{"id":61852,"date":"2015-12-04T08:56:01","date_gmt":"2015-12-04T13:56:01","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=61852"},"modified":"2015-12-04T11:41:38","modified_gmt":"2015-12-04T16:41:38","slug":"a-reflection","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2015\/12\/04\/a-reflection\/","title":{"rendered":"a reflection…"},"content":{"rendered":"\n

I’m old enough to have health problems of my own so I have a physician seeing after me<\/font><\/em> [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<\/font><\/em> my patients [and appreciate being seen after<\/font><\/em>]. But last week, I had my yearly wellness visit<\/font><\/em> 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.<\/em>"<\/p>\n

So I sat down in the waiting room to do my forms. I’m the guy who actually hears the background Musak®<\/span> 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<\/font> magazines and aging US News & World Reports<\/font>]. 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<\/em>" and did some kind of memory test to look for my dementia and reviewed my "shots.<\/em>"<\/p>\n

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<\/a>. I discovered it a few years back [see PHQ-9®™…<\/a>]. 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…<\/em>" [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<\/em>" [we’re starting to see Medicaid and the ACA-insured, and with that comes a lot of "have to do this<\/em>" kind of things].<\/p>\n

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. <\/p>\n

My intuitive response to waiting room screening for mental health issues is decidedly negative. And when I read things like that article by Dr. Nemeroff entitled Getting treatment for depression is critical<\/font><\/a>  [see why?…<\/a>], I involuntarily cringe. I have a similar reaction when Dr. Insel bemoans…<\/div>\n
\n
Brain expert: Why I jumped ship to Google<\/a><\/div>\n

… 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<\/font><\/em> – 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.<\/p>\n<\/blockquote>\n

…or when I read things about the global burden of depression<\/font><\/em> like:<\/div>\n
\n
"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<\/font> medical disorders,<\/font> such as<\/font> myocardial infarction and<\/font> stroke…"<\/font><\/em><\/div>\n
VNS Therapy in Treatment-Resistant Depression<\/a> [2006]<\/font><\/div>\n<\/blockquote>\n
…but I’m aware that my examples here are skewed, two from Nemeroff and one from Insel. And that’s exactly what I was reflecting about. Have I become so jaded by looking into all this commercially or ideologically corrupted literature that I’m biased against something like waiting room screening because I see anything remotely like it as trolling<\/font><\/em>? Am I missing the possibility that it might actually be a good idea? a valid version of early detection<\/font><\/em>? I met no Buddhas on the road thinking about it on the long drive. So when I got home, I went literature diving. My first outing yielded this… <\/div>\n
\n
Screening and case finding instruments for depression<\/a><\/div>\n
Cochrane Reviews<\/font><\/strong><\/div>\n
By Gilbody S, House A, and Sheldon T<\/div>\n
19 October 2005<\/div>\n

<\/p>\n

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.<\/div>\n
Authors’ conclusions:<\/font><\/strong><\/em> 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.<\/font><\/strong><\/div>\n
Background:<\/font><\/strong><\/em> 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.<\/div>\n
Objectives:<\/font><\/strong><\/em> 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.<\/div>\n
Search strategy:<\/font><\/strong><\/em> 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.<\/div>\n
Selection criteria:<\/font><\/strong><\/em> 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.<\/div>\n
Data collection and analysis:<\/font><\/strong><\/em> 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.<\/div>\n
Main results:<\/font><\/strong><\/em> Twelve studies [including 5693 patients] met our inclusion criteria. Synthesis of these data gave the following results:<\/div>\n
    \n
  1. \n
    the recognition of depression<\/font><\/strong>: according to case note entries of depression, screening\/case finding instruments had borderline impact on the overall recognition of depression by clinicians [relative risk 1.38; 95% confidence interval 1.04 to 1.83]. However, substantial heterogeneity was found for this outcome. Screening and feedback, irrespective of baseline score of depression has no impact on the detection of depression [relative risk 1.00; 95% confidence interval 0.89 to 1.13]. In contrast, three small positive studies using a two stage selective procedure, whereby patients were screened and only patients scoring above a certain threshold were entered into the trial, did suggest that this approach might be effective [relative risk 2.66; 95% confidence interval 1.78 to 3.96]. Separate pooling according to this variable reduced the overall level of heterogeneity. Publication bias was also found for this outcome.<\/div>\n<\/li>\n
  2. \n
    the management of depression<\/font><\/strong>: according to case note entries for active interventions and prescription data, a selected subsample of all studies reported this outcome and found that there was there was an overall trend to showing a borderline higher intervention rate amongst those who received feedback of screening\/case finding instruments [relative risk 1.35; 95% confidence interval 0.98 to 1.85], although substantial heterogeneity between studies existed for this outcome. This result was dependant upon the presence of one highly positive study.<\/div>\n<\/li>\n
  3. \n
    the outcome of depression<\/font><\/strong>: few studies reported the impact of case finding\/screening instruments on the actual outcome of depression, and no statistical pooling was possible. However, three out of four studies reported no clinical effect [p<0.05] at either six months or twelve months.<\/div>\n<\/li>\n<\/ol>\n
    No studies examined the cost effectiveness of screening\/case finding as a strategy.<\/div>\n<\/blockquote>\n
    I had an odd reaction to this meta-analysis. It was so what-I-thought<\/font><\/em> that I didn’t exactly trust it, plus it was 10 years old. But I did decide that chasing this down would be worth the effort. It might take a while because this has obviously worked its way into government guidelines. So I’m going to table it for a time when I run out of other things to look into. In the meanwhile, I’m going to see how it worked its way into my clinic. If you know of some studies or why this has found its way into my doctor’s office and my clinic, I’d appreciate hearing what you know…<\/div>\n
    \n
    Note<\/font><\/strong><\/em>: One reason for tabling this until I get my bearings is that this<\/a><\/em> was the next thing I ran across [671 references!]…<\/div>\n","protected":false},"excerpt":{"rendered":"

    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 […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[5],"tags":[],"class_list":["post-61852","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/61852","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=61852"}],"version-history":[{"count":31,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/61852\/revisions"}],"predecessor-version":[{"id":61883,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/61852\/revisions\/61883"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=61852"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=61852"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=61852"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}