Depressions

New York Public Library entrance

“I see from the medical assistant administered PHQ-2 that you have been feeling down lately. Tell me about that.”

“Uh, I am here for my knee. Why was she asking me about depression?”

“Well, we want to put a focus on mental health, you see…”

“What about my knee?”

“We’ll get to that at your next visit. Right now all we have time for is delving into this positive two question depression screen.”

“You guys never did this before.”

“I know. But here we are. Better late than never. So are you thinking about killing yourself?”

“NO!”

“Should we put you on medication?”

“I don’t like drugs.”

“Counseling then! Good choice. I’ve got a list of counselors in the area…”

“I am not paying for counseling and I haven’t got time for it in the first place. My knee is what is getting me down.”

“Yes, well. Come back in two week’s time and we can talk about the knee.”

*****************************************

That wasn’t real. But it could be….

The healthcare organization I work for is now measuring my quality based on my medical assistant asking patients questions about depression once a year right before they check the blood pressure. 

I have yet to have a patient say this was a good addition to their rooming procedure but that is beside the point. Why are we focusing on this in the first place?

To save lives.

Personally, I hate questionnaires. They are an attempt to oversimplify a very complex problem. Can we really put depression into a box? Should we?

If the PHQ-2 is positive it should be expanded into the PHQ-9. The PHQ-9 should be used to monitor response to treatment. 

I much prefer a conversation with a patient to reviewing a questionare. I can tell, usually, when a patient is having a hard time but even if I can’t I still ask once a year at the physical as part of my review of systems. And if they say they are having problems I pry, by golly. Are we talking about a chemical imbalance or did their mom just die? Is it affecting their ability to hold a job? To take care of their family? My medical assistant shouldn’t be the one asking the questions. It should be ME. That is my job. Which then brings me to documentation. Make it easy for me. Don’t hide it on a different screen. My review of systems documentation should be sufficient shouldn’t it?

It frees the physicians up to do other more important things.

What is more important than mental health? But then, I wonder, are we perhaps overemphasizing it on some level, too?

When we made pain into the “fifth vital sign” we created a whole population who became focused on feeling no pain, a pharmaceutical industry happy to create addictive drugs that prevented anyone from feeling pain, and physicians caught in the middle. Ultimately, the prescription narcotic addiction crisis was the unintended consequence.

So I worry that we will over diagnose depression. I am not sure that assigning labels like that is all that helpful for most people. I worry that those who are truly ill, who need the most help, will be pushed out of an already failing system that becomes glutted with everyone else. I am already seeing this trend. Making my very ill patients wait three to six months for an appointment with a reputable psychiatrist is unacceptable but it is par for the course nowadays.

The mental health system in the US sucks and that’s the truth. It especially sucks around here. There is a dirth of good psychiatrists in my area. Same with counselors and psychologists. What are we supposed to do? Should we as primary care just push drugs on everyone? Drugs that have side effects and risks and which are not appropriate for all patients? Who then will manage those drugs? Me? With very minimal training? And if we push drugs but cannot effectively pair it with counseling support, what have we accomplished? We are supposed to help, to make people better aren’t we?

I’d really like to know YOUR thoughts…

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177 thoughts on “Depressions

  1. I think it’s okay for a primary care doctor to prescribe mental health meds in a pinch, if they feel comfortable doing it, but leaving it there without a referral to a psychiatrist seems risky with all the different kinds of medications and side effects. And if the condition is serious enough for mental health meds, then it’s serious enough for some counseling, otherwise you’re just covering up the problem. How much counseling depends on the patient. And yeah, the mental health field is a mess – not enough time for counseling and too many forms. That’s why I finally left it.

    Liked by 2 people

  2. First off, I love that this is “Depressions,” not “Depression.” ♥

    After that, I second the below:
    “Personally, I hate questionnaires. They are an attempt to oversimplify a very complex problem.”

    The more I read lately, the more I discover I dislike anything that makes one human being out to be exactly like every other human being. (Nope. Lots of different inputs, lots of different outputs.) All these things that present the world thusly are basically, IMO, created by people who see humans as lesser versions of computers. They didn’t understand humanity before diving into computers, so how again would they find it afterward?!

    Recognizing complexity means recognizing we’re not machines. Humans don’t operate like physics or chemistry, where x input–within y realm–yield z output 100% of the time. That’s part of the magic, and part of what makes machinists angry. We’re all supposed to follow the right rules, dammit!

    Whenever I go to the clinic, BTW, I find some occasion or another to say, “No, no, you don’t need to explain any more, I’m not rating you in my brain (and I’m not going to follow up on ratings sites, either).” I almost invariably think of you, and sometimes say, “I actually follow doctors, and … I do know you’re human.”

    I just lost my most recent doctor a month or two ago. I tried to figure out where he’d gone, but no one would tell me. An NP said, “oh, you can’t find him where he’s gone! He’s doing mission work full time from now on!”

