Screening for mental illness: a balancing act
What is the best way to reach people who need treatment?
Mental health has been at the forefront of health policy at least since the COVID-19 pandemic. The AIHTA has analysed whether and under which aspects screening for mental illness in primary care would be suitable.
Almost one in five adults in Austria is affected by at least one mental illness each year. The most common mental health issues are depression (ten per cent), anxiety disorders (seven per cent) and harmful substance use or addiction (around twelve per cent). In general, unemployed people, people with financial worries and those caring for a sick family member are more likely to be affected. In its report, the Austrian Institute for Health Technology Assessment (AIHTA) therefore explored whether and how screening for mental illness in adults could be implemented in the primary care setting.
High number of unreported cases
This is all the more true given the large number of unreported cases of people suffering from mental illness who do not seek help. The study situation provides multiple indications of this: Data from Austria and Germany show that around 60% of people with mental illness do not seek any type of help. But what is the best way to reach people who need treatment?
The aim of screening is to identify people who suffer from certain conditions but do not yet know it or have a predisposition to it. With regard to mental illness, this also means "recognising physical symptoms early that may indicate a mental illness ", explains Julia Kern, lead author of the report and research associate at the AIHTA. Insomnia, fatigue, listlessness - patients often complain of somatic symptoms without thinking of a mental health problem. The first port of call for such complaints is often the family doctor. Setting up an appropriate screening programme in primary care would therefore make sense.
Screening: more than just a test
However, the implementation of such a health programme would have to be approached comprehensively. This is because: "Screening for mental illness should never be seen as just a test that is carried out as part of a check-up, for example," says Kern. International studies have proven the accuracy of tests - which are usually questionnaires for patients. However, this approach falls short. Kern: "It's about mapping and implementing the entire screening process." This begins with the definition of the goal to be achieved, includes invitation management and thus the definition of the groups of people to be screened and continues through to the organisation of treatment options if necessary.
Pros and cons of screening
In 2020, no formal screening for depression was recommended as part of the revision of the Austrian periodic health examination (VU), partly due to the length of the test and the limited therapeutic options for people with mild depression. There was also the fear of unnecessary additional prescribing of psychotropic drugs. Inanna Reinsperger, project manager at AIHTA, adds: "The potential damage of generalised screening ranges from unnecessary tests and longer waiting times for diagnosis and treatment with a high number of false-positive results, to delayed diagnoses for people with false-negative results, as well as overdiagnosis and treatment." If there are not enough treatment places available, waiting times for those affected are likely to increase. Another challenge concerns the acceptance of the VU as a setting for this type of screening. This is because: "Currently, only around twelve per cent of people take part each year - and people with mental illnesses tend to do so even less often," say the authors.
When analysing nine international systematic reviews and 28 guidelines on this topic, the following picture emerged: The evidence for screening the entire population for mental illness is thin. At the same time, there are a number of tried-and-tested tests and evidence-based guidelines that recommend screening – namely for specific groups of people and patients. "We also looked at guidelines for physical illnesses such as heart failure, diabetes and cancer. They state that affected people should also be regularly screened for mental illnesses such as depression or anxiety disorders," says Reinsperger. This direction could be further considered. "Screening in groups with specific diseases based on recommendation from corresponding guidelines would be conceivable in primary care."
Alternatives to screening: promoting destigmatisation
However, the authors' propose to examine possible alternatives to a screening programme to begin with. Reinsperger: "The primary goal must be to minimise the suffering caused by mental illness. The aim here is to find the most sensible method that also stands up to a cost-benefit analysis." The problem area is large: a first step could be to expand the number of available therapy places and financial support for those affected. Another concrete proposal from the AIHTA concerns comprehensive education and information for the public. "Everything should be done that contributes to destigmatisation. Mental illnesses are still a taboo," says Kern. There is also a lack of knowledge about possible symptoms and where to get help. There is also room for manoeuvre when it comes to the choice of treatment. Kern: "Depending on the severity of the illness, it is important to also consider lighter, shorter forms of therapy." Reinsperger adds: "There needs to be clearly defined pathways for which diagnosis leads to which treatment. There is a lot of catching up to do."
Original publication
Kern, J., Reinsperger, I. und Hofer, V. (2024): Screening auf psychische Erkrankungen bei Erwachsenen in der Primärversorgung. HTA-Projektbericht 159
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