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To screen or not to screen: that is indeed the question. John Cox, BM, BCh DM (Oxon) FRCPsych

To screen or not to screen: that is indeed the question. John Cox, BM, BCh DM (Oxon) FRCPsych Professor Emeritus Keele University, Staffordshire Past President Marce Society and Royal College of Psychiatrists. John1.cox @virgin .net. Introduction: Contemporary issues

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To screen or not to screen: that is indeed the question. John Cox, BM, BCh DM (Oxon) FRCPsych

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  1. To screen or not to screen: that is indeed the question. John Cox, BM, BCh DM (Oxon) FRCPsych Professor Emeritus Keele University, Staffordshire Past President Marce Society and Royal College of Psychiatrists. John1.cox @virgin .net

  2. Introduction: • Contemporary issues • Speed of cultural changes in UK. • Individualistic ,competitive , materialistic, market driven. • Yet 25th Anniversary of the PBU! • NHS 65th anniversary! • EBM and VBM; evidence and Values. • Lack of relationship based Person Centered health care 1986

  3. Screening: a misused and misunderstood word A public health service in which members of a defined population, who do not necessarily perceive that they are at risk of, or are already affected by a disease or its complications, are asked a question or offered a test to identify those individuals who are more likely to be helped than harmed by further tests or treatments reduce the risk of disease or its complications (National Screening Committee 2000) • Criteria for appraising programmes:

  4. The Condition • An important health problem • Natural History of the condition understood. • All primary prevention interventions have been implemented

  5. The Test • Simple Safe precise and validated • Acceptable to the population • Agreed policy on further diagnostic investigations following a positive screen.

  6. The Treatment • An effective intervention. Evidence that early treatment is advantageous. • Evidence-based policies about which treatment option • Patient management options optimised prior to screening.

  7. The Screening Programme • There must be evidence from the high quality RCTs that the screening programme is effective in reducing morbidity and mortality. • The programme is acceptable to the public and the professionals. • Benefits outweigh the risks

  8. Values, ethics and humanity: EBM and VBM; clinical common-sense • National Institute of Clinical Excellence. Antenatal and Postnatal Mental Health Guidelines.

  9. Severe mental illness Schizophrenia Bipolar disorder Depression Mild, moderate or severe Anxiety disorders Panic disorder Generalised anxiety disorder Obsessive–compulsive disorder (OCD) Post-traumatic stress disorder (PTSD) Eating disorders Mental disorders during pregnancy and the postnatal period

  10. ??? • Need to develop new classifications of • perinatal mental disorder ICD-11 and DSM-5 • eg mandatory 3 months specifier.

  11. At first contact with maternity services, ask specific questions about: Past or present severe mental illness Previous treatment by psychiatrist/specialist mental health team Family history of perinatal mental illness Prediction

  12. ??? • Risk factors well-established for over 30 years. • Why have the midwifery profession and the medical profession not acted? • Why have obstetricians in the UK no postgraduate training in mental health?

  13. Use the ‘Whooley’ questions at first contact with primary care, at the booking visit, and postnatally Other self-report measures can be used as part of subsequent assessment Identify possible depression Detection

  14. ??? • No established evidence-base for the Whooley questions yet! • Are they too woolly?! • Evidence for use of screening scales such as the EPDS considerably more conspicuous!

  15. During the past month, have you often been bothered by feeling down, depressed or hopeless? During the past month, have you often been bothered by having little interest or pleasure in doing things? Consider a third question: Is this something you feel you need or want help with? The ‘Whooley’ questions

  16. provide treatment within 1 month of initial assessment Subthreshold symptoms Previous depression or anxiety 4–6 sessions of brief psychological treatment such as interpersonal therapy (IPT) or cognitive behavioural therapy (CBT) No previous depression or anxiety Social support such as regular informal individual or group-based support Psychosocial treatments

  17. Mild or moderate depression Self-help strategies Counselling (listening visits) Brief cognitive behavioural therapy Interpersonal psychotherapy Management of depression

  18. ??? • Is it the content of the therapy, or its regularity by a usually female professional, that is effective? • Is the health visitor, children’s nurse or psychologist providing the empathic support traditionally given by the mother?

