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![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
Depression is not one thing
Is underrecognition of depression really a problem?
Multiple Paths to Diagnosing Depression
Resonse to Fogel's comments on Baik et al 3(1), 31-37.
Detecting and treating depression in primary care settings
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Paul R Thomas, London, UK General Practitioner
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Dowrick’s critique of the first line of Baik’s paper triggered something for me. The paper starts: ’under-recognition of depression in primary care is a critical public health problem’. Dowrick challenges this and points out that those without a diagnosis of depression can sometimes do better those with one. This reminds me, as Dowrick points out, that depression is not one thing. It is a syndrome with recognisable objective and subjective features, but these arise from multiple interacting factors. Relationship difficulties, debt, bullying at work, unfulfilled dreams, unresolved past hurts, conflict with neighbours, bereavement, lack of skill and space to get things in perspective, no holiday for years, poor housing, physical illness, a damp day. Many of the people I see have all of these, and all at the same time. I even have a rehearsed routine - I write what the patient lists, and I read the list back… I say “are you telling me that you have… and… and…. And you are wondering why you feel depressed?” Sometimes it even gets a smile. Very often it provides the basis of a plan to deal with things on all fronts. In the UK the label of depression can result in being unable to get health insurance. The label carries stigma and can worsen self-esteem. It can be a very helpful label, but not if seen as a simple response to a complex problem that has not been explored. General practitioners and other primary care professionals are not usually trained to get beyond a simple interpretation. We also have no meaningful interaction between mental health specialists and generalists to work out something better. We do not have the ‘carve-up’ of the USA, but we have our own informal chasm between the disciplines. The Royal College of General Practitioners Council, in summer 2004, agreed a statement about mental health. The Health Inequalities Standing Group, a sub-committee of the RCGP, had developed this after broad consultation. The statement is nine pages long and includes recommendations for all sectors. It recognises the multi-faceted nature of many mental health problems and the need for complex integrated strategies to deal with them. Here are two paragraphs: · General practitioners and other primary care professionals frequently identify, treat and refer people who have severe mental health problems. However we more commonly encounter patients who are both mentally healthy and unhealthy at the same time. Physical, emotional and psychological symptoms are intertwined. The continuing splitting of ‘mental’ from ‘physical’ functions itself, perpetuates the stigma, discrimination and exclusion associated with having a ‘mental’ illness. · The core of the generalist role is to help patients make sense of often-paradoxical symptoms in the context of their whole life story. Listening and helping patients to reflect can often be more relevant than having ‘correct’ answers. How someone is able to function within a family and a community is more important than their diagnostic label. At its best, when the system is welcoming and the clinicians have the skills and make time, general practice is ideally placed to work with patients with mental health problems; however, poor primary mental health care also has the potential to do harm. I really liked Baik’s paper. I very much liked this whole edition of the Annals and its coverage of mental health issues. It has helped to move forward the debate about how to practically deal with real human beings, each with a fragile and often paradoxical sense of self. Under-recognition of depression in primary care may not be a critical public health problem. Conversely, widespread acceptance that a mental health diagnosis such as depression is a discrete entity may be. Competing interests: None declared |
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Christopher Dowrick, Liverpool, UK Professor of Primary Medical Care, University of Liverpool
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Seong-Yi Baik and colleagues have produced a thoughtful qualitative study of the processes that family doctors go through in arriving at a diagnosis of depression. Their descriptions resonate well with the realities of clinical decision-making in primary care. However I have fundamental concerns about the validity of the premise underlying their paper. I do not agree that 'underrecognition of depression in primary care is a critical public health problem'. The authors fail to cite several papers - e.g.Dowrick et al BMJ 1995,311,1274-6, or Goldberg et al BrJGenPract 1998,48,1840-4 - which show that patients whose depression goes undignosed tend to have a better outcome than those who are diagnosed: primarily because their conditions are milder. This ties in with the finding from the Hampshire Depression Ptudy that GPs are in fact very good at detecting severe cases of depression and in general only miss one case in every 28.6 consultations (Thompson et al BrJPsych 2001,179,317 -23. Indeed, I think that family doctors these days (of whom I am one) are more likely to over-diagnose depression. Since the concept of depression now brings with it some very simple treatment procedures (prescribe one pill a day and/or refer to practice counsellor), it is very tempting for us to shoehorn all sorts of problems into this diagnostic label, package the patient nicely, and send them on their way with a minimum of disruption to our busy working lives. But in so doing, we risk ignoring the complexity of their lives and belittling the reality of their distress. And by medicalizing their distress, we also risk reducing their sense of agency and self-determination, which are crucial ingredients in human flourishing. (see Dowrick C. Beyond Depression OUP, 2004) Competing interests: None declared |
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Herbert C. Schulberg, Ph.D., White Plains, NY, USA Psychlogist, Weill Medical College of Cornell University, Bruce L. Rollman, MD, University of Pittsburgh School of Medicine
