Schuyler W. Henderson, M.D.

Assistant Editor

IN CONTEXT

Should Screening for Depression Among Children and

Adolescents Be Demedicalized?
ALLAN V. HORWITZ, PH.D.,

AND

Every child should be screened for mental illness once in their youth in
order to identify mental illness and prevent suicide among youth.
VPresidents New Freedom Commission, 2003

PLACING SCREENING IN THE CONTEXT OF NORMAL

INTENSE ADOLESCENT EMOTION

One of the most fundamental questions in psychiatry

regards the distinction between mental disorders and
normal, albeit painful and undesirable, human functioning that presents a problem in living. Mental
disorders are conditions in which something has gone
harmfully wrong with the functioning of some
biologically designed mental process or mechanismVa
harmful dysfunction. In contrast, normal psychological
processes in response to lifes vicissitudes often give rise
to intense negative emotions or other negative condi-

In Context is a venue for scholarly contributions from experts on scientific,

social, political, and cultural issues pertinent to childrens mental health. In
Context presents topics that do not immediately fall under the purview of scientific
research or clinical practice but that nevertheless affect the lives and mental health
of children. Its goal is to educate clinicians and researchers, to encourage discussion, and to foster interdisciplinary collaboration.
Accepted January 22, 2009.
Dr. Horwitz is Dean of Social and Behavioral Sciences at Rutgers University.
He is, with Jerome Wakefield, the author of The Loss of Sadness: How
Psychiatry Transformed Normal Sorrow into Depressive Disorder. Dr.
Wakefield is University Professor, Professor of Social Work, and Professor of
Psychiatry at New York University, and the author of many articles on psychiatric
diagnosis and the concept of mental disorder. He is coauthor with Allan Horwitz
of The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into
Depressive Disorder.
Correspondence to Allan Horwitz, Ph.D., Rutgers University, Sociology and
Health Institute, 77 Hamilton Street, New Brunswick, NJ 08901-1248; e-mail:
avhorw@rci.rutgers.edu.
0890-8567/09/4807-06832009 by the American Academy of Child and
Adolescent Psychiatry.
DOI: 10.1097/CHI.0b013e3181a5e3ad

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JEROME C. WAKEFIELD, PH.D.

tions. These distressing emotions might warrant professional support or intervention, but they have different
prognoses and open up a different range of options for
intervention than do disorders.
Our book, The Loss of Sadness: How Psychiatry Transformed Normal Sorrow Into Depressive Disorder, argues
that the current DSM definition of major depressive
disorder (MDD) does not validly distinguish problematic, but natural, human emotions in response to loss
and stress from depressive disorders.1 For example, people who have symptoms of just 2 weeks of depressed
mood, diminished pleasure in usual activities, insomnia,
fatigue, and problems in concentrating meet the MDD
criteria, yet this sort of reaction can naturally occur
in response to many major losses in life. Although the
definition contains an exclusion for uncomplicated bereavement, it does not exclude responses to other major
losses, such as the dissolution of a marriage, the loss of
ones job or retirement fund, or a terminal medical diagnosis. The result, we claim, has been to pathologize
normal emotions because of a failure to place the symptoms of intense sadness in the context of life events.
We did not questionVand in fact affirmedVthat
genuine depressive disorders exist, are serious and sometimes life threatening, and urgently need attention. Nor
did we question that good clinicians can go beyond the
current diagnostic criteria and use information about the
context of symptoms to judge whether a condition with
depressive symptoms is normal or disordered. Rather,
we questioned the validity of the current diagnostic criteria in drawing the distinction between intense normal
responses and medical disorders.
Separating normal sadness from depressive disorder
and placing emotions in context is especially difficult
and important among adolescents. Levels of negative
affect in response to stressful events are extraordinarily

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HORWITZ AND WAKEFIELD

high during adolescence, particularly early adolescence.

