Wednesday, December 06, 2006

Mandatorily Yours

The Associated Press today reported a story about a recent JAMA article on the mental health problems of new mothers in the post-partum period. This study was a 30 year followup of over two million Danish women. It found that one out of every 1,000 women develop a mental disorder of some type after giving birth. For first-time mothers the highest risk period was in the first three months after birth. Clinical depression was the most common diagnosis seen, followed by bipolar disorder and schizophrenia.

Given our recent blog thread about mandatory screening for hospice patients, I was not surprised that some versions of this story included a suggestion to mandate mental health screening for pregnant women. Mandated screening for disease is nothing new. Many states have laws requiring hospitals to screen newborns for genetic metabolic diseases. Schools are required to screen children for vision and hearing problems. Certain occupations require mental health or medical screening as part of the job application process. Correctional facilities are required to screen all new intakes for physical and mental illness.

Given that this is common, what's one more law requiring another screen? New Jersey's mental health screening law looks pretty reasonable. It's intended to provide education about depression to the new mother and the family. It offers referral information and other resources. It doesn't require the participation of scarce psychiatrists.

It's hard for me to put my finger on exactly why laws like this get to me. The most obvious question is, since this is such an obvious good idea why do we need to make a law about it? The Surgeon General's office doesn't require legislation whenever they start a public education campaign about the disease du jour. The CDC doesn't require legislation to put out medical alerts about breaking issues. It just seems like a bit of overkill.

The second somewhat more cynical concern is that mandated screening is also sometimes linked to mandatory reporting. This is seen more often in the realm of infectious disease where infected patients are reported to the local health department for contact tracing. I remember though in the early days of the AIDS epidemic that patient registries were linked with proposed policies for things like mandatory quarantines. Once identifying information is mandatorily collected (and in corrections I associate this with DNA collection) it cannot be withdrawn. And the future doesn't always guarantee this information will be used beneficially.

The third and final reason I object to this kind of legislation is that it really interferes with patient autonomy and the right of physicians to decide when and where to bring up delicate medical issues with their patients. What if the mandated screening is for a disease with no known cure? Would I be required to find out my fate even if I didn't want to know it?

Perhaps I am being a bit too dramatic, but over the years I've learned that you can never be too cynical when it comes to legislative involvement in health care. I'm sure some parents occasionally wish they had chosen cats over children or may think they must have been crazy to have kids, but I don't think we need to have Congress tell them so.


Sarebear said...

Definitely agree! I couldn't exactly put my finger on it either, until you laid out much of what I couldn't pull together.


Midwife with a Knife said...

For the record, part of the reason for the postpartum check is to screen for postpartum depression, psychosis, etc. If people aren't at least asking about mood/sleep/apetite/etc. at the postpartum visit, they're not being good doctors. So... I don't think we need a law. (Education is never a bad thing, but laws get cumbersome and create paperwork!)

HP said...

Here, after having my daughter, I was screened for PPD, both in the days afterwards in hospital and at post-natal checkup weeks later. It wasn't mandatory, it was just a routine part of after-patient care and, in both settings, quite subtle.

True, not everyone might experience such a level of care but to legislate it seems kind of a heavy handed approach to me and it raises similar concerns to me as to where such legislative processes might end.