The WebMD Depression and Suicide Assessment — for Women Only?

WebMD is a major source of health news and information. According to Wikipedia, as of February 2014, WebMD was averaging about 156 million unique visitors and more than one billion page views per month. MarketWatch indicates that, at this writing, WebMD has a market capitalization of nearly $2 billion. Accordingly, it seemed worthwhile to record some thoughts that arose as I reviewed a particular WebMD webpage.

What Triggered My Curiosity

This inquiry began when I took the WebMD Depression Assessment. It concluded that I wasn’t depressed. I knew that, but now I had quasi-clinical proof.

The Depression Assessment started off like this:

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I noticed, at the bottom of that screen, that the Depression Assessment was “Reviewed by Arefa Cassoobhoy, MD, MPH.” I wondered who Dr. Cassoobhoy might be, so I clicked on the link. Here’s what I saw:

Cass

I, myself, had once been disserved to the point of malpractice by a pretty young doctor, from an apparently upper-caste Indian-American family, who could not be bothered with an ordinary older white man’s health — who, in fact, did not even seem to register that her treatment was neglectful. So I did find it interesting that WebMD would place responsibility for its Depression Assessment in the hands of someone who has had “a special interest in women’s health” ever since her college research into “prenatal care choices made by women with Medicaid” and continuing to a current practice in which she “continues to see female veterans.”

Depression and the Sexes

An emphasis on women, in the WebMD Depression Assessment, could have made sense in light of the common belief that, except in the 18-24 age group, women experience depression at twice the rate of men.

That common belief has lately been called into question, however. Consider, first, some data on suicide. Here is a chart from the Centers for Disease Control and Prevention (CDC):

f_ten

Overall, in the U.S., the number of people who kill themselves is about the same as the number of people who die of breast cancer, although the sexes are substantially reversed, with men constituting about 80% of suicides (see e.g., AAS, 2014; CDC, 2013; DeSantis et al., 2011). There is no telling how the latter figure might drop if it enjoyed funding and public attention like that devoted to the former.

Google searches indicate that academic websites mentioning social work education and breast cancer are about twice as numerous as academic websites mentioning social work education and suicide. It appears, moreover, that many social work webpages mentioning suicide are oriented toward primarily female suicide “attempts.” (I put that word in scare quotes because, as noted by a psychiatry professor cited by Science Daily, “attempted suicide most often is not an attempt to actually end one’s life.”) According to the American Foundation for Suicide Prevention (AFSP), females commit three out of four suicide “attempts.”

It seems odd that women are twice as likely to be diagnosed with depression, and yet men are four times more likely to kill themselves. One possibility is that depression has been defined in a way that incorrectly excludes many men. This possibility has been explored by Simon Rice (2011). Rice suggests that male depression is not primarily manifested in the relatively feminine terms used in the Diagnostic and Statistical Manual. Those terms, emphasizing feelings, tearfulness, and other internalizations, are contrasted against prototypically male behaviors — “stoicism, self-reliance and aggression” — that men often manifest in negative life situations (Rice, p. iii). In an article in JAMA Psychiatry, Martin et al. (2013) report that, when such male-oriented criteria are included, “sex disparities in the prevalence of depression are eliminated.”

There is, in other words, the likelihood that depressed men do not behave like depressed women — that psychiatry has defined depression in such a way as to exclude much of what men do when they are depressed. Alternately, one might dispense with the psychiatric arcana and focus on the real-world question of whether people are at risk of decompensating or self-destructive behavior due to mental or emotional states arising from adverse life experiences. In that case, again, it appears that men are at least as vulnerable as women.

Research and debate may continue, for years to come, on the question of how psychiatrists should define depression and whether the disorder, appropriately redefined, would contradict the received wisdom on the prevalence of depression between the sexes. In the meantime, however, it seems advisable to consider whether society in general, and social work education in particular, have enforced and fostered a sexist divergence of depression treatments and experiences in practice, cosseting the females while criminalizing the males.

