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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152 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 1 person

  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 1 person

    • 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 1 person

    • 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. 🙂

      Like

  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 1 person

  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 1 person

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