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Tuesday 23 December 2014

Screening for Childhood Mental Illness in BC: Good Idea or Pharma Marketing?

In recent years there have been many incidents of violence perpetrated by children and adolescents, many of them in the school system. Given the often-tragic results, there is an understandable lament that troubled youth could not be identified earlier and put into some form of treatment. Why not have an effective and comprehensive screening program in medical practices and in the schools to help identify problems before they become crises?

In British Columbia there is a proposal to do just that. The Practice Support Program for Child and Youth Mental Health (PSP-CYMH) trains physicians in the use of screening tools to help identify childhood mental illnesses. In its second phase, school personnel are to be included in some of the training.

This sounds like a good idea. When a tragedy happens, we often hear that the perpetrator turned out to be suffering from a mental illness. But we usually know this because the person was already in some form of mental health care: he or she had a therapist, a psychiatrist, was taking medication, and so on. Case-finding is irrelevant in such situations, as the case has already been found and action is being taken.

The implication seems to be that if we beef up the mental health service, fewer instances of violence will occur. But this begs a few questions:

  1. Given that most perpetrators are already in care and nevertheless offended, doesn't this call into the question the notion that treatment will prevent bad outcomes?
  2. If there was a better-funded service, would the perpetrators have been in two forms of therapy rather than one? Five, maybe? Ten? Is there any evidence that this would help?
  3. Is there any evidence that more elaborate mental health screening results in reduced levels of youth violence or better long-term mental health outcomes?

Mad in America ( is a website founded by Robert Whitaker, author of "Anatomy of an Epidemic," a remarkable book that examines the research literature on the long-term effectiveness of common mental health treatments. It hosts blogs and reporting from a wide variety of perspectives, most of which are skeptical of current mental health practices. Some of the posts are extreme and angry, most are not.

In July of this year, Rob Wipond, a Victoria-based freelance journalist, wrote about the PSP-CYMH that calls much of the program into question. See what you think:

One concern that is frequently raised about mental health screening initiatives is that they identify patients who can then be sold psychoactive medications. Authors of the initiatives almost always talk about the enhancement of social supports, the provision of psychotherapy, involvement with community, and so on. But in the real world of medical practice, screening usually translates into prescriptions written.

It is no wonder that so many of these initiatives have received generous financial support from the pharmaceutical companies whose products will be sold as a result. That said, I can find no evidence of direct pharmaceutical industry funding for the PSP-CYMH initiative.

It is possible, though, to look at the materials supplied to physicians as part of the program. Here they are:

You can even try them out for yourself. I was a sometimes anxious kid and have spent much of my life thanking the fates for not having my case found - believing as I do that things would have turned out much worse for me as a result. I was interested in the child form of the SCARED inventory of childhood anxiety, available here:

It's not a great measure, and hasn't been well thought through as published for BC Physicians. Look at the instructions, for example, which invite children to "fill in one circle that corresponds to the response that seems to describe you." There are no circles; the format has been changed to a table for checkmarks. This is an extremely minor problem, but one that suggests no one has even proofread the materials.

I thought back to one of the more anxious years of my own childhood and filled out the questionnaire as I believe I would have, had I been honest, back then. Sure enough, my score exceeded the screening cutoff. Try it yourself.

No problem, perhaps, if the help given as a result is useful, evidence-based, effective over both the short and long term, and aware of the context of the child's life. But if you are imagining legions of child and youth clinicians and support workers lolling about with nothing to do because not enough cases have been found, think again. Child and youth mental health services are already oversubscribed - not just in BC but in virtually every jurisdiction with which I am familiar.

It is very difficult to escape the notion that children identified through screening and subsequent assessment will be unable to access any resources other than medication, and that the result of the program will be even more children on psychoactive medication than there are now. Not such a bad outcome if the evidence supports the effectiveness of such an approach over the long term. But the evidence is fairly equivocal on this issue, to put it generously.

So what do you think? Should we be screening to find more cases of child and youth mental health problems? As I suggested at the outset, it doesn't sound like such a bad idea. But considering the state of the services available, the quality of the research on pharmacological interventions in children, and the criticisms levelled by Wipond and those he cites in the article, it's a bit hard to understand how violence might be reduced or the care of seriously ill children will be enhanced by the current initiative.

One of Wipond's sources is University of Victoria-affiliated drug policy researcher Alan Cassels, whose recent TEDx Victoria talk can be found here:

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