To screen or not to screen? A balancing act.

CAPS (Counseling & Psychological Services) and other mental health advocacy groups on campus, like NAMI, Peer for You, and Neurocare, have redeveloped their approach during the past few years. As a senior, the climate surrounding mental health has transformed considerably the past three years. New student groups have appeared, a new Wellness Center was constructed, and CAPS has shifted away from their cumbersome and inefficient appointment-only approach. This was not always the case, and upperclassmen know this all too well.

When I was in my first semester of sophomore year, I went through an extraordinarily difficult time at Duke. I dealt with constant feelings of worthlessness and self hatred. At night I couldn’t sleep and during the day I didn’t eat. One night, I had looked around on the CAPS website and found an online depression screening tool. I took the test and was relieved to receive a “diagnosis” of not depressed. After my symptoms worsened as I stumbled through the semester, my friends implored me to go to CAPS. There, I met with a psychiatrist for about 15 minutes who ran through a series of questions eerily similar to the online depression screening I had taken weeks before. After this visit, I was diagnosed with Major Depressive Disorder, meeting all the major “criteria” of a depressed person.

These tests were virtually the same, yet, somehow the results did not match. There are certainly advantages to providing easily accessible screening tools for individuals, but these often come at a significant cost to accuracy. Mental illness is especially unique because it isn’t like a physical ailment. If I break my leg in soccer, the pain is immediate and clear. My leg may bend an unnatural way and begin to swell. Diagnosing a mental illness is much more difficult because there is no tangible way to identify it, and the boundaries of healthy vs. sick are less clearly defined. Furthermore, self-recognition of mental illness proves significantly more elusive. How you feel and what you think is determined heavily by your environment. For example, a more stressful day is more likely to trigger thoughts of feeling overwhelmed and helpless than a less stressful day.

As such, the time and location one decides to take a depression screening will likely influence the results. Additionally, these factors may also influence one’s decision to screen in the first place. Experts point out that screening tools do not diagnose mental illnesses by themselves, but they can draw attention to symptoms that may raise red flags, which in turn signal the existence of a more serious problem. Effective screenings should be followed up by more thorough one-on-one evaluations. Opponents of online screenings worry that overscreening can lead to overdiagnosis and overtreatment. One could argue, however, that serious overtreatment of mental health is a less of two evils, considering the alternative is serious undertreatment. In a society with limited resources, the concern of overtreatment is valid as we run the risk of having less resources to devote to those with more serious mental health concerns.

Self screenings exist for a range of illnesses including depression, PTSD, bipolar disorder, and anxiety disorders. Research has shown that screening tools are plagued with inaccuracies, yielding false positives and false negatives (like in my case) left and right. Additionally, self-screenings should never take the place of visits with actual mental health professionals. Given the serious deficiencies in the mental health infrastructure in this country, access to this counsel is not as easy to obtain. Suppose someone self-screens and is “diagnosed” as bipolar. Suppose this person is without healthcare or a healthcare plan that covers mental health care (which is not uncommon). What are they to do with these results? Will self-identification with a disease they may or may not have change the way they think about themselves? Could it change the way others see and treat them? These consequences must be taken into consideration, especially since mental illnesses are still highly stigmatized in the US.

While screening for mental health is crucial, it must be done well and under the counsel of a professional. Instead of advocating for heightened self-screening, I would advocate for greater advocacy to de-stigmatize mental illness and ensuring all Americans have access to licensed professionals to diagnose and treat serious mental diseases. De-stigmatizing these diseases will encourage use of mental health care and expanded access will ensure all Americans have the opportunity to find help when they are in need. Furthermore, let’s refrain from reducing the complexities and intimacies of mental illness to a 10-minute online quiz. It’s time to treat these illnesses like any other.