Metal Health under the magnifying glass

Screen test

President George Bush personally backs a drive to screen the entire US population, including preschool children, for undiagnosed mental illness. Thousands of schools are already participating in screening their pupils. But is screening effective, who really benefits and would such a policy ever be accepted in the UK?

It’s now just over two years ago that 15-year-old Chelsea Rhoades arrived at school, was ushered into a classroom
and – according to legal documents – told she needed to take a “test”.

Chelsea duely signed an assent form, and, with other pupils at Penn High School in the US state of Indiana, completed the test. Chelsea was required to answer questions such as whether she felt suicidal or had tried to kill herself. All she had to do was answer ‘yes’ or ‘no’. Simple. The test took just 10 minutes.

The legal documents state Chelsea was then taken aside by one of the people who had administered the test and told – quite up front – that she had obsessive compulsive disorder and social anxiety disorder. The documents state these diagnoses were made because Chelsea, when filling out the form, had indicated, for example, that she like to help clean the house and did not much like to “party”. Chelsea was told that if her “condition” worsened she should be taken to the local mental health centre for treatment.

The test that Chelsea had completed was, in fact, called Teenscreen, one of dozens of mental disorder screening programmes being implemented across the United States. Since 2001, the makers of Teenscreen say its programme – used to screen for depression, anxiety, and substance abuse – has been used in almost 500 schools, doctors surgeries and youth centre in 43 states. Last year, 122,000 youngsters completed Teenscreen.

The mental health screening policy was introduced by the Bush administration, and its ambitious aim is to screen the entire US population, including preschool children, for mental illness. This policy – effectively President Bush’s War On Mental Illness – was spawned in April 2002 when Bush established a “New Freedom Commission on Mental Health”. Its remit was to investigate the US mental health service and to resolve the problems “that allow Americans to fall through the [mental health] system’s cracks.”

The commission reported back to Bush stating that “despite their prevalence, mental disorders often go undiagnosed”. The commission’s subsequent goals included building mental health care that is “consumer and family-driven”, to speed up research and to ensure that “early mental health screening, assessment, and referral to services are common practice.” These goals were greeted by an all-round thumbs up by all main US mental health professional and user groups, from the American Psychiatric Association to the National Alliance for the Mentally Ill. US government reports spoke of “recovery” and the importance of community-based mental health services. All the right buttons were hit.

Community mental health service cash has since flowed. Last year US government grants included: $92.5m for “mental health transformation” over five years to seven states; $184.5 million over six years for 25 children community mental health services; $17.5 million over five years for a national training center for child and adolescent mental health; $13.2 million over three years for mental health services for older adults; and $7.2 million over three years for projects aiming to divert people with mental health problems away from the criminal justice system and into community services.

While this cash has been welcomed, it is, however, the screening policy that continues to face vehement criticism on a number of fronts.

One fear voiced by critics is that the scientific “evidence” on screening effectivenesss is being bull-dozen by pharmaceutical firms whose commercial clout and influence pervades the entire US psychitric system. Critics say it is these drug firms who will gain most from screening. This is because, they argue, screened people identified as having a mental health problem will be subsequently treated, above all, with medication. For example, one Teenscreen leaflet states that of a sample of 255 high school students, 24% of students subsequently referred to mental health professionals were prescribed medication. “Screening is a drugging dragnet,” is how Jim Gottstein, president of the Alaska-based Law Project for Psychiatric Rights, puts it.

Teenscreen, run by Columbia University and which says its receives no funding from pharmacuetical firms, stresses that its screening makes no medication recommendations. “Our goal is to provide parents…with information about a possible problem and to link youth in need to qualified professionals who can perform a complete diagnostic assessment,” Teenscreen’s website reads.

However, the drug firm behind one computerised medication plan specifically recommended by Bush’s Freedom Commission has handed over large amounts of money to the Bush administration. The Texas Medication Algorithm Project (TMAP) advises on medication for psychotic patients. One first line antipsychotic drug TMAP recommends is Zyprexa, a drug made by Eli Lilly which helped fund TMAP’s development. George Bush Senior was a member of Eli Lilly’s board of directors and in 2000 the company donated 82 per cent of its $1.6m political contributions to George Bush Junior and the Republican Party. According to the US-based Center for Responsive Politics, manufacturers of drugs and health products contributed $764,274 to the 2004 Bush campaign.

Critics argue that it is these heavy-weight political and econonic forces that drive forward the US screening programme, rather than the programmes’ proven effectiveness. In May, 2004, the American national treatment advisory body, the US Preventive Services Task Force, stated there is “no evidence” that screening for suicide risk reduces suicide attempts or mortality. Before this, in 2002, it had concluded that evidence is “insufficient” to recommend for or against routine screening of children or adolescents for depression. Nevertheless, Teenscreen, for example, keenly promotes its effectiveness. Its website points to two published research papers by Teenscreen’s own developer, psychiatrist David Shaffer. His research says Teenscreen identifies young people both at risk of suicide and those with depression, anxiety, and drug or alcohol abuse.

Another criticism levelled at Teenscreen and other screening programmes is that they are compulsory in all but name. Teencreen does stress that its tests are not compulsory. However, schools and other bodies have been criticised for implementing screening on a “passive consent” basis. This means that schools, having informed parents of the screening plans, will not screen a pupil only if the parent writes to forbid it. Lawyers acting for the parents of Chelsea Rhoades plan to sue her school for invasion of privacy. In a trial due later this year, they are to argue that the parents did not even receive notice of the planned screening to take place at the school. Previous similar legal actions have, however, failed. In November last year, San Francisco appeal judges ruled that parents have no rights to override school policy.

Nevertheless, on the ground screening is fast becoming part of the fabric of US mental health policy. Activists such as service user Abigail Adams, of the Freedom Center “survivor” organisation in Massachusetts, say they are not against screening per se. But it is how screening fits into the bigger picture that concerns her. She fears that screening programmes are gateways for youngsters to a mental health service underpinned by an “abusive” biomedical approach to mental ill health and where drugs, such as anti-depressants and Ritalin, are prescribed in unprecedented levels to children. “I am well aware of the abusive type of care these kids can receive – and they do not have access to alternative care and support,” she says. In addition, Gottstein is concerned with the mounting pressure to medicate troubled young people. “I know poor parents and single mothers who are told their child will be kicked out of school if their kid does not take prescribed psychiatric drugs, or their kids will be taken into care,” he says. “I do not think a month goes by when I do not hear of someone in the situation.”

Adams is now working with her local Massachusets high school to discuss how it implements a screening programme called the SOS Signs of Suicide, sponsored by a range of professional mental health bodies, and which has been used in more than 1,500 schools since 2000. Adams says: “We want to see the screening implemented as humanely as possible, that anonymity for the student is protected and that it is more voluntary.”

As yet little there has been no genuine indication of plans to introduce such a screening policy into the UK. However, one psychiatrist, Prem Kunjukrishnan, of Dewsbury & District Hospital, once commented at the website of the British Medical Journal: “On this side of the Atlantic, the powers that be in the Department of Health will, undoubtedly, watch with interest what unfolds as this [screening] gets underway.” If so, prepare for a fiery controversy.

* A shortened version of this article first appeared in Openmind magazine.

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