June 29

Journalism vs. Promotion: TeenScreen–A Study in Contrasts UPI report compared to Washington Post

Though proponents claim that screening prevents suicide, no evidence supports such claims: “No major studies conclusively show that advance indication of which children are in danger can actually stop them from coming to harm…In addition, a misidentification could needlessly label a child for life, and potentially expose him to risky medications.”
Shankar Vedantam of The Washington Post ducked the scientific and ethical issues that are the heart of the heated debate, failing to mention that TeenScreen’s false identification score is a whopping 84%–which means that most teens who are referred for treatment (mostly prescribed drugs) are not depressed or suicidal. The article fails to present critics’ point of view, resorting instead to the underhanded ploy that psychiatry’s stakeholders employ: namely, critics are disparaged as “driven by anti-psychiatry ideologies such as Scientology.”

The Post report was held up for several weeks: the article is promotional rather than journalistic. The influence of a former board member presents a conflict of interest. Though the conflict is acknowledged, the bias remains. “Much of the initial funding [for Columbia University’s TeenScreen] came from the late William J. Ruane, a former board member of The Washington Post Co.”

Notwithstanding its director’s claim, TeenScreen is promoted and supported by industry and government.  
The article could have been written by TeenScreen PR firm, Widmeyer Communications:

"Combining our extensive knowledge in education; results-oriented communications expertise; in-house research, polling and design; and advertising capabilities, Widmeyer Communications devised a comprehensive national public health campaign involving media relations, partnership development, research, public affairs and advertising."
See: http://www.widmeyer.com/archives/2004/08/columbia_univer_1.php

The commercial value of mental screens such as TeenScreen, is demonstrated by empirical evidence:
“The growing use of screening has coincided with a rapid increase in the number of youngsters being prescribed powerful antipsychotic medications such as Risperdal and Zyprexa that have not been specifically approved for use by children. There was a fivefold increase in the use of these drugs in children between 1993 and 2002, according to one analysis published this month in the Archives of General Psychiatry, and a 73 percent increase in such prescriptions between 2001 and 2005.”

No comparable evidence exists to demonstrate TeenScreen’s  clinical value—only the vaguest of speculation:
Garrett Smith (who committed suicide) “had seen a psychiatrist shortly before he committed suicide and was given a prescription for an antidepressant.”  Curiously, Vedantam fails to mention that antidepressants trigger suicide—as the FDA mandated black box label warning indicates. He reports instead vague speculative musings: "Without any doubt, had TeenScreen been available… I am convinced we would have been empowered to save his life."  

Contact: Vera Hassner Sharav

United Press International
Ped Med: Screening for teen depression
By Lidia Wasowicz May 19, 2006, 3:21 GMT

SAN FRANCISCO, CA, United States (UPI) — As part of a plan for preventing teen suicides, a presidential task force has recommended school screening of youngsters for tell-tale signs of emotional and behavioral trouble.

‘Identifying those at risk for suicide and helping to provide them with treatment is an important strategy that needs to be tested to see if it can have a significant impact,’ said Richard McKeon, special expert on suicide prevention at the Substance Abuse and Mental Health Services Administration in Rockville, Md., the federal agency charged with implementing the commission`s recommendation.

‘Voluntary screening can be a useful tool (but) the SAMSHA position is not in favor of universal mental-health screening.’

McKeon and colleague Leah Young stressed they wanted to reassure the public talk of a mandatory mental-health checkup for all children and adolescents is greatly exaggerated.

‘I don`t know how or where that interpretation got started, but it`s out there causing lots of concern,’ Young acknowledged. ‘We`ve been charged with coming up with a roadmap for the future. It is not SAMSHA`s position in any way, shape or form to recommend universal screening for mental health.’

Even with these assurances, critics view such massive efforts, well-intentioned as they may be, as too much of a gamble. No major studies conclusively show that advance indication of which children are in danger can actually stop them from coming to harm, they say.