Many young people are emotionally immature and impulsive and demonstrate a high degree of intensity and
lability, especially in response to common adolescent
stressors such as romantic breakups or arguments with
parents. Most of these distressing states will be short
lived and highly situational.2 In the absence of careful
distinctions between mental disorders and developmentally normal negative emotions, enormous proportions
of transient and self-limiting cases of normal sadness
can be mislabeled as depressive disorders. In particular,
the current movement to screen adolescents for depression requires further attention to issues of diagnostic
validity.

SCREENING FOR DEPRESSION AMONG

ADOLESCENTS

In recent years, screening for mental illness, especially

for depression and suicidal potential, among children
and adolescents has become a major endeavor. In 2003,
a presidential commission recommended that every
adolescent in the nation should be screened for signs of
potential mental illness and referred to treatment if
necessary. The commission cited the Columbia University TeenScreen program as a model for successful
screening endeavors.3 The next year, President George
W. Bush signed a bill that authorized $82 million to
fund screening programs beginning in sixth grade.
Forty-four states have implemented some sort of
screening program in schools, and the number of
students who participate in such programs is expanding
rapidly. In 2009, the U.S. Preventive Services Task
Force recommended the screening of adolescents
(although not children) for depression as long as adequate diagnostic and treatment services are available.4
A number of rationales underlie this push to use and
expand screening for mental illness among adolescents.
Youths seemingly have very high rates of depression.
Most studies identify between a quarter and a half of
adolescents as having mood disorders, yet most conditions are unidentified and untreated.5 Early screening is
also viewed as a way to prevent the subsequent onset of
mental disorders because most adults who have depression report that their first episodes occurred when
they were young.6 In addition, successful screening presumably can prevent impairments such as poor school

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performance, interpersonal problems, and substance

abuse that sometimes stem from mental disorders.
Advocates also cite the prevention of youth suicide,
which is the third leading cause of death among 15- to 24year-olds, as a particularly urgent rationale for screening.
For all these reasons, aggressive screening programs that
do not wait for problems to become manifest but strive
for early detection and intervention have been widely
advocated as ways to stop the downward spiral of
increasingly worsening problems among youths.

SCREENING AND THE CONFUSION OF NORMAL

SADNESS AND DEPRESSIVE DISORDER

Screening programs that can distinguish with a reasonable degree of accuracy adolescents who have depressive disorders from those whose emotions reflect
fluctuating levels of normal sadness would be valuable.
However, current screening instruments do not cogently make this separation.
Screening procedures usually proceed in two stages.
In the first, adolescents respond to short self-report
instruments that inquire about common symptoms of
sadness, anxiety, boredom, and irritability as well as
thoughts of suicide or suicide attempts. Typical questions ask students about their feelings over the past
several weeks: Have you often felt sad or depressed or
Have you slept more during the day than you usually
do. Students who answer yes to a small number of
such questions or to any of the questions about suicide
are referred for a second-stage interview with a mental
health professional that provides a more thorough diagnostic assessment and possible referral for treatment.
The first-stage screening instruments identify high
proportions of adolescents as at potential risk for mental
disorderVon average, such instruments indicate that
about a third of adolescents have or are at risk for depressive disorders. One study of the TeenScreen instrument identified from 28% to 44% of all the students as
having the potential for suicide. When criteria broaden
to include conditions that are labeled as minor or
subthreshold states, more adolescents are considered
to be at risk for disorders than are viewed as normal.7
The initial checklists inquire about ubiquitous feelings such as sadness, irritability, or oversleeping but do
not consider the context that gives rise to such feelings. Everyday occurrences such as being grounded by

