Soon after her sister committed suicide, Caroline Downing started doing poorly at school. During math tests she would freeze up, and she found her mind wandering constantly. Officials at St. Andrew’s Episcopal School in Potomac, Md., gently suggested that the high school sophomore get a mental health screening.
The idea of a psychiatric evaluation sent chills down the spine of Caroline’s mother, Mathy Milling Downing, who believed that her younger daughter, Candace, had committed suicide because of an adverse reaction linked to a psychiatric drug – the antidepressant Zoloft.
Shortly after Candace’s death, the Food and Drug Administration placed black-box warnings on several antidepressants to say they elevated suicidal thinking among some children. If Caroline were going to get the same kind of mental health care as Candace, Downing wanted no part of it.
Downing’s family offers a powerful case study into the pros and cons of new guidelines recommending widespread screening of adolescents for mental disorders.
In April, the U.S. Preventive Services Task Force, a federal group that makes public health recommendations, said that all adolescents between ages 12 and 18 should be screened for major depression.
Before that, the Institute of Medicine, which advises Congress on scientific matters, told policymakers that early screening was key to reducing the financial and medical burden of mental disorders in the United States.
Downing said she agreed to have her older daughter screened because the child was obviously in distress, but she told school officials that if an evaluation led to a prescription for medications, she would refuse to go along.
The screening, unsurprisingly, found that Caroline’s emotional problems were linked to her sister’s death. After several intensive evaluations that delved into the girl’s mental and emotional history, and that obtained a family history and detailed information about Candace’s death, Caroline was placed in “art therapy” – painting or making sculptures with a therapist who simultaneously used the sessions to draw out the teenager’s emotional problems.
The therapy had an immediate and beneficial impact and turned Mathy Milling Downing into a fan of mental health treatment done right.
“My grades went from almost failing algebra to honor roll,” Caroline Downing, now 20, said in an interview.
The treatment worked, she said, because “getting all the stuff out of your head that you don’t need there gives you more room for all the stuff you need to have in your head.”
The very different experiences of the two sisters illustrate the paradox at the heart of screening recommendations: What matters is not whether screening is done but how it is done, and how screening information gets used.
In the case of her younger daughter, Downing said, a child psychiatrist put Candace on Zoloft after a very brief evaluation because the child was experiencing anxieties during tests. When Candace turned 12, the psychiatrist upped the dose on the grounds that it would help her academically.
When Downing expressed concerns about the drug, she said the doctor blew her off: “He said, ‘What are you worried about? It is safe and effective.’ ”
One day in January 2004, Candace had just finished watching a show on Animal Planet with her father and sister. She had been laughing during the show. A short while later, Downing said, Candace hanged herself in her bedroom, using a belt from a bathrobe and a rod on her four-poster bed.
Candace’s treatment, Downing said, involved a one-size-fits-all approach to mental health that sees medications as a magic pill. By contrast, she said, the multiple screenings that Caroline received carefully evaluated the child as an individual and homed in on the kind of therapy that was best for her.
“Screening a child to find out what the root of the problem is can be useful,” Downing said. “In the case of my daughter (Caroline), it helped (that) they found a connection between her focusing problems and the death of her sister.”
The recommendation by the Preventive Services Task Force, which advises primary care physicians on contentious medical issues, says that children between 12 and 18 should be routinely screened in doctor’s offices.
But the task force offered an important caveat: Screening made sense only if the children then had access to the kind of specialized and individualized care that Caroline Downing received.
The new guidelines reversed an earlier recommendation by the same group in 2002 that said there was insufficient evidence to recommend screening children for depression.
The panel of experts evaluated numerous studies, including several looking at the potential adverse effects of medications.
Ned Calonge, the chief medical officer for the Colorado Department of Public Health and Environment and a senior member of the task force, said the panel had concluded that there were effective screening tools for depression, as well as effective drug and psychotherapy treatments for children ages 12 to 18.
But there were potential risks to the use of drugs among children, he said.
As a result, Calonge said, the panel believed psychotherapy ought to be the first line of treatment for all adolescents with depression, rather than antidepressant drugs such as Prozac, Paxil and Zoloft (which are known as selective serotonin reuptake inhibitors, or SSRIs).
“We wanted to recommend against the idea doctors would do a screen and pull out their prescription pad,” he said. “The recommendation says you have to do really close clinical monitoring. So don’t pull out the prescription pad and write an SSRI prescription; the best treatment is psychotherapy.”
Calonge said the response to the recommendations has generally been positive, but the biggest concern by far has been the worry that such screening would cause many children to be placed on drug therapy.
Vera Sharav, a prominent critic of psychiatric drug therapy and president of the Alliance for Human Research Protection, for example, said widespread screening would result in doctors’ writing many new drug prescriptions, perhaps at the behest of drug companies.
But Calonge said his task force imposed rigorous conflict-of-interest guidelines on its members to keep away advocates motivated by financial considerations or pet theories.
A similar recommendation for screening was delivered to policymakers in March by the Institute of Medicine. Unlike the Preventive Services Task Force, the IOM panel did not limit itself to recommending screening only for depression or only to teenagers but said that screening in general could be useful, given that so many mental illnesses first begin to manifest themselves among children.
About one in four visits to pediatricians’ offices are for behavioral problems, said Thomas Boat, executive associate dean for health affairs at the University of Cincinnati and a vice chair of the IOM panel.
“Pediatrics has not really owned up to the fact this is a major health problem in kids that they need to be responsible for,” said Boat, who is himself a pediatrician.
While screening could also be offered in schools, he said that physicians’ offices were best set up for screening children.
Both Boat and Laurie Flynn, national executive director of TeenScreen, a mental health screening program affiliated with Columbia University, emphasized that screening tests had to be cleared by parents before they were administered.
TeenScreen focuses on screening children between ages 11 and 19 – and gets signed parental consent before administering the tests. Flynn said the program is active in 530 schools and community settings but is increasingly focused on screening youngsters in the offices of primary care doctors, as new guidelines have suggested.
The typical screen requires a paper-and-pencil or computer test that takes about 10 to 12 minutes for a child to complete. The test raises red flags in about 25 to 30 percent of the children, Flynn said, and those children are then given a more comprehensive, 20-minute evaluation to make sure they understood the questions correctly.
About 16 to 17 percent of kids out of the 40,000 that TeenScreen evaluated last year were referred for a formal psychological evaluation. Between half and three-quarters of the families typically follow up on the recommendation; TeenScreen is not involved in making formal diagnoses of mental health disorders or recommending particular kinds of treatment.
Steven Hyman, Harvard University’s provost – who is also a psychiatrist and former director of the National Institute of Mental Health – said he sided with the recommendations of the Preventive Services Task Force that mental health screening for children should be limited to depression, and to adolescents.
Like all public health measures, he said, screening made sense only for conditions that were widespread; where tests were accurate; where treatments are available; where the costs of administration were not prohibitive; and where the screening techniques did not lead to large numbers of normal children getting misdiagnosed, and large numbers of children with real disorders getting missed.
“A good reason to screen for depression is it can be a brief, discreet and relatively private interaction,” Hyman said. “Depression meets the public health challenge that makes screening worthwhile.”