I’m old enough to have health problems of my own so I have a physician seeing after me [as they say around here], and I work some in a rural clinic myself. Except for still being awed by how many overmedicated patients show up, I rarely think about the things I write about here when I’m either patient or doctor. I just see after my patients [and appreciate being seen after]. But last week, I had my yearly wellness visit on Monday and then worked myself on Tuesday, and I found myself reflecting on the role of patient and doctor [from the inside]. When I got to my appointment, the receptionist said, "This is a wellness visit so I need for you to fill out some forms. Use the marker for the one on top, and the pen for the second one."
So I sat down in the waiting room to do my forms. I’m the guy who actually hears the background Musak® in stores and so I was painfully aware of the television in the waiting room with an endless stream of ads for medical products with a few health tips thrown in here and there. The magazines were in the same genre, things like prostate health and the like with sponsored ads [I longed for the days of old People magazines and aging US News & World Reports]. The machine graded form [marker] was a Review of Systems – fairly standard. But then there was a mental health questionnaire, something new, apparently trying to find out if the scourge of mental illness and suicidality could be detected in this local waiting room. I was so tempted to answer with a bunch of misery just to see if anyone read it, but I was good and accurately attested to my stellar mental health. At the end of a helpful doctor visit, he apologetically said, "Sorry – We have to do this" and did some kind of memory test to look for my dementia and reviewed my "shots."
The next day at work, after my clinic our new medical director came around to show me the new form the patients had to fill out on each visit. It was the PHQ-9. I discovered it a few years back [see PHQ-9®™…]. It’s a mental health questionnaire created by Robert Spitzer [funded by Pfizer]. Four years ago, I wrote "This article came out 12 years ago, and the PHQ-9 obviously hasn’t caught on, since this is the first I’ve heard of it…" [so much for my predictive powers]. I asked him why we were doing it [having just seen a way overly full clinic and hardly in the looking-for-work mood]. He said [sheepishly], "Sorry – We have to do this" [we’re starting to see Medicaid and the ACA-insured, and with that comes a lot of "have to do this" kind of things].
As I was driving to my daughter’s for Thanksgiving [8 hours and two States north], I found myself thinking about those forms. I’m the only psychiatrist in my county or the several counties north to the state line that’s not inside of a tv set [a few telepsychiatrists at a few mental health clinics here and there]. So I wondered who was going to deal with the yield from these forms. In our clinic, if they’re seen by our clinic doctors, they’ll just send them to me [groan]. But what does my internist do with the ones from his office? My guess is that he’s expected to follow-up and maybe prescribe something [double-groan]. My wife was napping, and this stayed on my mind for a while.
… after giving heart and soul to mental-health problems over the last 13 years working in government, I have not seen any improvement for either morbidity or mortality for serious mental illness – so I’m ready to try a different approach. If it means using the tools available in the private sector, let’s go for it.
"Major depression is now recognized as a highly prevalent, chronic, recurrent, and disabling biological disorder with high rates of morbidity and mortality. Indeed, major depression, which is projected to be the second leading cause of disability worldwide by the year 2020, is associated with high rates of mortality secondary to suicide and to the now well-established increased risk of death due to comorbid medical disorders, such as myocardial infarction and stroke…"
Cochrane ReviewsBy Gilbody S, House A, and Sheldon T19 October 2005
The use of depression screening or case finding instruments has little or no impact on the recognition, management or outcome of depression in primary care or the general hospital.Authors’ conclusions: There is substantial evidence that routinely administered case finding/screening questionnaires for depression have minimal impact on the detection, management or outcome of depression by clinicians. Practice guidelines and recommendations to adopt this strategy, in isolation, in order to improve the quality of healthcare should be resisted. The longer term benefits and costs of routine screening/case finding for depression have not been evaluated. A two stage procedure for screening/case finding may be effective, but this needs to be evaluated in a large scale cluster randomised trial, with a prospective economic evaluation.Background: Screening or case finding instruments have been advocated as a simple, quick and inexpensive method to improve detection and management of depression in non-specialist settings, such as primary care and the general hospital. However, screening/case finding is just one of a number of strategies that have been advocated to improve the quality of care for depression. The adoption of this seemingly simple and effective strategy should be underpinned by evidence of clinical and cost effectiveness.Objectives: To determine the clinical and cost effectiveness of screening and case finding instruments in: [1] improving the recognition of depression; [2] improving the management of