In addition, a misidentification could needlessly label a child for life, and potentially expose him to risky medications, they worry.

Proponents, on the other hand, point out pinpointing troubled teens for treatment before it`s too late is a crucial step toward boosting their quality of life and sparing them from a tragic end.   They cite research showing high school screening correctly identified two-thirds of participants who subsequently attempted suicide or developed major depression in young adulthood.

One might also deduce from the findings that the identification of at-risk children in itself is inadequate for precluding the predicted tragedy. Even with the forewarning, the teens wound up trying to kill themselves or succumbing to severe mental illness, critics say.

Another study showed a specially designed computerized test, taken by nearly 40,000 high school students in 2004 alone in what might be the nation`s largest mental-health screening effort for this age group, was able to tease out 100 percent of the young people who faced a high risk for suicide.

This is a big selling point for the ‘TeenScreen’ questionnaire. Developed in 1991 at Columbia University on the basis of the latest brain research, the test is available in at least 460 schools, doctors` offices, clinics, youth groups, shelters and other sites in 42 states and Washington, D.C., as a way to ‘make voluntary mental-health checkups available for all American teens.’

The screening tool scored high marks with the President`s New Freedom Commission, which cited it as a model program in 2003.

Its benefits were underscored in a five-year survey of New York high school students, led by TeenScreen creator Dr. David Shaffer, which showed the assessment correctly identified adolescents not only at current but also future risk of suicide, into adulthood.

Nevertheless, patient rights advocates like Vera Hassner Sharav, founder and president of the New York-based Alliance for Human Research Protection, take issue with the questionnaire. Sharav sees it as overreaching and worries it can result in many children being needlessly referred for mental-health services that often incorporate pharmaceutical treatments.

The outspoken rebel with a consumer cause argues one would be hard-pressed to find a teen who could honestly reply in the negative to questions such as:
‘In the last year … has there been a time when you felt you couldn`t do anything well or that you weren`t as good-looking or as smart as other people?’ or, ‘In the last year … has there been a time when you couldn`t think as clearly or as fast as usual?’

Some of her concerns are buttressed by results from the same study that showed how well TeenScreen can pick out teens in real trouble.
The survey also found 84 percent of the high school students deemed suicidal in fact were not. That means of the 6,000 screened teens referred for further evaluation and assistance in 2004, 5,040 may have been singled out in error.

‘It is important not to lose sight of the fact that many of these so-called false-positive causes may be experiencing painful depressive symptoms with social and academic impairment and are likely to benefit from treatment,’ the study authors wrote.

While few would disagree severely depressed adolescents, suicidal or not, can profit from professional intervention, critics like Sharav take issue with what they see as a dangerous stretch beyond sound scientific policy.

They perceive an overdose of professional presumption and prescription, with too many children being labeled with conditions they may not have and proffered treatments they may not need.

Part of the skepticism may be grounded in the public`s eroding trust in the healthcare establishment. Shaken by widely reported revelations of improprieties — from withheld negative study results to life-threatening medical errors — and supported by previously inaccessible information, the care seekers are dashing away from the notion of care providers as the unquestionable final authority.

The targets of the criticism may not approve of the trends, but understand them.
‘Patients and parents have more information through the Internet than ever, and unfortunately, for the most part, they don`t have the training or ability to be able to interpret or sift through the good stuff from the really bad stuff that`s out there,’ said Dr. William Narrow, associate research director of the American Psychiatric Association.

‘Unfortunately, the medical profession on an individual patient-doctor contact level has been squeezed so much by financial factors, that relationship is very tenuous,’ he added.

‘When you get 15 to 20 minutes per patient, it`s hard to build a relationship when the doctor is forced to turn over patients like tables in a restaurant. Unfortunately, that relationship has eroded, and it`s not entirely the doctor`s fault.’

Next: Use of antidepressants in adolescents kicks up controversy.
UPI Consumer Health welcomes comments on this column. E-mail Lidia Wasowicz at lwasowicz@upi.com.

