Dark Side of Mandated Depression Screenings

Depression is a serious health problem in the United States. Yet a little-known federal task force, with no oversight from Congress or the Obama administration, has just required the health care industry to deal with that disorder in a very disturbing way.

It is disturbing as a clinical matter because of possible adverse effects on the lives of patients suffering from depression, particularly those under the age of 25. In announcing the new rules, this task force could well become a true “death panel,” not by refusing treatment but by encouraging the wrong treatment.

This approach is also disturbing as an economic matter because of the adverse effects on overall health care costs.

The United States Preventive Services Task Force (USPSTF) looked at all aspects of early detection and treatment of depression among adults. As one of the most common mental disorders in the U.S., depression is a serious condition affecting millions of people, as well as their friends and family. Because it may not have definitive, outward symptoms, identifying those who may be suffering from it and providing them with the help they need is crucial.

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Seeking a solution, the USPSTF strongly “recommended” doctors screen everyone over age 18 for signs of depression, and provide them with the “necessary care.”

But keep an eye on those quotation marks. When this task force makes a strong “recommendation” — a so-called “A” or “B” recommendation, as they did here — the “necessary services” automatically get special treatment under your health insurance policy.

In essence, under a little noticed provision of the Affordable Care Act, they become services for which there is no deductible, co-pay, or other marginal cost to the patient.

Thus, the financial incentives for ordering and accepting treatment, even if it may not be the best treatment for the patient or may not be cost-effective, are suddenly much stronger. In the case of mild depression, for example, financial incentives for physicians and drug companies, and the lack of financial checks and balances in the form of patient co-pays — could lead to more prescriptions for anti-depressants. That could happen when something as simple as increased exercise might be better, safer, and less expensive, except that health club memberships are not covered by insurance.

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Also, by favoring certain illnesses over others, they are raising the cost of treating all other illnesses not on the favored list.

The reason is simple. There is no “free lunch.” If your insurance policy costs the same next year as it did last year, but it must now cover certain favored illnesses without co-pays or deductibles, the co-pays or deductibles for all other illnesses or treatments not on the “favored” list must go up. Or, the cost of the policy itself must go up.

Don’t forget the benefits to a drug company if it has the patent on the only medication used to treat an ailment on the “favored” list.

Back to the clinical issues: There may be real problems with the mass screening of patients for signs of depression, and quick and dirty “treatment” ordered by doctors of every kind, from podiatrists to proctologists. In the last 20 years there has been a 400 percent increase in the use of antidepressants, with an estimated one in ten adults taking them. Many patients do better with a combination of psychotherapy and medications, but health insurers pay best if patients are seen in a conveyor belt fashion.

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Researchers have also identified a troubling side effect of a widely prescribed class of antidepressants: SSRIs. Safety data from the FDA has found that SSRI use is associated with an increased risk of violent behavior, specifically in those under 24 years old.

In a large Swedish study, those ages 15 to 24 and taking SSRIs were statistically more likely to be arrested for violent crimes. Among young men, there was a 40 percent increased risk of being convicted of a violent crime. The number was significantly higher among young women: 75 percent. There is no known link between criminal activity and antidepressant use in older patients

Between 2004 and 2012, there were 14,773 reports of psychiatric drugs causing violent side effects. Couple that with FDA estimates that less than 1 percent of all serious events are being reported to it, and the actual number of side effects are certainly higher.

Why might this be? SSRIs, like some other drugs, work differently in the brains of adolescents and young adults. These drugs may even boost the risk of suicidal thoughts in children, teens and young adults but not older adults.

The implications of all this? The correlation between psychiatric drugs and acts of violence and homicide is well documented by both international drug regulatory warnings and studies. In addition, there are dozens of high-profile acts of violence or mass murder committed by individuals under the influence of psychiatric drugs: SSRI medications were on the list of prescribed medications for the Aurora, Colorado movie theater shooter, James Holmes, as well as Sandy Hook shooter Adam Lanza.

As a practicing physician, I can’t imagine many of my non-primary care peers acting as psychiatrists. For medicolegal and reimbursement reasons, unless you do primary care and feel comfortable diagnosing and treating depression, you aren’t going to be evaluating patients. As a patient, do you want your vascular surgeon diagnosing and treating your depression?

The USPSTF raises expectations, but like many unfunded government mandates, does only that. The result is a perfect storm for inadequate treatment of depression in the U.S.

Dr. Ramin Oskoui, a cardiologist in the Washington, D.C., area, is CEO of Foxhall Cardiology PC.