I was sitting in the waiting room Friday morning waiting for an ENT appointment [to check a worrisome non-healing lesion in my nostril]. The big tv was looping through an animated description of some balloon thing they could do to your sinuses and a hearing aid spiel about why getting them from an ENT is better than [anywhere else]. I was reading on my phone about depression screening rather than from the various WebMD magazine-lets lying around. When the receptionist gave me the papers to fill out, I half expected there to be a PHQ-9 like at my internist’s office or in the waiting room at the clinic where I work. There wasn’t. But there was one about whether I needed that sinus balloon job and one in case I’m hard of hearing. When I went to the examining room, another tv set was silently mime-ing how to use an epi-pen and cycling through the various hearing aid batteries available at the front desk. The highlight of the visit was the pronouncement that it looked like "a wart" instead of all the ominous options that occurred to me when I found it. I gladly left my "wart" in a jar for the pathologist. On the way home, I wondered why I have such a strong visceral reaction against the idea of screening for depression in doctor’s waiting rooms. Here are some words:
US Preventive Services Task Force Recommendation Statementby Albert L. Siu, MD, MSPH and the US Preventive Services Task Force [USPSTF]JAMA. 2016 315[4]:380-387.
Description: Update of the 2009 US Preventive Services Task Force [USPSTF] recommendation on screening for depression in adults.Methods: The USPSTF reviewed the evidence on the benefits and harms of screening for depression in adult populations, including older adults and pregnant and postpartum women; the accuracy of depression screening instruments; and the benefits and harms of depression treatment in these populations.Population: This recommendation applies to adults 18 years and older.Recommendation: The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. [B recommendation]
- Screening for Depression—A Tale of Two Questions
- US Preventive Services Task Force Recommendation Statement on Screening for Depression in Adults Not Good Enough
- Recommendations for Screening for Depression in Adults Michael Thase [full text]
- Patient Health Questionnaire [PHQ-9]
- Task force urges depression screening for all U.S. adults
- Universal Depression Screening Urged
- Missing in action: Did US journalists miss a huge opportunity to critically examine mental health screening?
Besides antidepressants, they’re talking about Cognitive Behavior Therapy. CBT is a legitimate and effective therapy, but it’s not generic. In my area, most mental health types would list it as their first line discipline. But I don’t think I’ve seen a full course of what Aaron Beck would call CBT in the eight years I’ve been involved. What happens in formal trials and what happens in the "natural world" are very different things. So I suspect that the majority of waiting room depression would be treated with medication.
And then there’s the question of what constitutes depression. Would it be people who say they’re depressed? – which is what unhappy people nowadays say to describe how they feel – bad marriages, no marriages, the burden of a difficult biography, personality disorders, situational crises, grief, lonliness, etc. The formal diagnosis of depression has become corrupted in the recent era – simplified to mean almost any constellation of discrete symptoms and causes. So even discussing it as if it’s a unitary entity is hard to justify.
But I don’t think those things are why depression screening evokes such a visceral "No" when I hear it. One part of that is the global burden of depression meme that introduces so many articles on antidepressants [and blogs by our former NIMH Director for one] implying that through some not-so-clear-mechanism, the incidence of depression-the-vaguely-biological-entity is accelerating. It makes little sense. If there were a genetic or neural circuit etiology, why would it be increasing? And were that true, what does the symptomatic treatment with medications have to with that? Those arguments invariably precede a pitch for more funding for brain research or some new, innovative, treatment for depression, loosely based on a 2004 population study by the World Health Organization. And so this whole line of thinking seems flawed to me, a cascade of unproven and unexamined assumptions that have achieved an autonomous momentum that will only be amplified by waiting-room-depression-screening.
- Little interest or pleasure in doing things?
- Feeling down, depressed, or hopeless?
- Trouble falling or staying asleep, or sleeping too much?
- Feeling tired or having little energy?
- Poor appetite or overeating?
- Feeling bad about yourself – or that you are a failure or have let yourself or your family down?
- Trouble concentrating on things, such as reading the newspaper or watching television?
- Moving or speaking so slowly that other people could have noticed?
- Or being so fidgety or restless that you have been moving around a lot more than usual?
- Thoughts that you would be better off dead, or of hurting yourself in some way?
