Johannes Hebebrand - "without weighing all implications, screening may do more harm than good"

Pre- and postnatal screening for mental disorders - Geneva keynote speaker 2017

Johannes Hebebrand: towards a focused approach to screening for mental disorders

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Early detection seems to be the current magic word for both somatic and mental disorders. And, at first sight, the tools are there. Rapid advances in molecular genetic techniques, in theory, allow prenatal detection of monogenic and chromosomal disorders; highly efficient newborn screenings are conducted in many countries all over the world.

Clinicians in child and adolescent psychiatry and psychology, paediatricians, general practitioners, and school physicians may apply one of the many established questionnaires available to screen for mental symptoms. But does it make sense to apply these instruments for universal screening? What are the underlying aims? Are we able to provide follow-up diagnostic assessments and treatments for those individuals who screen positive? Are societies ready and willing to specifically initiate universal screening for mental disorders?

Source of confusion
In his keynote lecture at the ESCAP 2017 Congress, professor Johannes Hebebrand (University of Duisburg-Essen, Germany) provided an overview of the current pre- and postnatal screenings up to the age of eighteen. "The first question to answer for clinicians, is about what they actually want to accomplish with a specific screen", says Hebebrand. "The word screening in itself is a source of confusion. It is used in many ways for different aims in a variety of trajectories. I think that child and adolescent psychiatry should have a more focused approach to this. Both researchers and clinicians should be sensitive to the use of this word. Whereas screening of high-risk populations or high-risk individuals appears appropriate in many circumstances, the step to a population-based universal screening requires a thorough evaluation of the evidence base and the societal implications. The more diffuse and unspecific the idea of screening is in the minds of clinicians, the greater the risk that we are not accomplishing anything with screening, or that we may even be doing harm."

Weighing implications
"We do indeed need to have a consensus among experts and others – from outside the medical field – who can weigh all medical and societal implications before implementing universal screenings for mental disorders. The complexity of these implications is much greater than most people think: what is the reason for doing a screening, are we fully aware of potential side-effects, do we have treatment in place, do we have the diagnostic resources available to actually initiate this and what are the implications for society?"
"The obvious example is screening a child for a disorder, without being able to offer a timely diagnostic assessment and treatment if necessary. In such a case, screening may do more harm than good to the mental health of the child and its family."

US Preventive Services Task Force
Professor Hebebrand argues that European child and adolescent psychiatry needs a common standardisation for the way screenings for mental symptoms are applied. He refers to the website of the United States Preventive Services Task Force (USPSTF), which could set an example for broadening the evidence base for medical screening and for a responsible way of implementing the available instruments. Hebebrand: "Similar to European guidelines for diagnostics and treatment, we need a European standard for whether or not to apply medical screening for autism, depression, ADHD, substance use disorders, et cetera. And if so, how to go about this. This guidance could be developed and maintained by a group of medical experts, ethical and legal experts, and policymakers. Ideally, screening for both somatic and mental disorders should be addressed under one roof in order to promote an overarching multidisciplinary approach."

Place of reference
Hebebrand envisions this European platform for prenatal and postnatal screening being suborganised per disorder or field of expertise and acting as a future place of reference for healthcare professionals and investigators from different backgrounds. "This is important, primarily for all of our colleagues in clinical practice who are confronted with questions around screening on a daily basis", says Hebebrand, whose keynote lecture at the 2017 ESCAP Congress was also meant to engage experts from relevant fields to create the basis for this European screening association. "To organise this, we need experts and funding to start with", Hebebrand says. "We are talking about substantial efforts to get this work done. This is a serious issue that requires a lot of thinking before we will be able to organise this on a European level with all the current national differences and overlaps."