By Theory Possessed   /   Spring 2023   /    Notes & Comments

Mental Medicine

Are we living in an “emergent democracy of the sick”?

Joseph E. Davis

Eugenia Kozyr/Unsplash.

Should all adults under the age of sixty-five be routinely screened for anxiety? A draft recommendation issued last fall by the United States Preventive Services Task Force, a volunteer group appointed by a division of the US Department of Health and Human Services, concluded that screening is justified by the pertinent medical literature—and that it would provide “a moderate net benefit.” Although the task force technically is independent of the government, its recommendations carry significant weight for standards of care: Health insurers, for one, are often required by the Affordable Care Act to cover services the task force recommends.

Drawing public attention to specific medical issues is another function of the task force, and its new recommendation received wide and favorable coverage in the mainstream media. The reason should not surprise us. In our “emergent democracy of the sick,” to borrow a phrase from sociologist Philip Rieff, the idea that 30 percent of Americans have an anxiety disorder and that most cases go undetected and untreated seems obvious and uncontroversial. We lack sufficient awareness of the “crisis,” Dr. Lori Pbert, a task force member and the group’s spokesperson, told the press. Citing “barriers” to treatment, she called for greater access to mental health care and “more resources to be able to meet the demand” and beef up our “undersized mental health care workforce.” More disorder, more screening, more care: the familiar talking points, all dutifully repeated.

One of those taking a sharply different view was prominent psychiatrist Allen Frances. “Dangerously dumb” was his succinct verdict. Frances chaired the task force that prepared the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), published in 1994, and he has since become a critic of what he has called “out-of-control” psychiatric diagnosis. In the space of a single tweet, he offered several reasons for his negative judgment. Routine screening, he argued, would lead to a great deal of misdiagnosing. Short screening instruments yield many false positive rates, and there is insufficient time for a proper diagnosis in a typical fifteen-minute primary care visit. As a result, even more people will be inappropriately put on psychoactive medications, and since therapists are already in short supply, the “great needs” of the severely ill will be further neglected.

The members of the Preventive Services Task Force, including Dr. Pbert, are not unaware of these issues, but they remain confident that wholesale screening for anxiety will produce a net benefit.

Whence that confidence?

Although anxiety is an everyday word, the task force reassures us that it is not talking about common fears and worries. Rather, “anxiety” is the group’s shorthand for the eleven psychiatric anxiety disorders identified in the most recent DSM (a “text revision” of DSM-5 that was published in March 2022), ranging from “specific phobia” to “social anxiety disorder” to “panic disorder.”

This anxiety is a medical condition, an illness you have. According to the task force, it can be a “chronic condition characterized by periods of remission and recurrence,” though “full recovery may occur.” It has a “prevalence,” an “onset,” and a “natural history” with “recognized signs and symptoms.” Anxiety also has “risk factors,” can be “comorbid” with other disorders, especially depression, and can have “long-term effects.” It is a disordered “stress response,” an internal dysfunction of some mental process.

Aligning its taxonomy with that of the DSM, the Preventive Services Task Force distinguishes pathological anxiety from normal emotion on the basis of whether the “fear or worry” is “excessive” or of “greater duration,” or causes more “impairment” in the activities of daily life. These terms involve a comparison and presuppose, at minimum, a relevant life context to which the “fear or worry” is a response, and some baseline, some appropriate response to that context against which the anxiety is judged abnormal—that is, excessive or out of proportion.

The appraisal of an emotional response, in other words, necessarily involves an appraisal of the context in which it arose. Our emotions emerge from our interactions with situations. They involve the meaning of events in relation to what we care about and what we aspire to achieve. Imagine various work-related scenarios: There are rumors of layoffs; you get another mediocre performance review; you have a tense, competitive relationship with a coworker or boss. Then on the home front: You have a strained or even estranged relationship with a son or daughter. More globally: Reading the news each day brings further details of rising crime rates or political turmoil; your social media feed shows your life to be uninspiring compared to those of others.

No wonder you’re worried, on edge, feel threatened, have trouble sleeping. In the absence of more detailed information about these situations and the meanings they have for each person, attempts to differentiate normal from abnormal emotions on the basis of severity, duration, or functional criteria simply make no sense.