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IN CONTEXT

parents, rejected by peers, or failing an important test

can easily result in a positive prescreen score. For
example, the best predictor of depressive symptoms
among adolescents in the large AddHealth study was the
recent breakup of a romantic attachment.8
The second-stage diagnostic interviews are supposed
to mitigate any concerns about confusing normal sadness with depressive disorder. However, these interviews
make use of the DSM criteria that do not place feelings
of sadness in the context of life events and that require
only a 2-week period of symptoms. Of course, good
clinicians do not apply diagnostic criteria blindly or
mechanically; that is the point of sending adolescents
who screen positively on to a clinical interview. Nevertheless, the DSM criteria can be applied literally to
warrant second-stage diagnosis, and over time, a large
proportion of adolescents satisfy those criteria.
Several symptomatic features that go beyond DSM
criteria are commonly cited as distinguishing depressive
disorder from intense normal sadness. In the hands of
a skilled clinician, all of these indicators can enhance
diagnostic validity. However, they also have validity
problems of their own when used without taking into
account contextual factors. First, the longer duration
of depressive symptoms is often used to identify
disorder. In contrast to the transitory nature of much
normal sadness, depressive disorders often do persist for
protracted periods. However, that does not mean that
long duration necessarily implies disorder. A chronic
stressor can bring about a lengthy period of sadness that
is normal, so this evaluatory principle relies on context
for its validity. Whereas duration is an important component of diagnostic decisions, enduring symptoms do
not in themselves indicate the presence of a disorder.
Second, recurrence is often seen as an indicator of
disorder. Depressive disorders are indeed, on average,
more recurrent than normal sadness. However, recurrence can be misleading if whatever happened before is
happening again. A teen who experiences several losses
over time might be viewed as having a recurrence, but
the repeated distress is due to environmental events and
normal range responses, not to a pathological dysfunction in sadness.
Third, impairment is often considered an indicator of
disorder. Yet, normal intense sadness is also impairing.
Think here of the lack of normal social role functioning
during periods of normal grief after the loss of a loved
one. Indeed, most theories of the biological functions of

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grief and sadness suggest that it is part of the function of

such negative emotions to cause the individual to step
aside from usual role functioning and to reassess the
situation after a major loss.
Because of these validity issues, the accurate application of the decontextualized DSM MDD criteria even
when duration, recurrence, and impairment are taken
into account is no guarantor that a disorder has been
identified. As noted, some clinicians will use their judgment to override the criteria and to exclude symptoms
because of intense normal reactions to life events from
diagnosis. However, the MDD diagnostic criteria themselves do not make these distinctions. Although secondstage interviews diagnose only a relatively small proportion of youths who screen positively with a depressive
disorder, it is difficult to have confidence that this group
actually has such a disorder. Moreover, it is difficult
to have quality control in situations of mass screening
where time-consuming clinical evaluations are often unfeasible so that symptom criteria alone are emphasized
because of the sheer number of people being processed.
There are some caveats about the nature of our
argument regarding misdiagnoses of normal sadness
as disorder. First, high prevalence rates in themselves
do not mean that adolescent depression cannot be a
disorder. Obviously, there can be prevalent disorders.
Rather, current criteria do not acknowledge that intense
normal sadness symptomatically resembles depressive
disorder, so high prevalence is likely due in part to false
positives. Nor is our argument that any condition triggered by context is normal. Toxic environments can
trigger disorder in adolescents, as in adults. However,
we also know that people frequently respond with biologically designed distress to loss and stress, and this
need not be disorder.

SCREENING AND YIELD

The goal of screening is to identify and possibly

prevent disorders. For the reasons detailed above, this is
particularly tricky when it is so difficult to distinguish
depressive disorder from normal adolescent experiences.
This has a direct effect on understanding the yield and
risk/benefit analysis of screening.
Screening scales require minimal duration to indicate the possible presence of a depressive disorder. The
markedly transitory nature of so much adolescent