    So, basically, yeah. He didn’t care about my weight. He looked me in the eyes while typing, and engaged me as a human being, and was genuinely just a fine damn human being with whom to consult. I miss him, but am glad my newer doc still isn’t so bad. He’s no my-last-doc, but he understands what I’m asking and why, and can answer these questions quickly and without in any way indicating he thinks patients are mentally four years old. It’s not quite the high I’ve become used to, but it’s still delightful, to know I can walk in and have someone click all the x’s before going, “This is what you’re after, yeah? Here’s what you need to know about that …” ♥

    Liked by 3 people

    • I loved your post about ACE’s today. The medical implications are fascinating and humbling. So much of who we are is outside of our control. I am so sorry you lost your physician! I have fantasies of doing volunteer work myself someday…

      Liked by 3 people

    • I’ve had pharmacist tell my patient crazy things, like, “Lexapro is only for depression. It won’t help your anxiety.” Not every one does that mind you but sometimes it feels like we are not fighting on the same team. On the other side I have a couple of pharmacists that I can call and ask questions of any time. I love them dearly. πŸ™‚

      Liked by 1 person

  3. My late husband was deaf and legally blind, but also schizoaffective (I am doing a webcomic from his memoirs: http://www.adeafinthefamily.com) but once they couldn’t find ‘pancreatitis’ as they thought he must have because of the infection in his system, they took out his gall bladder and sent him home. When his symptoms got worse, they thought he was just mental and sent him home with nausea pills. He died a few days later of sepsis. Sometimes it’s not depression…

    Liked by 3 people

  4. When my partner–a family therapist with as MSW degree–worked in a community clinic, she once had a GP turn to her for advice on antidepressants. It was frightening. But they were both trying to hold people together in the absence of the support both they and the patients needed.

    Liked by 2 people

  5. What a gr at post followed by insightful comments. I was very lucky to have a brilliant doctor who got me the treatment I needed quickly when my world fell apart due to a major depressive event. I got pills plus regular meetings with a wonderful psychiatrist followed when I was ready by CBT. That was 17 years ago and I have been able to maintain my mental health since then with a very low dose of Citalopram and the strategies I learned from CBTdepression is a living hell as dangerous as cancer and oftentimes as deadly. The drugs are a sticking plaster- but the insights of a good psychiatrist and the practical strategies offered by CBT are what enable sufferers to go on living and help themselves.

    Liked by 3 people

    • Yes! Therapy and meds should always go hand in hand but it is a time and money commitment that most patients are unwilling to make. It is hard to take time off and the cost IS prohibitive, especially for high deductible plans. In the past mental health benefits were often specifically excluded from insurance policies and there are discussions of allowing that again. It would be a great tragedy.

      Liked by 1 person

  6. Under our present government we are undoubtedly heading the same way. Our ‘Health Minister’ has few friends in the Cabinet, having alienated the entire health service; and with ‘no’ money to fight no a wage increase that was due ten years ago.

    The cheap way, favoured by those ‘thinly’ in power here is to outsource the lot of it, on the basis that the profit motive looks after people better… or was that better people?

    Liked by 2 people

  7. I have had an appointment with a MD that insisted I must be depressed because I was overweight…WTF was lI could say in my mind…something completely unrelated to why I went to see him…needless to say I changed doctors…and no I wasn’t depressed….I was pretty sure it was something the computer or insurance demanded them to focus on….as it is when my current MD ask me an off the wall question during my visit, its always after she has looked at the screen…I am so happy our patient MD relationship has evolved to her saying…Look I need to ask, I know you don’t want a colonoscopy, I am checking no as we I am speaking….but the insurance insist I ask….I really hate that the insurance companies push procedures…..if we are not on top of our care, the insurance companies would be raking in the money from unwarranted procedures….crazy……no wonder our healthcare is in such a mess…..

    Liked by 2 people

  8. This is global, unfortunately. We are being run by bureaucrats, who speak through computer geeks.
    One of my oldest French BFF’s has clear sciatica. His GP told him in June to get an appointment with the specialist. Not until September. Ok. Can I get Tradol for the pain meanwhile? No. Only the specialist can prescribe that. Can I at least get a scan to make sure. No. Only the specialist can. So meanwhile he can barely walk a 100 yards (with an english cane) and not stop.
    It took the french doctors and emergency at one of the Paris Hospitals 2.5 weeks to NOT diagnose that I had vasculitis and polyarthritis as a result of a bacterial infection. I had to cut my trip short, fly back 12 hours, go straight to the hospital in Mexico, where my MD daughter had already assembled a multi-disciplinary team at 9PM. Diagnostic in 4-5 hours. Complete with 1AM scan. Treatment is getting me back on my feet. (Daughter #2 says it’s because we are the “1%”). (You ask me if I am “depressed” I will say pissed!) πŸ˜‰
    I’ve said it before: Doctors and maybe patients have to raise their voice. We are going into the wall.

