents more vulnerable to have feelings of shame and to feel rejection by their environment, for what is even more necessary guarantee respect and privacy, while fighting against stigma. And poetic tragedies such as "The suicide virgins" serve to put the focus of attention on the mental health care of adolescents and their families who need it.


References:

US Preventive Services Task Force. (2014). Depression in children and adolescents: screening.

Roseman, M., Kloda, L. A., Saadat, N., Riehm, K. E., Ickowicz, A., Baltzer, F., ... & Thombs, B. D. (2016). Accuracy of Depression Screening Tools to Detect Major Depression in Children and Adolescents A Systematic Review. The Canadian Journal of Psychiatry, 0706743716651833.

Thombs, B. D., Roseman, M., & Kloda, L. A. (2012). Depression screening and mental health outcomes in children and adolescents: a systematic review protocol. Systematic reviews, 1(1), 1.