Dr Google says I’m depressed
At the end of August, Google announced its new partnership with the National Alliance on Mental Illness (NAMI) in which they plan to add an optional depression screen for those who use “clinical depression” as part of their search term.
Integration of this tool, the Patient Health Questionnaire-9 (PHQ-9), aims to provide better education to the general population regarding depression, encourage people affected to seek help, and better equip patients for their conversation with clinicians.
There have been conflicting opinions on this initiative, both from experts and users, in how this feature will positively or negatively impact the disease burden of depression.
How could this be good?
In Australia, it is estimated that nearly 20% of the population are affected with a high prevalence mental health disorder, with depression being one of the most common. Depression also has strong public health implications, considering its causative association with functional impairment and increased risk of suicide.
Yet, nearly 85% of patients in an Australian cohort study reported at least a one-month delay in seeking care despite initially realising they had symptoms suggestive of clinical depression.
Those in favour of the PHQ-9 initiative argue that by providing a more accessible screening tool, users will have a better understanding of depression, and those affected will be more likely to seek care.
This argument can be further explored in two parts. Firstly, there are numerus depression screening tools, such as the PHQ-9, Montgomery-Asberg Depression Rating Scale, Aphasic Depression Rating Scale, and many more. These depression screening tools are widely and freely available in the public forum, allowing people to perform their own assessment.
However, with numerous options available, choosing the most appropriate tool can be difficult, and these public tools are seldom linked to score interpretation or appropriate referral pathways. Hence, the Google initiative will also feature interpretation of results and provision of further information regarding support materials and helplines to address the result.
An offshoot of this innovation, proposed by Dr. Ken Duckworth, NAMI’s Medical Director, is that using an integrated digital platform may also change the treatment of depression to include technology-enhanced methods.
What are the potential negatives?
In this era of big data, an online depression screen may appear to be a big-ticket item, facilitating the use of population data to enhance medical research. However, data usage can also be a source of apprehension by users.
The Google disclaimer does little to alleviate these concerns, somewhat perplexingly stating that they respect privacy and confidentiality, yet then state “some anonymized data may be used in aggregate to improve experience”.
Another deterring factor is the understanding that the PHQ-9 is, at the end of the day, a screening tool and not a diagnostic tool for Major Depressive Disorder. It is a well-known fact that screening programs may at times negatively impact on individuals.
The PHQ-9 has 89.5% sensitivity and 77.5% specificity for depression, which still leaves plenty of room for false negatives and false positives, which may result in late-diagnosis or over-diagnosis respectively.
Some are also concerned that this feature will lead to increased rates of self-diagnosis, self-management, and an increase in inappropriate antidepressant prescriptions.
The role of clinicians in the diagnosis and management of mental health illness is inherently crucial. In Australia, 71% of depression cases are managed in a general practice setting, with GPs responsible for assessing patients’ risks, discussing management plans, and providing education.
Additionally, the argument of equipping patients with relevant knowledge prior to meeting their clinicians may not be transferrable to the Australian context, as GPs tend to use the K10 Questionnaire for depression and anxiety as the gatekeeper for the Mental Health Care Plan – not the PHQ-9.
This feature is currently only available in the United States. It will be interesting to see how this will shape the future of mental health.
There is no question on the need for more public information regarding depression for all members of society, whether they are affected with depression or not. However, the application of a population-based screening program for depression should be done with caution, keeping in mind false results. Further integration into the healthcare setting and relevant support services is likely to be needed for this to be successful.
Positives and negatives aside, the intent behind the initiative is admirable, and this is likely still a work in progress – a work towards reducing the disease burden of depression.