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The Newest Medical Threat


How would you like it if every time you went to your doctor, for whatever reason, he asked:

Over the past two weeks, have you felt down, depressed, or hopeless? Have you felt little interest or pleasure in doing things?

Get ready for a further medicalization of the common tribulations of life. The U.S. Preventative Services Task Force (USPSTF) recommends that primary-care physicians ask their adult patients those questions, or use some other depression-screening method, whenever they visit. The USPSTF, “a panel of independent, private-sector experts in prevention and primary care,” is part of the federal Agency for Healthcare Research and Quality.

Under the recommendation, if a patient answers yes to the questions, it would trigger “full diagnostic interviews that use standard diagnostic criteria … to determine the presence or absence of specific depressive disorders, such as major depression and/or dysthymia,” which is defined as “a chronic low-grade depression.” If a “disorder” is found, “treatment may include antidepressants [drugs] or specific psychotherapeutic approaches (e.g., cognitive behavioral therapy or brief psychosocial counseling), alone or in combination.”

The USPSTF says the recommendation is valid because “depressive disorders are common, chronic and costly.” The task force estimates that 5 to 9 percent of adults in primary-care settings suffer from depression and that primary-care physicians miss half of them. The prime candidates are said to be “women, those with a family history of depression, the unemployed, and those with chronic disease.”

I have two questions of my own. What if a patient refuses to answer the questions? Or, having been diagnosed with depression, what if he refuses to be treated?

These aren’t smart-aleck questions. As psychiatrist Thomas Szasz has pointed out, in the regular medical context, it is well recognized that there is a difference between being ill and being a patient. Illness refers to an objective medical condition, ascertainable by diagnostic tests that reveal a problem with cells, tissues, or organs. Being a patient is a social role that isn’t established until freely undertaken. A diabetic is not a patient until he chooses to be treated by a doctor. Just as one can be ill without being a patient, so one can be a patient without being ill (by faking, say).

The rules are different in the mental health context. First: “There are no objective diagnostic tests to confirm or disconfirm the diagnosis of depression…. Psychiatrists do not even perform physical examinations,” writes Dr. Szasz in Pharmacracy. Despite all the pharmaceutical commercials on television about chemical imbalances, depression and other “mental illnesses” are not detected through analyses of brains or body fluids. That’s because they are metaphorical illnesses, like homesickness. As the USPSTF indicates, diagnosis is based on what people tell doctors. (This doesn’t mean depressed people don’t suffer, only that they don’t have a disease.)

Another difference is that in the mental-health context the patient role does not require consent. It can be imposed through commitment to a mental hospital and, now, “outpatient commitment.” Thus, someone who does not regard himself as sick and does not wish to take potent, even risky drugs can be legally forced to do so at a psychiatrist’s command rubber-stamped by a judge. However, as Szasz writes in his newest book, Liberation by Oppression, “the belief that mental diseases are curable with antidepressants and antipsychotics is founded on faith, not fact. Hence, policies based on it are destined to fail.” Policies such as the one being pushed by the USPSTF.

These considerations along with a final element make this a potential horror story. As tort law now stands, a psychiatrist in private practice can be held liable if a patient kills himself or someone else. This is the so-called “duty to warn” principle. Under the USPSTF recommendation, if a person commits murder or suicide, will others be able to sue his primary-care physician for not asking the depression-screening questions or for not imposing treatment? If so, a patient who refuses to answer the questions or accept treatment will pose a threat to his doctor’s practice. This will assuredly be detrimental to the confidential doctor-patient relationship.

As Dr. Szasz writes, “Every psychiatrist has been transformed into an undercover agent.” The USPSTF recommendation would make every primary-care physician an undercover agent too.

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    Sheldon Richman is former vice president and editor at The Future of Freedom Foundation and editor of FFF's monthly journal, Future of Freedom. For 15 years he was editor of The Freeman, published by the Foundation for Economic Education in Irvington, New York. He is the author of FFF's award-winning book Separating School & State: How to Liberate America's Families; Your Money or Your Life: Why We Must Abolish the Income Tax; and Tethered Citizens: Time to Repeal the Welfare State. Calling for the abolition, not the reform, of public schooling. Separating School & State has become a landmark book in both libertarian and educational circles. In his column in the Financial Times, Michael Prowse wrote: "I recommend a subversive tract, Separating School & State by Sheldon Richman of the Cato Institute, a Washington think tank... . I also think that Mr. Richman is right to fear that state education undermines personal responsibility..." Sheldon's articles on economic policy, education, civil liberties, American history, foreign policy, and the Middle East have appeared in the Washington Post, Wall Street Journal, American Scholar, Chicago Tribune, USA Today, Washington Times, The American Conservative, Insight, Cato Policy Report, Journal of Economic Development, The Freeman, The World & I, Reason, Washington Report on Middle East Affairs, Middle East Policy, Liberty magazine, and other publications. He is a contributor to the The Concise Encyclopedia of Economics. A former newspaper reporter and senior editor at the Cato Institute and the Institute for Humane Studies, Sheldon is a graduate of Temple University in Philadelphia. He blogs at Free Association. Send him e-mail.