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We commend Dr. Baik and her colleagues for their cogent analysis of the complex factors influencing the primary care physician’s diagnosis of depression. Of particular interest is their depiction of three distinct processes whereby the physician can gather information needed to formulate this psychiatric diagnosis. While the “ruling out” process is often employed in clinical practice, Baik, et al note that this strategy does not necessarily pertain when experienced physicians recognize “something different” in their patient’s presentation. Baik, et al conclude that a physician’s level of experience, familiarity with the troubled patient, and amount of time allotted for the visit generate multiple diagnostic strategies for the assessment of depression. Despite acknowledged limitations in the authors’ methodology for deriving needed data, their conclusion already has a face validity not to be ignored. Thus, several alternatives emerge with regard to the “ruling out” manner in which primary care physicians often are taught to diagnose depression.1 First, it is striking that the two symptoms most often used by physicians to screen for depression according to Baik, et al are sleep problems and low energy level despite the greater sensitivity of sad mood and anhedonia in identifying this mood disorder.2 Can physicians, therefore, be taught to screen with the latter rather than the former symptoms so that depression is a diagnosis of inclusion rather than exclusion? Second, can the rank of depression in the physician’s diagnostic hierarchy be elevated when he/she is provided clinical information such as the patient’s score on the PRIME-MD or PHQ-9 communicated via an electronic medical record? 3 Furthermore, does the physician’s willingness to use such clinical information relate to his/her experience level and degree of familiarity with the patient? Third, is the physician’s reluctance to pursue the diagnosis of depression in the face of time constraints diminished when a care manager is available in the practice to assist in the assessment process ? 4 The forgoing questions are of more than academic interest since most educational programs for improving physician recognition of depression are standardized rather than creative in nature. To their credit, Baik, et al remind us that one educational package does not fit all clinicians and that customized approaches warrant significant attention if the recognition of depression is to be improved at all levels of primary care practice. 1 Depression Guideline Panel. Depression In Primary Care. Volume 1. Detection and Diagnosis. Agency For Healthcare Policy and Research, 1993. Rockville, MD 2 Whooley M, Avins A, Miranda J, Browner W. Case-finding instruments for depression. Two questions are as good as many. J Gen Intern Med 12: 439-445, 1997. 3 Rollman B, Hanusa B, Gilbert T, Lowe H, Kapoor W, Schulberg H. The electronic medical record: A randomized trial of its impact on primary care physicians’ initial management of major depression. Arch Inter Med 161: 189-197, 2001. 4 Bruce M, Ten Have T, Reynolds C, Katz I. Schulberg H, Mulsant B, Brown G, Pearson J, Alexopolous G. Reducing suicidal ideation and depressive symptoms in depressed older primary care patients. A randomized controlled trial. J Amer Med Assn 291:1081-1091, 2004. Herbert C. Schulberg, Ph.D., Dept.of Psychiatry, Weill Medical College of Cornell University, White Plains, NY Bruce L. Rollman, M.D., Dept. of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA Competing interests: None declared |
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Seong-Yi Baik, Cincinnati, OH Assistant Professor, Barb Bowers, Linda Denise Oakley, and Jeffrey Susman
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On behalf of the co-authors, I truly appreciate your comments on our article. Your insight offers a very interesting comparison among the different disciplines. As this study was the very first step toward designing quality interventions in primary care, we will keep your valuable comments in mind as we conduct future studies. Seong-Yi Baik Competing interests: None declared |
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Joshua Fogel, Brooklyn, NY, USA Assistant Professor, Department of Economics, Brooklyn College
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Baik et al. (1) use grounded theory to understand how primary care clinicians recognize depression in their patients. As an individual with a PhD in Clinical Health Psychology and someone who has practiced in a variety of settings including primary care settings, I found this article quite exciting. The example provided to illustrate the concept of “recognizing the person” where a family physician describes using all of ones senses and giving “complete” attention to the patient for the first 15 seconds is quite similar to the approach that psychologists and other mental health professionals use when encountering a patient. Mental health professionals are taught to intensively observe a patient. This includes focusing on the body language, tone of voice, and observed affect of the patient. After observing the patient, mental health professionals carefully attend to one’s feelings which are used as a gauge for understanding the psychological issues that the patient is experiencing. This approach mentioned by Baike et al. (1) can be a skill that primary care clinicians can learn to regularly perform as part of clinical practice. Although Baike et al. (1) study this with regard to depression, primary care clinicians can use this approach for trying to understand the variety of mental health issues that can occur in primary care settings. Besides depression, a number of studies show that mental disorders are quite common in primary care. For example, approximately 33% of primary care patients have a mental disorder (2). Besides the recognition, diagnosis, and treatment of mental disorders by medically oriented primary care clinicians, there may be a need to consider collaboration with clinical health psychologists. Health psychology differs from traditional psychology in that there is a strong focus on short-term treatment and a de-emphasis of psychopathology (3). Health psychologists often use a cognitive- behavioral approach for treatment and their scope of practice includes the interface between physical health and mental health. In many ways, health psychologists are primary care clinicians for the multiple psychological issues faced by primary care clinicians. For example, McDaniel discusses approaches for family physicians and psychologists to collaborate in primary care (4). By understanding and putting into practice the concepts of Baik et al. (1), primary care clinicians can help patients with depression recognize and be more comfortable with a depression diagnosis and consequently obtain the treatment that they truly need. 1. Baik S-Y, Bowers BJ, Oakley LD, Susman JL. The recognition of depression: The primary care clinician’s perspective. Ann Fam Med. 2005;3:31-37. 2. Vazquez-Barquero JL, Garcia J, Simon JA, et al. An epidemiological study of morbidity and use of health resources. Br J Psychiatry. 1997;170:529-535. 3. Fogel J. Health psychology: A new form of psychotherapy? MedGenMed. 2003;5;29. Available at http://www.medscape.com/viewarticle/447435 . Accessed January 23, 2005. 4. McDaniel SH. Collaboration between psychologists and family physicians: implementing the biopsychosocial model. Prof Psychol Res Pract. 1995;26:117-122. Competing interests: None declared |
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