    Liked by 3 people

  9. I understand the question, but if you don’t go to the doctor often, your doctor may not know you or know you enough to determine if your depression is due to a major loss or if you have deeper mental health issues.

    Liked by 1 person

  10. First of all, I’ve had doctors that I hold up as close to gods, who saved my life and the lives of my children. I also had a few that literally killed me and destroyed my quality of life. Nobody is perfect. I tell a new doctor that I have half a functioning heart, heart failure, afib, chronic lyme and active severe EBV—and he asks if I am depressed. Seriously? If I say I can’t sleep, ‘oh, I can give you antidepressants, in fibro pain, again, antidepressants. Of course I’m depressed but I am not suffering clinical depression. There is a difference. When you lose a child or loved one you are depressed but usually it will lift as your grief becomes bearable. Many people cannot handle antidepressants, myself included. I can’t tolerate mind altering drugs or opioids. But the doctor will say, try a new one on the market. Yeah, I might do that–not–but let’s wait and see how many people it kills first. Some doctors I run into today have 15 minutes to guess your problem,without really listening to you, write a script and send you on your way. You call the pharmacist to see if the new drug interferes with your meds. He says call your dr–who is on vacation and left no one to cover him. With all the miracles we’ve gained in the past 50 years, we have lost in so many other ways. All I ask is for one real doctor who will take the time and curiosity to figure out how to heal me and work with me–yes I use herbs and supplements and to give me credit for having some common sense. Yes, I’m depressed, no I’m not in depression.

    Liked by 1 person

  11. I went to a doctor for my hip pain – which certainly isn’t something I imagined. I wanted help, and she basically told me to go talk to a psychologist for “my fear of diseases”.

    1. I rarely went to the doctors because I brushed off my ailments, when I finally went I did so because it became unbearable and in the process I brought up several concerns I had. Which includes painful periods, and even pain in my stomach when I’m not on my period. She simply said, “it could be a cyst”. Nothing else, no encouragement to go to a female clinic.
    2. She checked my hip, by rotating it and it hurt. Yet, when I complained about my pain she brushed it off again – simply saying “ok so it doesn’t hurt”. I was flabbergasted at how nonchalante she was. She then told me I should go talk to a psychologist or a counselor. In reality, she told me to suck it up and that I’m imagining it.

    I have a bipolar diagnosis and contact with the psychiatric team in my area. I genuinely felt like she was blaming my pain on mental disorder. Told the clinic’s owner and he shrugged it off, wishing me better luck at the next clinic. Even as I’m writing this it makes me infuriated how belittled I was made to feel.

    I get that it’s probably nothing dangerous, but at the very least she could tell me to go to a physiotherapist and not simply hint that my pain is “in my head”. Knowing my posture is crap and all that, I’m probably walking funny which is causing the pain – which means I would need to go to a physiotherapist to get it sorted, not a counselor.

    Rant over. Really like your blod, need to catch up on the entries, though.

    Liked by 1 person

      • 2nd bad experience at that health clinic, too. First was when the doctor refused to give me a sick leave after my mother was diagnosed with cancer and I hit a wall (figuratively speaking). She referred me to the psychiatric clinic, which fair enough, it’s where I’m supposed to get a sick leave from due to mental issues – but the issue was they had no times until December (this was late October).

        She seemed very non-understanding as well, saying it’s good for me to be among people (I just started so hadn’t made any friends).

        My study loan providers demand proof of study results, university, too. Sooo, guess who felt a thousand time worse with that hanging behind me haha.

        Definitely feel like I’ve been treated worse due to having the bipolar disorder.

        Like

  12. This is a so important topic and it was so nice to read all the problems from your point of view. I have no problems believing doctors have a genuine passion for helping and saving lives. And genuinely care about patients.

    I believe when it comes to mental health we have come a long way, but still are not nearly there! The drugs is an “easy” but not effective way of handling illness that probably have developed over years.

    I think it’s important with all the blogs and people standing up and speak out on mental illness to break the stigma. But I believe the road ahead is people finding their way out them self. With the help of them self and family and friends. Not drugs unless for the very serious.

    I have struggled with bipolar all my life and been isolated and very depressed for some years. And I do go see a psychiatrist but I have made my journey on my own. And that is the treatment I will recommend for everyone. Have depression more out of the doctors office. Inform and let people help them self. With breaking the stigma they no longer have to hide the feelings.

    A world when people can say I’m depressed, as easy as saying I got a cold. Then we have come a long way with openness and self treatment I think! I do know how serious a depression can be. I wrote a long post yesterday about this topic from where I was coming from with my life. And drugs did nothing for me, but photography did. Starting to walk around looking for beauty and happiness helped me a lot! πŸ™‚

    Liked by 1 person

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