Copyright 2006 by United Press International

Washington Post
Suicide-Risk Tests for Teens Debated
By Shankar Vedantam
Friday, June 16, 2006; A03

A growing number of U.S. schools are screening teenagers for suicidal
tendencies or signs of mental illness, triggering a debate between those
who seek to reduce the toll of youthful suicides and others who say the
tests are unreliable and intrude on family privacy.

The trend is being aggressively promoted by those who say screening can
reduce the tragedy of the more than 1,700 suicides committed by children
and adolescents each year in the United States. Many of the most passionate
supporters have lost children to suicide — among them Sen. Gordon Smith
(R-Ore.), whose son Garrett died in 2003.
One screening program, TeenScreen, developed by Columbia University, has
been administered to more than 150,000 children in 42 states and the
District. The state of New York plans to start screening 400,000 children a
year, and the federal government is directing tens of millions of dollars
to expand screening nationwide.

Use of the psychological evaluations is growing even though there is little
hard evidence that they prevent suicides. A panel of government experts
concluded two years ago that the evidence to justify suicide screening was
weak and that such programs, although well intentioned, had potential
adverse consequences.

The growing use of screening has coincided with a rapid increase in the
number of youngsters being prescribed powerful antipsychotic medications
such as Risperdal and Zyprexa that have not been specifically approved for
use by children. There was a fivefold increase in the use of these drugs in
children between 1993 and 2002, according to one analysis published this
month in the Archives of General Psychiatry, and a 73 percent increase in
such prescriptions between 2001 and 2005, according to Medco, a firm that
manages pharmacy benefits.

Proponents of screening say that it is no different than having health
checkups or visiting a dentist, and that the potential benefits are
incalculable. After Smith’s son killed himself, the Republican bucked the
objections of several conservative groups to push into a law an $82 million
effort to expand programs such as TeenScreen.

"Without any doubt, had TeenScreen been available to us as Garrett’s
parents, I am convinced we would have been empowered to save his life,"
Smith said in an interview. "Logic tells me the more you know, the more you
are able to help."
Garrett Smith died one day shy of his 22nd birthday. He had seen a
psychiatrist shortly before he committed suicide and was given a
prescription for an antidepressant. Sen. Smith said the family did not know
whether Garrett took the medication. Later, Smith said, several experts
concluded that Garrett probably had bipolar disorder, also known as
manic-depression. Antidepressants are not recommended for this condition,
and Smith said his son had probably concealed his symptoms during his
single visit with the psychiatrist. Still, he said, if the family had known
that Garrett had bipolar disorder, they could have acted years earlier.

The controversy over screening has become emotional. Opponents say such
programs have turned into fronts for the pharmaceutical industry to boost
sales. Advocates, meanwhile, say those against screening are often driven
by anti-psychiatry ideologies such as Scientology.

"It is industrial psychology at its worst," said Michael D. Ostrolenk, a
family therapist with the Eagle Forum, a conservative group founded by
commentator Phyllis Schlafly. "We think it is inappropriate to turn state
schools into laboratories for psychiatry." He added that the group is also
concerned that screening violates family privacy.

But screening has wide support among both Republicans and Democrats. In
2004, President Bush signed into law the Garrett Lee Smith Memorial Act to
boost funding for suicide screening, and the President’s New Freedom
Commission on Mental Health has been broadly supportive.
The debate over screening also turns on the scientific paradoxes of
suicide. It is rare enough that it is difficult to study by conventional
scientific trials, but common enough to claim the lives of more than 30,000
Americans each year — far more than those who die by homicide. There were
1,737 suicides by children and adolescents in 2003, the last year for which
national statistics are available.

