the clinic…

Posted on Wednesday 26 October 2016

A few years back, a woman in her mid forties showed up in the clinic "depressed" [visible from 50+ yards]. She wanted to talk about her symptoms and not her life. As it played out, one reason was because she didn’t have one [a life]. She was the housewife to her second husband, a man who worked hard, came home and ate, drank a couple of six-packs and was off to bed. His son by a previous marriage lived there and was a "freeloader druggie." Her son from a previous marriage was a college student rarely home except to eat. She worked full time as an Assistant Manager of a busy retail business. The manager often left her in charge [to run off for trists with her married boyfriend]. The patient to be was on the phone several times a day with her aging mother who lived in another state. Her mother was and always had been a "drama queen" and my future patient managed all of her affairs and money long distance. She was a "sort of therapist" for all of her siblings and her husband’s siblings in their dysfunctional marriages. Did I mention she was a full time night student taking a medical records course of study. Like I said, she didn’t have a life. Her PCP [Primary Care Physician] had plied her with various SSRIs with no effect. She didn’t tell me on that first visit, but she had a gun, bullets, and some suicidal fantasies.

The point of the post isn’t this patient’s case, but a paragraph or so will help get me closer to the point. Diagnosis? She met all MDD [Major Depressive Disorder] criteria. A twelve step diagnosis would’ve been [Malignant] Co-Dependency. A family systems theorist might label her with the "Executive Daughter" syndrome. But the Dx that I went for was "a Network case" [from the movie with the line, "I’m mad as hell and I’m not going to take it anymore!"].  I recall going for the anger because she didn’t seem to know she had it. But it wasn’t very hard to find. I saw her as frequently as I could and on my off weeks, she saw an LPC who was in the clinic. That’s where "Executive Daughter" dx came from. She had always essentially held her dysfunctional family together as her father’s "right hand man" – a family role. He was a soft alcoholic who appreciated her help. He had died several years ago, and the hardest anger for her to get to was directed towards him for putting her "in charge," then dying and leaving her to take care of all these "crazy f___ing" people.

It took a long while for her to figure out that the solution wasn’t making "them" change, it was in her stopping taking on their problems as if they were her own. Discovering the source of her anger helped, but changing roles is hard to do. On the other hand, not cringing every time the phone rang was a powerful reinforcer. To her surprise, when she started talking out loud, her husband got rid of his "freeloading druggie" son and drank much less himself. He said "I didn’t realize what we were doing to you." She dropped school ["just a way to get out of the house"] and moved to a better job. Progress once she got her rhythm was surprisingly swift. Recently, she showed up with a "relapse." He mother had a "light" stroke and a sibling’s husband died in a single week, and she found herself automatically sliding too far into the caretaker role once again and felt liked she was trapped again [forever].

The topic here is the PHQ-9 [Patient Health Questionnaire – 9 Item] [see how silly!…, remarkable…, simply absurd…, PHQ-9®™…]. The day this patient came back with her "relapse" was shortly after they started handing patients a routine PHQ-9 to fill out in the Waiting Room. It’s apparently a requirement for whatever certification the clinic is getting so they can take insurance. She said, "What is this shit?" I glanced at it and told her. She rolled her eyes, and then launched into what had happened.  It looked like this from what I recall in a quick glance…

[I particularly recall the "double answer" on number 9].

Last week when I was talking about the Collaborative Care Model [without ever talking to the patient…], I didn’t get around to talking about their use of the PHQ-9® to follow the patient’s progress, to decide when to change medications, etc. Nothing I know about the PHQ-9® makes me think of it as a candidate marker to follow the session to session effect of depression treatment, certainly not over observation or a simple question. Looking at that form, you’d think I ought to send her to the hospital on a stretcher. But I know her. Remember, I said:
    "showed up in the clinic ‘depressed’ [visible from 50+ yards]. She wanted to talk about her symptoms and not her life"
We’d talked about that part before. Her mother’s extreme melodrama and constant whining had put her off of talking about what bothered her. She didn’t want to be "like that." Instead, she "telegraphed" her internal states indirectly with depressive symptoms. We got onto that when I asked if she had talked to her husband about his son and his drinking. She had acted if he should know why she was so tangled up. She was bowled over when she tried saying it instead of "telegraphing" – he was glad to hear it and responded. That’s what got the ball rolling as she went from "ward" to "ward" setting boundaries "out loud." So the PHQ-9® was a telegram.

She felt really snookered. Her mother’s stroke wasn’t that light after all, and she really probably couldn’t live alone and take care of herself. Throw in the drama, and things were an unholy mess back home. It was the common problem of the elderly person who needed to go into care, but resists the need [with a heavy dash of lifelong Drama Queen-ness thrown in for good measure]. My patient felt sentenced to bringing her mother to Georgia to live with her, which would’ve been a fate worse than any she could ever imagine.