If one believes in the validity of Maria Montessorri ‘s work in in the urban areas of Italy a long. long time ago one would wonder about taking a screening for depression in the medical doctor’s waiting room. For her, she found that environments for children were key to learning and enjoyment of the educational process.
Your description of the waiting room reminded of an even worse version from Ray Bradbury’s Fahrenheit 451 novel. Not only were there blasting screens but they were not used to obliterate thinking they were used to sell, sell, and sell some more. I am reminded of Satre’s great play “No Exit”.
In that claustrophobic and soul destroying environment would any one not be distressed? Maybe “A Clockwork Orange” would also be a good literary reference to your commentary.
“Soma” from
Brave New World” also comes to mind.
You may remember Mickey that back in the day Psychoanalysis and its practitioners had an ongoing relationship to the literary and art fields. There was no only a strong and solid knowledge base of all things in the Western Canon and respect towards cultural works of all kinds there were direct use of works to highlight theories and ideas that were so very utterly and lovely even in their ugliness human.
Your scenario shows what severe losses we have incurred in the medical world and in daily life that makes an thinking human distressed. It is the use of imagination that is such a severe threat to the powers that be for in imagination even “The Mudlark” can imagine and discover a different healthier way of life. Viva imagination!!!!!! I think that says it all.
Fortunately, not everybody is in favor of aggressively screening for depression. Lancet has a nuanced current editorial discussing the downside. It is much less gung-ho than the JAMA pieces.
a good overview of depression screening is provided by
Screening for depression in medical settings 2015 update
Screening for depression in medical settings: A 2015 Update Public Health Research Centre Seminar University of Hong Kong 9th December 2014 James C. Coyne, Ph.D. Department of Health Psychology University of Groningen, University Medical Center Groningen (UMCG), Groningen, the Netherlands
http://www.slideshare.net/jamesccoyne/screening-for-depression-in-medical-settings-2015-update
I wrote about this when the garbage first hit the fan:
http://cantmedicatelife.com/2016/01/26/stuck-at-home-for-another-day-so-read-this/
Is Occam’s Razor really that difficult a concept, that at the end of the day, the simplest explanation is often the real reason? Dumbing down mental health a few more notches, and what do PCPs do reflexively almost all the time?
Pill for an ill. Shed a skill for a shill. Hey, anyone reading at my site knows my rebuttal, “get it right, face the truth”.
No pill for that, eh?!
I agree with Coyne here. Another aspect of this is what I call the distracted driver syndrome. Primary care and internists are distracted enough with EHR and all kinds of tangential BS and unrelated questions they have to ask. When I go in, please focus on my chief complaint like a laser beam. If my spouse is physically abusing me, I’ll let someone know, thank you (as if they even want to deal with that in the fifteen allotted minutes).
You can make an argument that drivers would be better informed about conditions with constant weather and traffic reports on their touch screen. I’d argue that is more than offset by the resulting lack of focus.
For the content of this post, I think the below link is a must read from Dr. Paul. He lays it out perfectly, government will miss use any and all of this information until proven otherwise
http://m.townhall.com/columnists/ronpaul/2016/02/08/mandatory-depression-screening-a-depressing-thought-n2116465
Its just amazing how many providers are willing to just give up their responsibilities as advocates strictly to appease these political morons.
Good luck, colleagues
This is what happens with top down medicine. Ron Paul is absolutely right…the office visit is insidiously becoming a data mining project. Aside from the fourth and second amendment concerns, that necessarily takes away from the patient care project it is supposed to be.
Why in the hell is there HIPAA anyway if this is the way it’s going to be?
This is why so many psychiatrists are off the grid (yet hypocritically support ACA without ever taking insurance under it).
“…the office visit is insidiously becoming a data mining project.” That’s a very smart observation, James. I Tweeted it. Thanks.
I recently saw an allergist that I liked quite a bit but during 90% of the time allotted he was busy entering data on the EHR. I’m sure he would have preferred not to be wasting time with it and engaging in more face to face contact but it was a requirement.
I can imagine any young physician with a high school background in programming has to be completely frustrated with the abject stupidity of EHR. It is well known in IT circles that the worst programmers often end up in medical IT.
I review a lot of medical records doing forensic cases and in the past twenty years they have gone from illegible to inane. Kaiser records are particularly wasteful and I seem to be constantly reminded every five pages that the patient does not smoke. You have to really dig to figure out what the doctor was thinking because most of it is repetitive checklist and endless dupblication. I remember in training we used to have process notes during therapy…these are pretty much nonexistent today.
