Re-rethinking the article by Thombs and colleagues
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* Wolfgang Linden
* Andrea Vodermaier

We take issue with all four key reasons given by Thombs and colleagues1 to advise against routine screening for depression.

First, *unacceptably high false-positive rates can result*. To support this point, Thombs and colleagues offered one reference that claimed there are 50% false-positive rates, whereas systematic reviews reveal the existence of quality tools with greater than 80% sensitivity and greater than 80% specificity where the false-positive rates are in a very acceptable 10%–20% range.2

Second, *screening absorbs valuable resources better spent elsewhere*. This opinion is already undermined because numerous clinics use screening procedures where patients respond via touch-screen computers or kiosks. System set-up cost is modest but long-term use is cheap.

Third, *there is no evidence that screening benefits patients*. Carlson and colleagues3 conducted a randomized controlled trial in which screened patients had better emotional outcomes than non-screened patients. Interestingly, one of the authors advising against screening in the *CMAJ* article1 also attempted to negate the positive outcomes of the Carlson and colleagues3 study in a letter to the editor.4 Furthermore, Thombs and colleagues consider only improved patient outcomes as a justification for screening, and they ignore the social justice of equal access to care and that routine screening allows for databased resource allocation.

Fourth, *treatment for depression is not very effective*. The authors cite only evidence that selective serotonin reuptake inhibitors are of limited use, but they ignore the impressive literature on the effects of psychological therapies on depression.5 Also detrimental to the stance of the authors are two systematic reviews revealing that psychological treatment is most effective for high levels of depression, and that psychological treatment for depression and anxiety in patients with cancer was three times as effective when patients had first been screened for actual existence of depression and anxiety.6

Last, why focus only on screening for depression when there other treatable types of distress, like anxiety or symptom burden, that affect patients’ quality of life?

## References

1.  Thombs BD, Coyne JC, Cuijpers P, et al. Rethinking recommendations for screening for depression in primary care. CMAJ 2012;184:413–8.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czo5OiIxODQvNC80MTMiO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTg0LzQvNDM4LjEuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

2.  Vodermaier A, Linden W, Siu C. Screening for emotional distress in cancer patients: A systematic review of assessment instruments. J Natl Cancer Inst 2009;101:1464–88.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiam5jaSI7czo1OiJyZXNpZCI7czoxMToiMTAxLzIxLzE0NjQiO3M6NDoiYXRvbSI7czoyMjoiL2NtYWovMTg0LzQvNDM4LjEuYXRvbSI7fXM6ODoiZnJhZ21lbnQiO3M6MDoiIjt9) 

3.  Carlson LE, Groff SL, Maciejewski O, et al. Screening for distress in lung and breast cancer outpatients: a randomized controlled trial. J Clin Oncol 2010;28:4884–91.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiamNvIjtzOjU6InJlc2lkIjtzOjEwOiIyOC8zMy80ODg0IjtzOjQ6ImF0b20iO3M6MjI6Ii9jbWFqLzE4NC80LzQzOC4xLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

4.  Palmer SC, van Scheppingen C, Coyne JC. Clinical trial did not demonstrate benefits for screening patients with cancer for distress. J Clin Oncol 2011;29:e277–8.
    
    [FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiRlVMTCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiamNvIjtzOjU6InJlc2lkIjtzOjEwOiIyOS8xMC9lMjc3IjtzOjQ6ImF0b20iO3M6MjI6Ii9jbWFqLzE4NC80LzQzOC4xLmF0b20iO31zOjg6ImZyYWdtZW50IjtzOjA6IiI7fQ==) 

5.  Driessen E, Cuijpers P, Hollon SD, et al. Does pre-treatment severity moderate the efficacy of psychological treatment of adult outpatient depression? A meta-analysis. J Consult Clin Psychol 2010;78: 668–80.
    
    [CrossRef](http://www.cmaj.ca/lookup/external-ref?access_num=10.1037/a0020570&link_type=DOI) 
    
    [PubMed](http://www.cmaj.ca/lookup/external-ref?access_num=20873902&link_type=MED&atom=%2Fcmaj%2F184%2F4%2F438.1.atom) 

6.  Linden W, Girgis A. Psychological treatment outcomes for cancer patients: What do meta-analyses tell us about distress reduction? Psychooncology 2011; Sept. 1 [Epub ahead of print].