Yet when questioned about defining pathological anxiety in an NPR interview last September, Dr. Pbert made no mention of context. She simply listed some common forms of distress: “things like feeling nervous, anxious or on edge, unable to control worrying, really having trouble relaxing, feeling restless, afraid something awful might happen and feeling anxious or worried for no particular reason.” Citing a survey, she went on to claim that “we know that early in the pandemic, the percent of adults with recent symptoms of an anxiety or depressive disorder actually increased from 36 to 42 percent.” Like diagnostic screening instruments, however, such surveys ask nothing about the respondent’s situation.

So what, we might fairly ask, is going on here? The Preventive Services Task Force acknowledges the need to situate emotions in a context. With respect to screening, it assumes that the context will come up later, during that brief medical appointment focused on other ailments. The task force speaks of “anxiety” as a stand-in for the various anxiety disorders as though they are equivalent, and avers that a single screening instrument will reliably detect them. The studies and screening tools the group refers to, however, do not remotely support such assumptions. And the task force’s rationale for recommending screening does not include any known benefit of its use for early detection. Indeed, for health outcomes such as “quality of life, functioning, or remission,” the task force finds no “direct evidence” of “benefits of screening for anxiety in primary care or compatible settings.”

If there is no direct evidence that screening in primary care either identifies mental disorders or promotes beneficial health outcomes, then why would a distinguished group such as the Preventive Services Task Force recommend it? Here, we come to what the recommendation is really all about.

To quote Dr. Pbert again, it’s about getting people “connected to care.” The actual concern is with extending treatment for distress, whatever the cause, dysfunction or not. Identifying discrete mental disorders is of ancillary concern, and so therefore are worries about false positive diagnoses and limits on a doctor’s time. The task force’s reasoning seems to be that many people are struggling (with the stress of the pandemic, among many other things), and treatments exist that can help. Ergo, getting more people under professional care will, on balance, be beneficial.

The key premise is that treatments help. The rationale for the task force recommendation is based on the benefits of clinical treatments, both “psychological interventions” (unspecified) and “pharmacotherapy” (medication).

For psychological interventions, the task force finds “adequate evidence” in the medical literature of a “moderate” magnitude of benefit with a “no greater than small” risk of harm. While there is reason to believe that the evidence for benefit is overstated (see below), it is also mostly beside the point. The recommendation is to screen people in primary care.

While primary care physicians may make a referral, they do not themselves provide psychotherapy. What they do provide—extensively, and routinely without evidence of disorder—are prescriptions for psychoactive medications. With regard to drugs, the task force concludes that, overall, such medications provide a “small benefit in reducing anxiety symptoms,” with harms that are “no greater than moderate.”

That hardly sounds like a net advantage. And there is considerable evidence to suggest that the net effect is harm.

Consider two recent large-scale analyses of clinical interventions. (Although both are concerned with antidepressant medications and depression, they are relevant here because most treatment guidelines make antidepressants the first-line medications for anxiety disorders and depression, and anxiety disorders greatly overlap.)

The first study was an analysis of all 232 randomized, controlled trials of antidepressants submitted by drug companies to the Food and Drug Administration between 1979 and 2016. The researchers did not find what is often asserted about these drugs—namely, that they provide a “small incremental benefit in reducing symptoms (beyond a placebo response)” across patients. Rather, the effect of the drugs was a “large near-term reduction in symptoms” for about 15 percent of the treated patients. The rest, the overwhelming majority of trial patients (85 percent), were subject to the many risks associated with taking antidepressants without any specific benefit from the drugs themselves.

The second study concerned both psychological and drug interventions. Since the 1980s, the researchers observed, the number of people being treated for depression with both types of interventions, but especially antidepressant medications, had sharply increased. Mysteriously, however, the prevalence of depression had been unaffected. What gives? Clinical trial data, the basis for the enthusiastic prescribing of antidepressants, the researchers found, is misleading. It overestimates short- and long-term treatment efficacy, and much of this efficacy disappears when the treatments are used in real-world settings. The prevalence isn’t changing because the treatments, on average, make little difference. And lest we forget, the drugs carry risks and may have “counterproductive consequences.”

Both studies affirm therapeutic value in interventions. The crucial question is: for whom? Consistent with the findings of many other studies, the answer is the relatively small number of those with the most serious, chronic problems. If we want to help, these are the people to identify. But for this limited, targeted, and discriminating task, wholesale screening is woefully misguided.

There is no denying that many people are dealing with emotional distress that is painful and can interfere with daily activities and work performance, but that does not mean they have a mental disorder. Their symptoms might actually be signs of something important outside their head: a problem in a relationship, a strained work environment, real danger, unrealistic standards or ambitions. Throwing prescription drugs at troubles like these will not return a net benefit.