Any IT that makes a task harder/slower or requires more people (scribes) is bad IT.
Looks like a case of classic trickle down economics to me –
Full marks to psychiatry for innovating the highly profitable check list and screening tool 😉
I’m still getting over the fact that the PHQ-9 was “developed” “with a grant”.
Pretty soon parrots will be asking for grant money before saying Polly Want a Cracker.
In fairness to the prevention task force, the guidelines repeatedly say adequate resources must be available to clinically evaluate and treat (if indicated). They do not advocate treating just off the results of the PHQ-9. As a screening tool the PHQ-9 is scaled such that a score of 15 has an 85% likelihood of meeting diagnostic criteria for moderate severe major depressive disorder. But it is not a diagnostic tool. They recommend people that screen positive be fully evaluated by competent clinician. They also recommend treatment provided by appropriate trained providers. This could be viewed in a positive light, as a step forward for destigmatization, for greater clinician availability and for putting reimbursement on equal footing with other chronic medical conditions.
Steve Garlow, I hate to be the voice of negativity but what you are stating should happen doesn’t occur most of the time. And by the way, do you really think clinicians would ferret out other conditions that can masquerade as depression when it alot easier to throw a drug at the problem?
Dr. O’Brien, you are right on target with your points. One reason I am switching PCPs, is I got tired of having a mysterious functional questionnaire shoved down my throat online before every routine visit that had nothing to do with my concerns. That wasn’t the only issue I had but I felt like my former PCP, while she had good intentions, was forced to operate in what you refer to as a distracted mode.
Finally, this is a true story. After I had minor surgery last year and was taken to my room, the admitting nurse asked if I was suicidal as I guess she was required to do. Needless to say, I was speechless. I guess the next step will be to ask the question before surgery and yes I am being sarcastic.
Screening for Depression is promoted by several groups
one group is” Mental Health America (MHA) – founded in 1909 – is the nation’s leading community-based nonprofit dedicated to helping Americans achieve wellness by living mentally healthier lives”
the state their advocacy as follows”
“MHA Screening: Understanding your mental health and learning about where you are in your mental health is essential in ensuring you stay mentally healthy. One of the quickest and easiest ways to determine whether you are experiencing symptoms of a mental health condition is to take an anonymous screen. MHA has online screening tools for depression, anxiety, bipolar disorder, post-traumatic stress disorder (PTSD), alcohol and substance use, early psychosis, work health, as well as screenings that are youth-focused and parent-focused. After completing their screening, individuals receive immediate results, education, resources and linkage to affiliates. Along with the results of their screens, individuals provide MHA with valuable demographic and survey responses that allow us to further support our mental health policy and education efforts.
To date, depression screens account for more than half of the screens completed. Of all respondents, 67 percent scored moderate to severe for any of the conditions, and of those, 65 percent report they had never been diagnosed. These statistics demonstrate the need to promote early education and intervention. As MHAScreening.org expands, MHA will continue to explore ways to respond to the needs of screeners by adding public education and treatment information in collaboration with national partners. Our goal is to get every American screened and aware of their mental health as a way to promote recovery and reduce the time of untreated mental health problems.”
their has been and continues to be a well funded advocacy campaign to promote depression screening… a “push” marketing strategy funded by Pharma? Insurers?
another group that advocates Depression Screening is the Anxiety and Depression Screening Association of America
from their website
ADAA is a national nonprofit organization dedicated to the prevention, treatment, and cure of anxiety and mood disorders, OCD, and PTSD and to improving the lives of all people who suffer from them through education, practice, and research.
Screening for Depression
If you suspect that you might suffer from depression, answer the questions below, print out the results, and share them with your health care professional.
this page contains the PHQ-9 and encourages people to complete the form
this is displayed below the survey form
Reference
Based on Patient Health Questionnaire-9 (PHQ-9) Developed by Drs. Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc
.
Just one more thing for my PCP to do after he ascertains my gravida and para status….and confirming I don’t smoke one more time…cuz that’s on everyone’s check box
All of the above post makes sense…after all the copy and paste (development) of the PHQ-9 was done with a bribe (grant) from pharma
This post was developed by a grant from Valeant, makers of Addyi (please do not drink alcohol while attempting to increasing sexual arousal, although this was a common 20th century practice).
What would you like to see if you had your druthers?
