Problems with research into the effects of screening

There are a number of problems with much existing research into the psychological effects of health screening.

1. Many existing studies use a retrospective or cross-sectional rather than a prospective design.

2. The use of overall means may mask important individual differences.

3. Where no psychological changes were detected, the types of measures used may not be sufficiently sensitive—specific measures are more likely to detect effects than more global measures of psychiatric morbidity.

4. There are indications that people who do not return follow-up questionnaires may be more distressed than those who do, suggesting the effects observed in research studies may be underestimates of the true distress experienced.

5. The point chosen as baseline can also distort the apparent pattern of results. Most studies of the effects of health screening have generally relied upon one pretest measure as their baseline assessment, taken after the offer of testing (two notable exceptions are studies by Sutton et al.(45) and Lerman et al.(46,>). It is possible that simply being offered the test may be stressful for some people, so the measures used may not give an accurate assessment of the person's usual state of psychological functioning for comparison with post-test levels of distress. For example, the option of testing may result in increased levels of anxiety at the point where 'pretest' measures are taken. If the level of distress shows a relative decrease from such pretest levels, it may be falsely concluded that the test has had 'reassuring' effects; this result may even conceal an increase in distress relative to levels prior to the offer of testing. In a bone density screening study by Rimes and Salkovskis/1 ,,4Z> there was an unanticipated decrease in distress between the two points before the scan, so that worry about osteoporosis was considerably and significantly lower immediately before the scan than at 2 weeks earlier. This fluctuation demonstrates the problems in relying on one pretest measure, and emphasizes the need for assessment both before and after the offer of the test. 6. Although randomized, controlled trials in which people are allocated to screening or not screening would reveal important results, they are often either impossible to conduct because the screening test is already available, or unethical because of the known medical benefits of screening. Therefore when a new test is developed there is only a relatively short window of opportunity where randomized trials may take place. It is, however, possible to randomize patients to different types of help in the screening programme—for example, comparing different types of counselling.

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