  19. Effective detection Effective assessment and referral to appropriate services Timely, appropriate management and treatment Accurate information about the disorder and the benefits and risks associated with interventions Provision of care in the most appropriate setting Appropriate communication about care with other services as required, taking into account confidentiality Choice Organisation of care

  20. ??? • Ethics of screening • National screening committee controversy with regard to the EPDS

  21. Coordinating board Specialist perinatal services in each locality providing direct services, consultation and advice Access to specialist expert advice on psychotropic medication Clear referral and management protocols Clearly defined roles and competencies for all professional groups Clearly defined pathways of care for service users Service delivery:perinatal mental health networks

  22. The Evidence Base: Research and Values relevant to my own international work

  23. Kasangati Health Centre Antenatal Clinic

  24. Antenatal interview: Eunice Sendagire Postnatal interview: Charles Kimbugwe

  25. (Lancet)

  26. Kendell et al 1987.

  27. New onset depressions Cox, Murray and Chapman 1993

  28. Identifying Perinatal Depression • Listen to what the mothers are telling you • ‘I have never felt like this before’ • It was ‘terrible’ ‘absolutely ghastly’ ‘something had got a hold’

  29. Screening Tools / Tests eg Edinburgh Postnatal Depression Scale Cox JL, Holden JM, Sagovsky R (1987): Detection of Postnatal Depression. Development of the 10-Item Edinburgh Postnatal Depression Scale. British Journal of Psychiatry, 150, p782-786 Cox JL, Holden JM, Henshaw, C (2013): Perinatal Mental Health: The Edinburgh Postnatal Depression Scale (EPDS) Manual Second Edition. RCPsych Publications. In Press

  30. Edinburgh Postnatal Depression Scale As you have recently had a baby, we would like to know how you are feeling now. Please underline the answer which comes closest to how you have felt in the last 7 days, not just how you feel today. Here is an example , already completed: I have felt happy: • Yes, most of the time • Yes, some of the time • No, not very often • No, not at all This would mean: “I have felt happy some of the time during the past week. Please complete the other questions in the same way

  31. IN THE PAST SEVEN DAYS 1. I have been able to laugh and see the funny side of things: • As much as I always could 0 • Not quite so much now 1 • Definitely not so much now 2 • Not at all3

  32. 2. I have looked forward with enjoyment to things: • As much as I ever did 0 • Rather less than I used to 1 • Definitely less than I used to 2 • Hardly at all3

  33. 3. I have blamed myself unnecessarily when things went wrong: • Yes, most of the time 3 • Yes, some of the time 2 • Not very often 1 • No, never0

  34. 4. I have been anxious or worried for no good reason: • No, not at all 0 • Hardly ever 1 • Yes, sometimes 2 • Yes, very often3

  35. 5. I have felt scared or panicky for no very good reason: • Yes, quite a lot 3 • Yes, sometimes 2 • No, not much 1 • No, not at all0

  36. 6. Things have been getting on top of me: • Yes, most of the time I haven’t been able to cope at all well 3 • Yes, sometimes I haven’t been coping as well as usual 2 • No, most of the time I have coped quite well 1 • No, I haven’t been coping as well as ever0

  37. 7. I have been so unhappy that I have had difficulty sleeping: • Yes, most of the time 3 • Yes, sometimes 2 • Not very often 1 • No, not at all 0

  38. 8. I have felt sad or miserable: • Yes, most of the time 3 • Yes, quite often 2 • Not very often 1 • No, not at all 0

  39. 9. I have been so unhappy that I have been crying: • Yes, most of the time 3 • Yes, quite often 2 • Only occasionally 1 • No, never 0

  40. 10. The thought of harming myself has occurred to me: • Yes, quite often 3 • Sometimes 2 • Hardly ever 1 • Never 0

  41. Translations Gibson et al 2009; Cox and Holden 2003 (Current count 54) German Spanish Arabic Maltese Japanese Dutch Punjabi Congolese Bangla Danish Taiwanese Finish Maori Ethiopian Nigerian • Norwegian • Greek • Italian • Hebrew • Portuguese • Slovenian • Chinese • Urdu • French • Vietnamese • Swedish • Hindi • Icelandic • Nepalese • Turkish

  42. Psychometric Properties False Positives; False Negatives

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