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HORWITZ AND WAKEFIELD

distress that screening instruments pick up yields

considerable instability of scores. Most studies find
that only about a third of adolescents who report being
depressed are still depressed after as short a period as
1 month. The TeenScreen study found that only half
of the students who provided positive answer to a
question about suicidal potential gave the same response
just 8 days later. In contrast, the median length of depressive episodes among adolescents with clinical diagnoses of depressive disorders ranges from 8 to 36 weeks.
It might be argued that some technical adjustment
could resolve these problems, such as repeated screening to catch enduring conditions. However, such adjustments, although they might help at the margins, fail to
address the basic challenge of distinguishing depressive
disorder from intense normal sadness because they stay
within the symptom checklistYbased decontextualized
approach. Multiple screenings would not eliminate the
obligation to act on positive one-time screens and would
not identify chronic stressors in the adolescents life.
Without bringing in the skilled judgment of the meaning of the symptoms in context, technical fixes to
symptom-based criteria suffer from a generic limitation
in validity.
The TeenScreen instrument is claimed to have high
levels of sensitivity (0.75) and specificity (0.83), but the
interpretation of these levels of validity is debatable because what seem to be reasonably high rates of sensitivity
and specificity can translate into high numbers of errors
when one screens entire school populations. Second
stage clinician diagnoses in the TeenScreen program
identify about four percent of adolescents as having
depressive disorders. This means that the positive predictive valueVthe proportion of positive screens that
second-stage diagnoses confirmVis approximately 16%.
Given these data about the yield of screening, two
recent trends in the parallel development of screening
in primary care raise concerns. First, given the time
pressures involved in responding to large numbers of
positive screens with limited resources, first-stage screening instruments are coming to be seen as sufficient indicators of mental health problems even in the absence
of confirmatory diagnostic interviews. Second, there
is a movement to expand diagnosis to cover minor
or subthreshold conditions that have fewer than the
five symptoms required for major depressionVa trend
seen in the routine scoring of some depression screening
instruments used in general medicine. These trends will

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be hard to resist in the screening of adolescents as well,

potentially erasing any obstacle to classifying adolescent
angst as a manifestation of disorder.

REFRAMING THE SCREENING MOVEMENT TO

REFLECT THE REALITY OF NORMAL INTENSE
ADOLESCENT EMOTIONALITY

Professionals must be especially sensitive to the possibility that the common emotional turmoil of adolescence is not mistaken for a mental disorder. Monitoring
the varying emotions of adolescentsVand especially the
sadness, moodiness, feelings of inadequacy, despair, and
extreme negative thoughts (That was so embarrassing,
I could just kill myself; if he doesnt come back to
me, I will kill myself) to which normal adolescents are
regularly subjectVmay or may not be a good idea.
However, it is surely an idea that deserves serious and
honest discussion before it is wholeheartedly embraced.
Although health professionals intervene in normal problematic conditions, from birth pain to ungainly noses,
when the potential exists for medical treatment of a
normal condition, there is usually vigorous discussion
about the risks versus benefits of tampering with a
normal system. In such cases, normal and disordered
variants that are superficially similar are carefully
disentangled (e.g., normal shortness versus hormone
deficiencyYinduced dwarfism, schizophrenia versus
hallucinations of a recently lost intimate during an
intense period of grief).
Little discussion, however, is taking place about the
adolescent depression screening movement, perhaps
because of the assumption that screening is actually
uncovering depressive mental disorders. Yet if such
screening is in the first instance uncovering common
human responses to environmental afflictions, then
screeningVin the course of searching for depressive
disorderVin effect monitors forms of unhappiness,
including forms of unhappy family life. The scrutiny of
such emotions and the use and response of the
educational and health establishments to the information they obtain from this surveillance deserves extensive
discussion. The appropriate dialogue will only come
about if the screening movement is willing to place its
goals, instruments, and DSM symptom-based criteria in
a broader context of the normal lability of adolescent
emotion.

