In cardiovascular disease prevention, screening did not increase work absenteeism in the year after men were informed they had hypercholesterolemia and an elevated risk for myocardial infarction.35 Interestingly, half of the men denied having hypercholesterolemia 1 year after being informed and had no changes on psychological measures.36 In general screening for coronary artery disease risk (CAD), an “above average risk” label for CAD did not adversely affect psychological state if the individuals were prepared for risk labeling. However, communication of abnormal results without adequate preparation did cause short-term psychological harm. Nonspecific support from a familiar generalist physician reduced the risk of psychological ill health.37 There ere no changes in General Health Questionnaire scores before and 6 months after a screening examination,38 and no evidence of raised concerns about health or risk of heart attack.39 There has been a tendency to be bothered by intrusive thoughts, but not to the degree that patients were upset.40 There was no difference between the high-risk and reference populations in satisfaction with life or emotional well-being in the year after screening, but a substantial number of people reported distaste at being reminded of their risk of CAD.41 The authors of one study noted that psychological distress significantly increased 3 months after screening.42
In a review of DNA testing,43 those patients who were depressed before the test were more distressed after testing, but those who were anxious before the test were less distressed after the test, having fewer intrusive thoughts. In this area, the test result did not determine the amount of distress experienced by those tested. In another review44 of studies about cardiovascular risk, acquired immune deficiency syndrome, cancer, Huntington’s disease, diabetes mellitus, spinocerebellar ataxia, and osteoporosis, positive results were associated in the short term with depression, anxiety, poorer perceptions of health, and psychological distress. There was no distress in the longer term and little evidence of adverse psychological effects for those receiving unfavorable test results.
Conclusions
This scan of the literature allayed much of my initial concern about the psychological safety of primary and secondary prevention raised by the papers by Bowman and Mold and their colleagues. Yes, phenomena similar to their findings have been noted for many other conditions, but fortunately the adverse effects are neither long term nor particularly serious. In addition, this brief summary suggests ways to minimize the impact as well: (1) assess the patient’s pretest psychological state for depression or pessimism; (2) provide pretest orientation and preparation for risk stratification; (3) minimize delay between testing and informing the patient about the results; and (4) use an established physician-patient relationship to give the patient general support. The unexplored and provocative conclusion is that some distress or anxiety may be desirable because it may help motivate a patient to adhere to recommendations for further testing or to start behavioral change.
The oath of Maimonides states: “I have been appointed to watch over the life and death of my fellow human beings. Here I am ready for my vocation, and now I turn unto my calling.” Maybe we have to cause a little hurt to help even more.