Implications

The preceding remarks imply that it might have been better if WebMD’s reviewer had been inclined to think critically about the intellectually pink tone of depression diagnosis, as defined in the DSM and as presented in the WebMD Depression Assessment. It was predictable that a practitioner with such a demonstrated focus on women would not tend to notice the sorts of perspectives stated above.

We will not know how many men have gone through the WebMD assessment to be told that, in fact, they are not depressed, even though their lives may be falling apart. Men given that diagnosis, and others like it, might reasonably draw upon male custom to conclude that their inner states are to be interpreted in light of external criteria. That is, they might construe and shape their thoughts and reactions as rational responses to assorted private and public sociopolitical provocations. What else should they believe, when the mental health experts are telling them that they are OK? Taking a pill or getting counseling to calm down could seem, in this light, to be the behavior of a quitter, backing out of the ongoing male struggle to eliminate depressing conditions by fixing things outside oneself.

The feminist skew in Dr. Cassoobhoy’s credentials would not have been tolerated if WebMD itself had been committed to a critical and balanced approach. It certainly seems unlikely that a comparably masculinist male MD would have been appointed to such a position. The people who made Cassoobhoy “responsible for reviewing WebMD content across the web site and ensuring its accuracy, credibility, and timeliness” (to quote the bio, above) evidently believed that her job was compatible with training and attitudes substantially oriented toward helping women rather than men.

Aside from whatever that state of affairs may imply across the spectrum of WebMD websites, one interpretation of WebMD’s decisions in this particular case is that men can be safely left to fend for themselves. Another is that serious mental illness in general has traditionally been defined so as to be “more common among women than among men” (Manderscheid et al., 1998, p. 69). Someday, I may explore the questions of whether such beliefs have contributed to the profound gender skew of the social work profession, the profession’s relative conservatism, or its preoccupation with careers focusing on mental rather than social health.

Suicide Prevention Advice

The WebMD Depression Assessment paid a bit of specific attention to suicide:

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When I went through a second time and clicked the box indicating “Thoughts of death or suicide,” I got the following message:

Please call your doctor or the National Suicide Prevention Lifeline at 800-273-8255 right away. Help is available.

This was bizarre, on multiple levels. For one thing, when I continued on and completed the assessment — even with that “Thoughts of death or suicide” box checked — WebMD concluded that I did not seem to have any form of depression. Why, then, had they insisted that I call for help immediately? Other online assessment tools (e.g., Britain’s NHS; Military Pathways) offered similar advice, but made it conditional: call for help if you have been thinking that you would be better off dead.

That WebMD advice was strange for another reason: it seemed that Dr. Cassoobhoy, approving it, might be unfamiliar with relevant research. According to the Congressional Research Service (2012, p. 12; see also World Health Organization, 2012, p. ii), “The evidence base for suicide hotlines is not sufficient to determine their effectiveness in reducing suicide rates, due to the difficulties inherent in conducting such evaluations.” In other words, calling a hotline is a nice idea. Maybe it will help the person; then again, maybe it will send him/her over the edge, literally. Is it more effective than other interventions that WebMD could sponsor or recommend? We have no idea.

Many (according to some researchers, half) of the people who kill themselves have in fact spoken with their doctors within three to six months prior to their deaths (e.g., Vannoy et al, 2011; Gliatto & Rai, 1999; see Nordqvist, 2010). The typical physician is not an experienced mental health professional. Vannoy et al. found that physicians often decline to discuss mental health with their patients; when they do, they are often not sure what to say to suicidal patients; and as a result, they frequently choose ineffective strategies. Vannoy et al. cite, as an example, the approach of arguing with the patient in a sort of conversion effort, attempting to convince him/her that (at least from the perspective of a happy, successful physician) life ain’t so bad.