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IN CONTEXT

Instead of hastily and prematurely implementing

sweeping screening programs, a more cautious approach
is called for. Smaller pilot projects could develop
procedures that are sensitive to the distinction between
contextually appropriate emotions and depressive mental disorders. One possibility would be to use media
presentations before administering screening scales that
present cases of normal problems of adjustment to
common adolescent stressors, as well as cases of depressive disorders. For example, such presentations
might use a case of a teenager who has experienced a
number of symptoms after the loss of a romantic partner
that dissipated a couple of weeks later. It could contrast
such a case with a case of depressive disorder that was
intractable to its context and endured well beyond its
precipitant.
Screening measures might also contextualize particular questions in symptom scales with qualifiers such as
for no good reason or way beyond what made sense
in the circumstances so that adolescents are aware that
negative emotions in themselves are not pathological.
For example, instead of asking Have you often felt sad
or depressed, a question could ask Have you often felt
sad or depressed for no good reason or to a degree that
went way beyond what made sense in the circumstances. Such procedures might help to minimize the
current large number of false positives that plague current screening efforts and signal that sadness is a normal
response to adolescent stressors. In general, we should
encourage the scientific testing and development of a
variety of approaches that can better separate contextually appropriate sadness from depressive disorders rather
than taking for granted that existing screening instruments are capable of making this distinction. In terms of
weighing contextual factors and important individual
meaningsVsuch as humiliation or hopelessnessVin a
diagnostic evaluation, there is much research on which
the screening movement might rely in formulating
context-sensitive instruments to test.9
Pending improvement in screening instruments
aimed specifically at identifying mental disorder, our
analysis suggests a possible reformulation of the entire
notion that depression screening is a medical intervention aimed at identifying disorder. Current screening

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programs areVand ought to be truthfully labeled asV

methods of identifying teenage distress, normal and
pathological, and likely mostly normal reactions to environmental stressors. Such programs might emphasize
that they encompass identifying suicidality and depression within their goals but that they primarily monitor
teen emotional disorder. Recognizing the normality of
many identified symptoms encourages a policy of
watchful waiting to see whether symptoms persist. In
addition, to the extent that many of the identified
problems are due to normal reactions to stressful environments, a different and broader range of treatment
options, including school and family interventions,
should be considered. Such a framework allows a more
optimistic prognosis and less potential for stigma for
many teens who do screen positively.
Disclosure: Dr. Horwitz receives royalties from the University of Chicago
Press for the sale of Creating Mental Illness and from the Oxford
University Press for the sale of The Loss of Sadness: How Psychiatry
Transformed Ordinary Misery Into Depressive Disorder. Dr.
Wakefield receives royalties from Oxford University Press for the sale
of The Loss of Sadness: How Psychiatry Transformed Ordinary
Misery Into Depressive Disorder.

REFERENCES
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2. Kovacs M. Depressive disorders in childhood: an impressionistic landscape. J Child Psychol Psychiatry. 1997;38:287Y298.
3. Shaffer D, Scott M, Wilcox H et al. The Columbia Suicide Screen: validity
and reliability of a screen for youth suicide and depression. J Am Acad
Child Adolesc Psychiatry. 2004;43:71Y79.
4. U.S. Preventive Services Task Force. Screening and treatment for
major depressive disorder for children and adolescents: US Preventive
Services Task Force recommendations statement. Pediatrics. 2009;123:
1223Y1228.
5. Lewinsohn PM, Rohde P, Seeley JR. Major depressive disorder in older
adolescents: prevalence, risk factors and clinical implications. Clin Psychol
Rev. 1998;18:765Y794.
6. Kessler RC, Walters EE. Epidemiology of DSM-III-R major depression
and minor depression among adolescents and young adults in the National
Comorbidity Survey. Depress Anxiety. 1998;7:3Y14.
7. Lewinsohn PM, Shankman SA, Gau JM, Klein DN. The prevalence and
co-morbidity of subthreshold psychiatric conditions. Psychol Med. 2004;
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8. Joyner K, Udry JR. You dont bring me anything but down: adolescent
romance and depression. J Health Soc Behav. 2000;41:369Y391.
9. Brown GW, Harris TO, Hepworth C. Loss, humiliation, and entrapment
among women developing depression. Psychol Med. 1995;25:7Y21.

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