A NEW REGULATORY CATCH-22: HYPOTHYROIDISM AND DEPRESSION

This is a story about how two organizations created by the U.S. federal government wound up making it much tougher for those unknowingly suffering from hypothyroidism to be diagnosed and treated appropriately for that common and often disabling disorder.

Some background: The U.S. Preventive Services Task Force (USPSTF), was created in 1984 by the federal government as an advisory group but given regulatory powers under the Affordable Care Act (ACA). It is a volunteer group of sixteen primary care practitioners appointed to 4-year terms by the director of the Agency for Healthcare Research and Quality (AHRQ), charged with assigning grades, i.e., A,B,C,D or I, to screening methods for various diseases based on the quality of the science supporting them. By "screening," they mean testing to detect the presence of a disease in a patient not manifesting any relevant signs or symptoms. They make these determinations on the basis of reviews of selected peer-reviewed publications.

The U.S. Preventive Services Task Force recently put out screening recommendations regarding those two conditions, and, if taken literally, would make it almost impossible for a person with undiagnosed hypothyroidism to be treated for it if that individual reports 1) no signs or symptoms, 2) depression, or 3) only signs and symptoms not unique to hypothyroidism. In 2015, this task force put out a report with an "I" recommendation, i.e., arguing that there is no scientific basis for screening for thyroid disease for anyone at any age. What this implies is that for a patient to be diagnosed with hypothyroidism, s/he would need to report symptoms, such as depression, that a physician would be likely to recognize as those of the disease, preferably those unique to the disease.

Here is the catch: according to a new recommendation ("B", meaning that the task force "recommends the service") that the USPSTF put out this year, screening for depression, done only via a questionnaire designed simply to screen for depression, should be routine. According to this statement, if a patient is indeed determined in this way to have depression, s/he should be given antidepressants and/or psychotherapy in the form of cognitive-behavioral therapy (CBT). That means that even if hypothyroidism is the primary disease and depression one of its symptoms, the depression must be treated as though it is a disease in itself, and not related to any other. This, as it turns out, goes against the view expressed in Harvard Medical School's newsletter, which is that hypothyroidism can be the source of depression.

But the grades that the USPSTF has assigned, i.e., "I" for thyroid disease screening and "B" for depression screening, override the wisdom of Harvard Medical School because of a certain provision in the ACA, which ties insurance coverage of a particular procedure to the grade that the USPSTF assigns it, which is considered to be the ultimate conclusion of evidence-based medicine. More specifically, insurance must cover only those screening procedures awarded "A" and "B" grades by the USPSTF. So the quiet patient with hypothyroidism accompanied by unreported symptoms of depression will not be screened for hypothyroidism, yet will be screened for depression (as will be the case for all patients), and quite likely wind up being prescribed only antidepressants.

Another little detail, easily overlooked but important, though: An "I" grade does not mean that the relevant screening process should not take place. It simply means that the science supporting the screening process is poor. It does not mean that screening method is expensive or dangerous, or that it is useless. It simply means that the methods used to develop the screening process were not described in the relevant peer-reviewed articles that the task force read and approved of. In fact, the task force effectively says that screening tests with "I" grades should be made on a case-by-case basis, and that better science needs to be done. But it will not be covered by insurance according to ACA rules. Will the lawyers and MBAs who run major medical centers which dominate medical care in some communities discourage physicians from performing all screening tests assigned an "I" rating? Will the necessary research to repair the "I" grade for thyroid disease screening take place, and if so when? These are questions that we can no longer ignore.

So what's going wrong here in the larger scheme of things? It's an over-simplification of medical reality, i.e., diseases do not always occur singly, and one disease can be a symptom or complication of another.

REFERENCES

Harvard Health Publications (2011) When depression starts in the neck. Retrieved 5 Oct 2016 from http://www.health.harvard.edu/newsletter_article/when-depression-starts-in-the-neck

Kaiser Family Foundation (2015) Preventive Services Covered by Private Health Plans under the Affordable Care Act. Retrieved 20 Oct 2016 from http://kff.org/health-reform/fact-sheet/preventive-services-covered-by-private-health-plans/

About the USPSTF (January 2016) U.S. Preventive Services Task Force. Retrieved 20 Oct 2016 https://www.uspreventiveservicestaskforce.org/Page/Name/about-the-uspstf

Grade Definitions (July 2012) U.S. Preventive Services Task Force. Retrieved 21 Oct 2016 from https://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions

U.S. Preventive Services Task Force. Final Recommendation Statement: Depression in Adults (January 2016) Retrieved 5 Oct 2016 from https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/depression-in-adults-screening1

U.S. Preventive Services Task Force. Final Recommendation Statement: Thyroid Disease: Screening (March 2015)  Retrieved 20 Oct 2016 from https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/thyroid-dysfunction-screening