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February 9, 2007

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published by the Alliance for Human Research Protection

Response to Promoter of TeenScreen
by Dr. Karen Effrem


FOREWORD:
TeenScreen is a subjective and unscientific suicide screening instrument, with vague and leading questions. It continues to be promoted across the country at both state and federal levels. It is also being promoted by the same public relations firm whose clients include the pharmaceutical companies and their front groups that make the very drugs that are all too frequently used in children and adolescents.  These medications have shown little evidence of effectiveness and are associated with suicide and other dangerous side effects.
 
President Bushs federal budget for 2008 continues the funding for the Garrett Lee Smith suicide prevention activities that include TeenScreen at the same level as last year.  This resulted in $9.7 million for TeenScreen grants in 2006.
 
Senator Gordon Smith is heavily promoting TeenScreen as in this report from Fox News. To their great credit, Fox opened the report by discussing the great deal of professional concern about using TeenScreen and then showed part of an interview with Dr. Karen Effrem explaining the vagueness and subjectivity of both the diagnostic criteria for depression and the TeenScreen instrument.  (See here for other problems with TeenScreen.)
 
Although the suicide of Senator Smiths son was tragic, as are all suicides, by some reports Garrett had already received a psychiatric diagnosis and was undergoing psychotropic drug treatment at the time, so TeenScreen would not have helped him. In fact, Smiths tragic death more points to the study performed by Columbia (which also developed TeenScreen) showing that young people dying from suicide are 15 times more likely to be on antidepressants than not (see below).  This same idea was underscored in the study that shows that those on drug treatment for schizophrenia between 1994-1998 were 20 times more likely to commit suicide than in the period of 1875-1924 when drugs were not used.   
A Response to Dr. Richard Friedmans Defense of TeenScreen
 
A commentary by Richard Friedman, MD, was published in December 28, 2006 issue of The New England Journal of Medicine in defense of TeenScreen, Columbia University's controversial mental screening questionnaire designed to expand the pool of teenagers who are deemed mentally ill. Recently, close to 50% of teens in a New York school who answered the TeenScreen questionnaire were referred for psychiatric intervention. (See: Almost 50% of Teen Screened Referred for Psychiatric Intervention)
 
Dr. Friedman is a clinical professor of psychiatry at Weill Medical College, Cornell University. He is also a lecturer at Columbia University's College of Physicians and Surgeons. His commentary is peppered with sweeping unsubstantiated statements such as: "Before screening, Courtney was part of a silent epidemic of mental illness among teenagers." 
 
Below ,Karen Effrem, MD, a pediatrician who serves on the Board of Directors of Alliance for Human Research Protection and EdWatch, offers a perspective quite different from that of Dr. Friedman.
 
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I suspect that readers of the New England Journal of Medicine would have quite a different view or at least serious questions about the process if they heard instead the story of Aliah Gleason and other statistics that Friedman omitted.
 
According to the published account[1], Aliah, 13 years old at the time, underwent a psychiatric screening at her school in Texas under unclear parental consent procedures.  The parents initially received a letter several weeks after the screening stating that their daughter reported, not experiencing a significant level of distress.  Shortly after that, however, a psychologist phoned her parents saying that Aliah had scored high on some suicide rating and that she needed to be evaluated.  Her parents reluctantly agreed to have her seen by a psychiatrist who did not admit her but referred her for follow-up.  Six weeks after that, she was forcibly removed from school by Child Protection and committed to the state mental hospital; denied family contact for five months; forcibly medicated with twelve different medications, including multiple atypical antipsychotics that are not approved for use in this age group, many simultaneously and all without parental consent; and physically restrained at least twenty-six times.
 
As vividly illustrated by the case of the Gleason family, as well as with numerous situations associated with TeenScreen, parental rights are not protected with screening.  Parental rights are routinely violated or minimized by TeenScreen.  Despite Friedmans claims of explicit parental consent, one of David Shaffer's research papers on TeenScreen lists passive consent as the type of parental consent obtained.[2] The definition of passive consent is that consent is assumed unless parents actively work to exclude their children.  In addition, in one place in the TeenScreen training manual programs are asked how many parents give passive versus active consent.[3] On another page, the forms ask if they will use active consent, waiver of consent, or no consent at all.[4]  Finally, the TeenScreen Newsletter trains their programs to avoid compliance with the federal Protection of Pupil Rights Amendment governing parental consent for non-emergency surveys and screenings.[5]  This is in direct contradistinction to the intent of the Garrett Lee Smith Memorial Acts stated intention of preferring programs that require active parental consent.[6]
 
Friedman minimizes the import of the impartial US Preventative Services Task Force report on screening for suicide which said in part, There is no evidence that screening for suicide risk reduces suicide attempts or mortality, there is limited evidence on the accuracy of screening tools to identify suicide risk, there is insufficient evidence that treatment of those at high risk reduces suicide attempts or mortality.[7] So, even if screening were accurate, as will be discussed below, there is no evidence that current treatments are able to reduce the number of attempts or mortality from suicide. 
 