In this regard, WebMD’s Depression Assessment seemed to be making a significant mistake. When you have someone on the line, listening to what you have to say about suicide, why on Earth would you send them off on an errand somewhere else? What if they have already tried a doctor or a hotline and didn’t like what they encountered there — is this the best we can do, to tell them to go get themselves into an argument with, or lectured by, another physician? Some readers may undertake the assigned errand. Many will not. The online assessment tool may be (in some cases, it probably has been) the last (and possibly the only) chance to inject an alternate perspective before people kill themselves.

There are numerous carefully researched suicide assessment instruments (see Ontario Hospital Association, 2011, pp. 38-61). There are also some commonsense qualifications that one might incorporate into an online response. One such qualification has to do with the reader’s current mindset. According to CDC, using data from 2008-2009, 3.7% of the U.S. adult population reports having suicidal thoughts per year, whereas only 1.0% reports making plans for suicide and 0.5% reports making a suicide attempt per year. That is, less than one out of seven persons having thoughts of suicide will make a suicide attempt. Further, CDC notes, there is only one completed suicide for every 25 attempts. Thus, contrary to WebMD’s breathless warning, there are substantial quantitative and experiential differences between those who vaguely consider killing themselves and those who have made specific and viable plans to do it. Telling every casual contemplator to go racing off to the E.R. will usually amount to crying wolf. It would make sense to ask a few more questions before rendering advice.

What I got from WebMD’s suicide warning was a sense of dismissiveness. It felt like they were trying to avoid liability by not getting involved — which might make sense if they did not have thousands of webpages exploring all sorts of life-and-death health topics. When I clicked that box, and transitioned out of the girly world of depression and into the male world of actual suicide, they — Dr. Cassoobhoy, I guess — seemed to want to get rid of me. Her site’s knee-jerk advice to contact some other source of help reminded me of a gag line I recently saw floating around on Facebook: “No matter how bad things get, remember that someone cares. Not me, but someone.”

As described in another post, I had that sort of experience myself, one time when I really did need to talk to somebody. The outcome was that making the effort to find someone to talk to made me feel worse than not trying. It reinforced the belief that I was no longer just an ordinary person: I had become, instead, a Problem, a maladaptive and messed-up misfit who needed Help. That sort of reframing might make would-be helpers feel better — among other things, it might help to transfer the sense of responsibility for a future death away from the casual bystander — but it does not seem likely to improve the mindset of the person supposedly being aided.

For a contrast, compare my post on Things to Do Before Killing Yourself. That post declines to adopt an overt suicide “prevention” approach, with its potential implication that the reader is stupid or irrational — that, in other words, there is something wrong with him/her that requires someone else to step in and take over. Yes, there are individuals with severe mental illness who do need help, sometimes to the point of institutionalization. Yet even with the customary deference to professional opinion, people are not necessarily inclined to believe that someone else knows what is best for them. As a general rule, the best course in many cases may be to respect the person and enlist his/her own critical thinking in the evaluation of options.

Given these thoughts on the WebMD Depression Assessment, I decided to review its list of research sources. I found that none of those sources offered direct support for the treatment of suicidality found in the WebMD Depression Assessment. Meanwhile, other sources disagreed with that treatment. For instance, in contrast to the WebMD referral to a doctor or suicide hotline based upon mere “thoughts of death or suicide” (which does not even clearly refer to one’s own death or suicide), the Suicide Prevention Resource Center (2012; see also Ontario Hospital Association, 2011, p. 5) identified three behaviors indicating immediate risk of suicide:

  • Talking about wanting to die or to kill oneself
  • Looking for a way to kill oneself, such as searching online or obtaining a gun
  • Talking about feeling hopeless or having no reason to live

The WebMD Depression Assessment asked about feeling hopeless, but did not link the answer to that question to any kind of suicide-related warning or suggestion. It did not ask at all about looking for a way to kill oneself.

In one regard, the WebMD Depression Assessment bordered on the ridiculous. As noted above, I could tell it (and other online tools cited above) that I was thinking about killing myself; they would pop up a warning about seeing a doctor or calling a suicide hotline immediately; and yet, at the end of the assessment, they would conclude that I did not seem to be depressed. The idea appeared to be that I could have a gun, and a plan to blow my brains out, and yet be pretty happy overall.