Among those younger than 20, the suicide rate is 2.14 per 100,000, a
fraction of the 14.6 per 100,000 rate for those older than 50. But national
surveys suggest that about 1 in 12 high school students tries to harm
himself or herself each year with an eye to committing suicide.
Because suicide victims often turn out to have had mental disorders such as
depression and bipolar disorder, David Shaffer of Columbia University, who
developed the TeenScreen questionnaire, and other specialists say
identifying and treating youngsters with such disorders may reduce the
number of suicides.

"If the only product of screening was to predict who is going to commit
suicide, you could argue about its utility," he said. "But the risk factors
for suicide are other treatable psychiatric disorders."

Laurie Flynn, national executive director for TeenScreen, the largest of
several such programs nationwide, said annual physical exams are less
likely than mental health checkups to reveal problems. Moreover, she said,
suicide screening can reveal problems that parents may never detect.
Flynn’s daughter attempted suicide when she was 17. When the school phoned
Flynn with the news, she said, her initial reaction was "You have the wrong

Shaffer and Flynn said the goal is not to put children on medication but to
alert parents to a problem, which they can then discuss with a
pediatrician, a psychiatrist or a clergy member. Flynn said TeenScreen is
supported by private donors and receives no money from the drug industry.
(Much of the initial funding came from the late William J. Ruane, a former
board member of The Washington Post Co.) Shaffer said the screening test he
developed is now in the public domain and he does not profit from its use.

In New York state, where 70 to 80 children commit suicide each year, Sharon
Carpinello, commissioner of the Office of Mental Health, said officials
plan to spend more than $60 million to expand youth suicide prevention
initiatives such as TeenScreen.

Although the argument that treating mental disorders would reduce suicides
is intuitively appealing, the U.S. Preventive Services Task Force, a
federal panel of independent experts, concluded in 2004 that there was
insufficient evidence either for or against general physicians screening
the public for suicide risk. Ned Calonge, chairman of the task force,
established to assess the evidence for various disease-prevention
strategies, said the panel would reach the same conclusion today.

"Whether or not we like to admit it, there are no interventions that have
no harms," said Calonge, who is also chief medical officer for the Colorado
Department of Public Health and Environment.

There is weak evidence that screening can distinguish people who will
commit suicide from those who will not, he said. And screening inevitably
leads to treating some people who do not need it.

Such interventions have consequences beyond side effects from drugs or
other treatments, he said. Unnecessary care drives up the cost of
insurance, causing some people to lose coverage altogether. For every 1
percent increase in premiums in Colorado, Calonge calculated, 2,500 people
lose their health insurance.

The same panel had concluded that there is sufficient evidence to recommend
screening adults for depression. This is in part because a variety of
medications have proved effective in treating adults. Only one drug,
Prozac, has been proved effective in clinical trials for treating
depression in children.

Steven E. Hyman, a former director of the National Institute of Mental
Health and now provost at Harvard University, said he favors developing
screening questionnaires and treatments for children to reduce the number
of suicides, but he is skeptical that such tools currently exist.
"By and large, brief diagnostic tests — especially doing broad screening
in children — are not well validated, and one has to be concerned about
missing real illness or, conversely, interpreting transient life troubles
as a mental illness requiring intervention," Hyman said.

"It doesn’t mean ignorance is good," he added. "But if your instrument is
poor, or you don’t know how to intervene to prevent a condition like
suicide, there is actually a risk of harm. Besides cost and intrusiveness,
there is a risk of harm in terms of stigmatization, but also interventions
that backfire."

© 2006 The Washington Post Company

FAIR USE NOTICE: This may contain copyrighted (© ) material the use of which has not always been specifically authorized by the copyright owner. Such material is made available for educational purposes, to advance understanding of human rights, democracy, scientific, moral, ethical, and social justice issues, etc. It is believed that this constitutes a ‘fair use’ of any such copyrighted material as provided for in Title 17 U.S.C. section 107 of the US Copyright Law. This material is distributed without profit.

One Woman’s Story of Hurt and Help
By Shankar Vedantam
Washington Post Staff Writer
Friday, June 16, 2006; A03

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