So the other thing that PHQ-9® measured was frustration. She had spent days calling hospitals, doctors, etc. trying to get someone to see that her mother couldn’t live alone, without success. Doctors and hospitals don’t initiate such things. Families and Social Services do. This is the reason every psychiatrist, psychologist, etc. should have as part of training a stint in a Social Agency. Her problem of an aging impaired parent, while common, is never easy. But in this case, everything was already in place – resources [check], fiscal assets [check], and an immediate cause [check]. All that’s needed is a savvy Social Worker and/or lawyer. My patient’s son [that college student I mentioned] had moved to his grandmother’s town to continue schooling, and moved in with her thinking he could "help Grandma." He ended up having to call the police when she got out of control and attacked him with a knife. "Grandma" ended up with an assault charge. He was busily looking for an apartment to get out of there. So there was a pending charge, a cause to go to the court and insist on an immediate mental competency assessment. That "other State" happened to be my home State and so I know the laws, so…

This patient is an action figure and I have no doubt that once given the path, she’ll take care of business [her mood was much lighter when she left]. I won’t prattle on about how much I think using a PHQ-9® to do waiting room screening or make clinical decisions is a pseudo-metric rather than the application of evidence-based medicine. It was developed by Robert Spitzer on a grant from Pfizer [who owns it]. It’s part of a fantasy that the psychic ills of human-kind can be reduced to some simple calculus that has a general application – a fantasy of policy makers like those that created that Collaborative Care Report [DISSEMINATION OF INTEGRATED CARE WITHIN ADULT PRIMARY CARE SETTINGS: THE COLLABORATIVE CARE MODE], rarely shared by clinicians. I wonder what a Consulting Psychiatrist who had never met this patient would say on seeing this PHQ-9® to a Care Manager to tell the Primary Care Physician?
    Ed Pigott
    October 26, 2016 | 7:05 PM

    While I don’t know if it is a requirement for the ‘certification’ of the clinic where you volunteer, I do know that the administration of depression screening measures such as the PHQ-9 by primary care docs are a mandated ‘preventative service’ under the Affordable Care Act that must be covered without the patient having to pay a copayment or co-insurance to meet their deductible (See:

    In other words, administering PHQ-9s are essentially free money for PCPs for this ‘preventative service’ and what treatment will they offer other than antidepressants as though they don’t already (over)prescribe the vast majority of these medications.

    You might want to ask the clinic administrator if they are billing for these PHQ-9 assessments. My hunch is they are.

    October 26, 2016 | 8:52 PM

    Thanks Ed. That’s a topic for a coming blog…

    Bernard Carroll
    October 27, 2016 | 1:39 AM

    When the nursing assistant takes your blood pressure, temperature, and pulse oximetry before you see the primary care physician at your scheduled checkups, it is clearly understood that these measures are screening procedures, not diagnostic in and of themselves. They can change the Bayesian prior probabilities for hypertension, say, but they don’t make the diagnoses. The intent is to help the primary care physician to focus in on issues that may need review, exploration, and workup. Properly used, the PHQ-9 likewise can alert the clinician to the need for review of psychological issues – and they will vary from case to case depending on the known past psychiatric history of the person.

    The problem is that these simple screening measures have been corrupted by clinically inept systems managers who are ignorant of the facts of nonspecific symptoms that cut across many psychiatric diagnoses. Just as internists teach students to treat the patient not the lab test result, so we should not be treating PHQ-9 scores in stand-alone fashion.

    Peter C. Dwyer, LCSW-C
    October 27, 2016 | 12:43 PM

    “The problem is that these simple screening measures have been corrupted by clinically inept systems managers who are ignorant of the facts of nonspecific symptoms …”

    That is one issue, but it is too narrowly focused.

    Institutional psychiatry has a vested interest in putting its invalid DSM labels and criteria in front of every set of eyes in the country. PhARMA has a vested interest as well – a way to goose doctors along to prescribe more SSRI’s. Both have vested interests in systems managers being ignorant about nonspecific symptoms.

    PhARMA and institutional psychiatry have devoted decades and billions to implanting in American minds the trope that mental distress and problems of living are, a priori, “psychiatric” brain diseases treatable with pills.

    Writers at this site are not fooled by this. But most Americans, including many “mental health” professionals and primary care doctors are. Many psychiatrists (whether they believe it or not) still push the “chemical imbalance theory,” acting as though DSM’s constructs are both valid and reliable.

    Moreover, the medical and “mental health” systems are constructed in a way that pushes even skeptical professionals to take the path of least resistance – treating the screening tool as a diagnostic instrument; and then doing the easiest thing in response – opting for drugs and short circuiting further inquiry.

    The core problem does not lie with benighted systems managers, but with deeper sources of distortion in the health and “mental health” systems. Simply noting tone deaf systems managers detracts from addressing the bigger issues; it is like blaming super market managers for the junk and processed food in a super market chain.

    James OBrien, M.D.
    October 27, 2016 | 1:27 PM

    Here’s the physician burnout antidepressant study I want to do:

    fluoxetine vs

    placebo vs

    getting rid of EHR MOC, preauth, Press Ganey, middlemen and burnout experts who recommend yoga and mindfulness

    It will yield the same expected result as my Viagra vs. women in Viagra TV ad study

    Cate Mullen
    October 28, 2016 | 8:40 AM

    FYI regarding your astute and nuanced need for an intelligent and savvy Social Worker
    Memo from AMA Auxilary
    NASW Nov. 1955
    Medical Social Work began in hospitals as early as 1905 in Mass. Gen.
    Initiative came from docs and laymen who believed adequate medical care and adequate medical education included attention to the personal and and social problems associated with illness
    Today,with medicine increasingly concerned with patient as person-underlined-
    …The doctor asks the Medical Social Worker to help with a patient when social,psychological,economic upsetsconnected with the patients illness hinder recovery.
    Memories on to state shortage of people to fill positions.
    Cost. 4,800 to 5.000 for two year post BA degrees
    Also social workers make good wives for doctors and family members of physicians are also good recruitments.
    Oh Vey! The baby was thrown out with the bath water!
    I love the vocabulary and stress on patient as person with human needs
    The sexism and. underlying covert racism brings me to tears
    What happened?

Sorry, the comment form is closed at this time.