More Demographics

In the course of looking into the suicide aspect of depression assessments, I came across other information. Here are two graphs worth noting. First, a chart provided by AFSP:

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(See also CDC.) That chart says that suicide rates have recently (e.g., in 2011) been highest for people in the 45 to 64 age group.

Second, a geographical distribution, also from AFSP: Clipboard02 On that map, purple (e.g., the rural West) is worst and orange (e.g., the mid-Atlantic states) is best.

I didn’t look for graphs on other suicide demographics, but it did appear that suicide rates vary with socioeconomic and educational factors. For instance, New York Times article cited findings that a 10% increase in the unemployment rate (from e.g., 5% to 5.5%) yields an increase of about 1.5% in the male suicide rate (i.e., an additional 128 suicides per month in the U.S.).

Combining all of the factors discussed above, one might ask WebMD: what better person to advise on depression and suicide than a young, eastern, highly educated, upwardly mobile Asian-American female specializing in women’s issues?

Summary

WebMD offers a vast set of webpages to advise the public on issues of physical and mental health. Those webpages reach millions of people. This post discusses one such webpage, presenting the WebMD Depression Assessment, in its form as of mid-June 2014. WebMD may (and should) alter that webpage, so as to rectify the problems discussed here. Whether it does so will not alter the primary message conveyed in this post, however.

The primary message conveyed here is that organizations like WebMD are capable of committing major ethical blunders in their development of such webpages. Blunders identified here include the generation of inappropriate content and the hiring of inappropriate oversight personnel.

The content of the WebMD Depression Assessment is inappropriate for two reasons. First, the assessment does not appear to be properly sourced in empirical research. Its own list of sources seems to imply that much of the assessment’s content was based merely on beliefs or background training held by its unnamed author(s).

Second, the assessment draws upon and conveys a ladies-only bias in the area of depression and suicidality. This bias recurs in the choice of photographs featured on the webpage, the palpably female-oriented résumé of Dr. Cassoobhoy, and the decision to rely upon diagnostic criteria that are plainly not typical in males experiencing significant adverse life events that predictably trigger depression and, often, suicidality.

It was no doubt tempting to hire a minority female to oversee, among other things, the WebMD Depression Assessment. In this regard, it appears that countless men in the U.S. and around the world have probably been disserved, as I was disserved in the prior incident mentioned above, by administrative indifference to the actual quality of services rendered. She’s female; she’s brown-skinned; what can go wrong?

What went wrong was that, on this WebMD page, women but not men had someone on their side, someone who (as promised by the WebMD language shown above) was supposed to “ensure the accuracy [and] credibility” of information provided to people in need of reliable guidance. Not to overstate the quality of her service to suicidal women: the assessment provided jarring treatment and lame advice to people of either sex who acknowledged vague thoughts about death or suicide. This could hardly be surprising: Dr. Cassoobhoy is not a researcher. It is not even clear that she is much of a clinician. According to her bio (above), her studies have focused on areas of health policy and management.

The WebMD language indicates that Dr. Cassoobhoy was “responsible for reviewing WebMD content across the web site.” It was not clear, from that language, whether she was the only such reviewer. Probably not: that would be a monumental task, covering a quantity and distribution of topics beyond the reasonable capability of any one person. Presumably Dr. Cassoobhoy was assigned to cover the Depression Assessment among other things. This would raise the questions of whether her work has similarly disserved men or other groups on other webpages, and why a person without a clinical mental health credential would be vetting the accuracy of advice to depressed and potentially suicidal individuals.

It goes without saying that people should be careful of what they read online. But not everyone has the time and training to be a scholar in every source they consult. A webpage approved by an M.D. and hosted by a reputable company like WebMD may be reasonably expected to mind the quality of its offerings. Perhaps this post will provide a nudge in that direction.

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