I work in an institution that is trying to employ a collaborative-care kind of model. Where PCPs do the prescribing but they consult with a psychiatrist, and they work with a non-licensed person who is trained to do behavioral activation therapy and administer the PHQ-9.
I don’t worry that much about the guy who does it at the practices, I’m familiar with. He’s smart and thoughtful and will probably go to grad school in psychology. He’s only supposed to work with people with mild to moderate depression, but the PCPs frequently use him to facilitate access to psychiatric care – so getting someone with a serious psychosomatic illness, who is burning through specialists, in to see a psychiatrist. But a fair number of patients who have been diagnosed by their primary care docs as having mild-moderate depression have quite a lot more going on – most often substance abuse but also cutting. He promptly refers them to the right level of care, though getting them in can be hard.
Personally, I’d feel better training psychologists in psychopharmacology and having them, rather than PCPs, prescribe psychotropics to the medically uncomplicated. (I’m sure I’ll get a lot of blow back on that.)
What I would advocate for, is a kind of annual visit with a psychologist that’s comparable to an annual with an internist. Someone who can track your mental health over time, encourage good care and know patients so that if things start to go awry, either that general practitioner or a different kind of specialist can be called in quickly. So, say, if a young person starts to develop psychosis, it can be watched for a while, and if it really does get serious, there’s already a mental health professional in the picture that s/he has known for a long time and trusts.
We overscreen for depression and overprescribe, but a lot of the patients with much more serious illnesses are falling through the cracks.
Mickey, what would you advocate instead of the questionnaire-based screening to help those who are not getting care get it?
And “yes!”, to your last point about feeling unseen when asked the questions in the PHQ-9. The person I know doing this work defers the PHQ-9 screening as much as possible, and always says that he knows it’s a hard thing to do. One woman said that she didn’t like taking the questionnaire, because it made her think about how unhappy she was.
I am now seriously considering the idea that the best way to train for real psychiatry today is medical school-flex internship (to prescribe)-Ph.D psychology. What does a psychiatry residency bring to the table that a Ph.D. program doesn’t anymore? Other than eventually having to do the task in 15 minutes instead of 50.
No, you don’t need three years to learn how to prescribe SSRI/SNRIs, SDAs and mood stabilizers, so let’s just stop with the charade. For those who say you do, then why are you OK with GPs prescribing 80-90 percent of those drugs and 100% under collabo-care?
JOB- that’s what I would do with the caveat that I think elderly people should be treated by geriatric paychiatrists. I also worked on a unit at a state hospital for medically complex patients with a psychiatrist and an internist (who had initially trained as a psychiatrist.). That psychiatrist used all of his medical knowledge – because he had lifers with schizophrenia who were on dialysis. But that’s the exception and not the rule.
I’m concerned that people are going to be diagnosed after a positive screen. I have noticed that the PHQ-9 isn’t just used for screening, it’s also being used for diagnosis. The original validation looked at the number of 3s (I think) a person checked, but most questionnaires look at the number of 2s and 3s a person checks or the total score. As someone who started out as a bench scientist and then moved into healthcare, to me this seems like bad practice. Until you have systematically validated the new scoring scale, you can’t really know how accurate it is.
I also frequently see it used to classify severity. Given that with some scales it’s possible to score in the moderate depression range without meeting the DSM criteria for depression, this is iffy at best. I’m not convinced that quantifying severity based on the frequency of symptoms is a good idea — people who are severely ill are probably going to have symptoms every day but there’s a difference between hour sleep deficit and a two and a half hour sleep deficit but it will score them the same if they occur with the same frequency. Given that most treatments have been validated using the HAM-D scale, assuming that an antidepressant would be superior to placebo in a patient with PHQ -defined severe depression is not necessarily a logical assumption.
It is also being incorporated into quality measures. It’s being pushed as an initial severity rating and possibly to measure treatment progress. The PHQ-9 was chosen over HAM-D because it’s easier to administer. I can easily see people with very severe depression having steady PHQ scores while the HAM-D scores drop. Using less accurate test because it is easier just doesn’t make sense. We don’t tell diabetics to monitor their blood sugar by testing their urine rather than blood simply because urine is easier to collect than blood.
Screening everyone for depression doesn’t make much sense if you’re going to make a diagnosis using criteria that are not particularly accurate and then monitor their progress using the same not so accurate methods.