Friedman also discusses the low specificity of TeenScreen as if it is of little significance, but in fact Schaffer admits that positive predictive value (PPV) of TeenScreen is a dismal sixteen percent.[8] Any other screening procedure would not even be considered with a PPV that low.  [A positive predictive value of 16% means that the false positive rate of this screening is 84% or that 84 out of 100 young people are incorrectly referred for treatment.]
 
According to TeenScreen 55,000 students were screened.  Of those, one third, or 18,150, screened positive and one half of those screening positive, or 9075, were referred for treatment.  If one applies Shaffers admitted 84% false positive rate to the 18,150 who screened positive, 15, 246 were false positives.  That could easily include all of the 9075 students that were referred for treatment.  If one then applies new data cited at the 2006 meeting of the American Academy of Child and Adolescent Psychiatry that 59% of children and adolescents with depression are treated with anti-depressants[9] then 5,354 students falsely and dangerously received antidepressants just from that one screening program.
 
Even if one is more conservative, and assumed that all 16% of the true positives (2,904) of those screened for suicide were in the group of 9,075 referred for treatment, that would leave 6,171 (9,075 2,904 or 68%) improperly referred for treatment and if 59% of those received anti-depressants, 3,640 children and adolescents still improperly received antidepressants from one screening program.
 
Either scenario raises grave concerns.  These antidepressants are under Black Box Warnings for suicidal ideation in children and adolescents. [10]  David Shaffer and colleagues from Columbia have admitted in children and adolescents (aged 6-18 years), antidepressant drug treatment was significantly associated with suicide attempts (OR, 1.52; 95% CI, 1.12-2.07 [263 cases and 1241 controls]) and suicide deaths (OR, 15.62; 95% CI, 1.65-infinity [8 cases and 39 controls]).[11] With the possible exception of fluoxetine, there is no evidence of efficacy of these medications in the treatment of pediatric depression.[12] To expose thousands of young people to these ineffective and dangerous medications needlessly is medically and ethically unconscionable.
 
The following excerpts from Thomas Woodwards testimony at the September 13, FDA hearing on antidepressants eloquently illustrate the tragic consequences and very real dangers of further expanding TeenScreen and programs like it: [13]
My name is Tom Woodward.  My wife Kathy and I had four children.  Julie, the oldest of our children, took her life on July 22, 2003. 
Julie was a gentle and beautiful young girl she was only 17.  She was deeply loved and is sorely missed by all that knew her.
Julie was a normal teenager dealing with normal teenage issues -- she had no history of self-harm or suicide.

"She was prescribed Zoloft and we were told that it was safe, very mild, extremely effective and essential to her feeling better. 
Seven days after taking her first Zoloft tablet Julie hung herself in the garage of our home.  Weve since learned that Julie began experiencing akathisia almost immediately after taking the first pill. 

"Julie never harmed herself in her 17 years the only variable was 7 days of Zoloft.  We are certain that Zoloft killed our daughter The problems associated with these drugs are particularly frightening in light of the Bush Administrations New Freedom Initiative a program designed to subject every school age child in this country to psychological testing.

[1] Waters, Rob (2005) Medicating Aliah Mother Jones Magazine http://www.motherjones.com/news/feature/2005/05/medicating_aliah.html
 
[2] Shaffer, D, et.al. HIGH-SCHOOL SCREENING FOR SUICIDALITY:  IMPLICATIONS FOR YOUNG ADULTS. http://www.afsp.org/education/shaff_pc.htm
 
[3] Columbia University TeenScreen Program (2003) Site Development Workbook 96 Universal Screening Model, page 45
 
[4] Columbia University TeenScreen Program (2003) Site Development Workbook 96 Universal Screening Model, page 70
 
[5] Columbia University TeenScreen Program (Fall 2003 ) TeenScreen News http://www.antidepressantsfacts.com/TeenScreen-crimin.pdf , which says, If the screening will be given to all students, as opposed to some, it becomes part of the curriculum and no longer requires active parental consent (i.e., if all ninth graders will be screened as a matter of policy, it is considered part of the curriculum).
 
[6] PL 108-355 Sec. 520E(c)(14) which says preferred programs will obtain informed written consent from a parent or legal guardian of an at-risk child before involving the child in a youth suicide early intervention and prevention program.
 
[7] US Preventative Services Task Force http://www.ahrq.gov/clinic/3rduspstf/suicide/suiciderr.htm#clinical
 
[8] Shaffer, D. et al. (2004). The Columbia Suicide Screen: Validity and Reliability of a Screen for Youth Suicide and Prevention. Journal of the American Academy of Child and Adolescent Psychiatry, 43(1), 71-79; p. 77
 
[9] Robinson, LM et. al. (2006) Poster session at the 2006 meeting of the American Academy of Child And Adolescent Psychiatry as reported in Brunk,, D (12/06) Diagnoses of Depression Doubled in a Decade Pediatric News
[10]FDA CDER (10/15/04) Labeling Change Request Letter for Antidepressant Medications
 
[11] Olfson, M and Shaffer D (2006) Antidepressant Drug Therapy and Suicide in Severely Depressed Children and Adults Archives of General Psychiatry 63: 865-72
 
[12] Jureidini, J et. al. (4/10/04) Efficacy and safety of antidepressants for children and adolescents British Medical Journal 328:879-883
 
[13] http://psychrights.org/Stories/WoodwardsFDAStatement.htm


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