depression, and [3] improving the outcome of depression.Search strategy: The researchers undertook electronic searches of The Cochrane Library [Issue 4, 2004]; The Cochrane Depression, Anxiety and Neurosis Group’s Register [2004]; EMBASE [1980-2004]; MEDLINE [1966-2004]; CINAHL [to 2004] and PsycLIT [1974-2004]. References of all identified studies were searched for further trials, and the researchers contacted authors of trials.Selection criteria: Randomised controlled trials of the administration of case finding/screening instruments for depression and the feedback of the results of these instruments to clinicians, compared with no clinician feedback. Trials had to be conducted in non-mental health settings, such as primary care or the general hospital. Studies that used screening strategies in addition to enhanced care, such as case management and structured follow up, were specifically excluded.Data collection and analysis: Citations and, where possible, abstracts were independently inspected by researchers, papers ordered, re-inspected and quality assessed. Data were also independently extracted. Data relating to: [1] the recognition of depression; [2] the management of depression and [3] the outcome of depression over time were sought. For dichotomous data the Relative Risk [RR], 95% confidence interval [CI] were calculated on an intention-to-treat basis. For continuous data, weighted and standardised mean difference were calculated. A series of a priori sensitivity analyses relating to the method of administration of questionnaires and population under study were used to examine plausible causes of heterogeneity.Main results: Twelve studies [including 5693 patients] met our inclusion criteria. Synthesis of these data gave the following results:
I have found reading about breast cancer screening, especially Peggy Orenstein’s writings, enormously helpful to my thinking about mass mental health screening. The DCIS “breast cancer” example also has the advantage of stripping away some of the distractions of whether we treat depression as a “real” medical disease. Because a lot of the risks vs benefits of screening are independent of ones views on that. A great starting place is:
http://mobile.nytimes.com/2013/04/28/magazine/our-feel-good-war-on-breast-cancer.html?pagewanted=all&referer=
It is easy to see APA and AACAP et al in the Komen role.
As a shout out to Dawson, the PHQ-9 with generic SSRI chaser prescribed by primary care with integrated psych managers is squarely a managed health public health model with nary big pharma in sight. But, it’s the EXACT SAME academicians (Del Bello, Wagner, Nemeroff, et al) dancing with the new 800 lb gorilla in the room.
There are of course other players too. However, the triumph of impresarios over artists (to borrow from Dr. Carroll) cuts across many of these issues. We as a community consistently fail to call out the naked emperors. Be it when presenting a hollow shell for pharma, or the hollow shell of these “metrics.” Take a look at the public health push in NYC from the past 10 years and you will see what is about to be writ large.
Thanks,
Here are George Dawson’s comments on the PHQ-9:
http://real-psychiatry.blogspot.com/search/label/PHQ-9
[see particularly The Day the Quality Died and its references]…
The last paragraph of Orenstein’s piece:
“It has been four decades since the former first lady Betty Ford went public with her breast-cancer diagnosis, shattering the stigma of the disease. It has been three decades since the founding of Komen. Two decades since the introduction of the pink ribbon. Yet all that well-meaning awareness has ultimately made women less conscious of the facts: obscuring the limits of screening, conflating risk with disease, compromising our decisions about health care, celebrating “cancer survivors” who may have never required treating. And ultimately, it has come at the expense of those whose lives are most at risk.”
I believe in the pain and suffering that Depression can inflict, on both and young and old. I believe in the positive difference that treatment by psychiatrists, including medication treatment, can make for those individuals. However, I am NOT convinced that we are taking seriously enough the impact of mass screening with PHQ-9s and the metrics for “treatment” that will follow. That we take seriously enough how this will come at the expense of those whose lives are most impacted, are most at risk. Nor seriously enough the other unintended adverse impact of the coupling of such screening with other ACA metrics.
The Day The Quality Died was a quality piece. Thanks for pointing it out.
When I do the patient forms, I always put gravida 5 para 4 just to see if they notice. Kind of like when Van Halen used to put a no brown M&Ms clause in their backstage rider. They didn’t care about M&Ms, they wanted to see if people were paying attention.
The only thing left to do in a world gone mad is to have fun with it.
Hi Mickey,
You said,
“”So I wondered who was going to deal with the yield from these forms. In our clinic, if they’re seen by our clinic doctors, they’ll just send them to me [groan]. But what does my internist do with the ones from his office? My guess is that he’s expected to follow-up and maybe prescribe something [double-groan]. “”
That is the exact question I asked the person I was put in touch with with regarding the mysterious functional assessment questionnaire I am asked to fill out before each visit to the PCP. I was told it goes into the patient’s chart but she was vague about providing more information. Anyway, I refuse to fill it out.