“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?”
“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…