{"id":68829,"date":"2016-10-26T15:03:24","date_gmt":"2016-10-26T19:03:24","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=68829"},"modified":"2016-10-26T20:45:25","modified_gmt":"2016-10-27T00:45:25","slug":"the-clinic","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2016\/10\/26\/the-clinic\/","title":{"rendered":"the clinic…"},"content":{"rendered":"\n

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.<\/p>\n

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 <\/font>[Major Depressive Disorder<\/font>] criteria. A twelve step diagnosis would’ve been [Malignant<\/font>] Co-Dependency<\/font>. A family systems theorist might label her with the "Executive Daughter"<\/font> syndrome. But the Dx that I went for was "a Network case<\/font><\/strong>" [from the movie with the line, "I’m mad as hell and I’m not going to take it anymore!"]. <\/font> 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"<\/font> dx came from. She had always essentially held her dysfunctional family together as her father’s "right hand man<\/font>" – 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<\/font><\/em>," then dying and leaving her to take care of all these "crazy f___ing<\/font><\/em>" people. <\/p>\n

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<\/font>" son and drank much less himself. He said "I didn’t realize what we were doing to you.<\/font>" She dropped school ["just a way to get out of the house<\/font>"] and moved to a better job. Progress once she got her rhythm was surprisingly swift. Recently, she showed up with a "relapse.<\/font>" 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<\/font><\/em>].<\/p>\n

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The topic here is the PHQ-9<\/a> [Patient Health Questionnaire – 9 Item] [see how silly!…<\/a>, remarkable…<\/a>, simply absurd…<\/a>, PHQ-9®™…<\/a>]. The day this patient came back with her "relapse<\/font>" 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<\/em><\/font>?" 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…<\/p>\n

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[I particularly recall the "double answer" on number 9].<\/p>\n

Last week when I was talking about the Collaborative Care Model [without ever talking to the patient…<\/a>], I didn’t get around to talking about their use of the PHQ-9®<\/font> to follow the patient’s progress, to decide when to change medications, etc. Nothing I know about the PHQ-9®<\/font> 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:<\/div>\n