When and Where Does Depression End?

For the past 7 years I have been seeing patients who have been carefully selected for having an alcohol or other substance use disorder.  My task is to determine if there is an associated psychiatric disorder, whether or not it can be treated, initiate treatment, and follow up.  Most of the people I see have anxiety and/or mood disorders and determining adequacy of treatment and the actual diagnosis can be a challenge.  I have highlighted a couple of the problems in the past including a high prevalence of primary sleep disorders and the issue of people with disorders of temperament that might seem like a primary disorder but that are fundamentally different.  These distinctions are critically important in terms of when the disorder ends if it is treated.  I don't think the problem have been adequately addressed in the literature.  In many ways it is a failure to recognize that conscious states exist out there that are not easily captured by a handful of descriptors or the derivative checklists.  Checklists are frequently seen are the endpoints in clinical research.  They are used to determine if treatments are effective.

A couple of texts (1,2) describe typical endpoints for depression.  In the first reference the authors discuss the concept and how it has evolved since the 1970s from broad terms like treatment resistant to more specific antidepressant resistant or refractory.  They discuss staging methods including the Thase and Rush staging method (TRSM), the European Staging Method (ESM), the Massachusetts General Staging Method (MGH-S) and the Maudsley Staging Method (MSM).  The ratings vary in how they rate the treatment resistant dimension (antidepressant resistant,  electroconvulsive resistant, duration of trials).  The MSM is the only scale that rates multiple dimension including symptoms severity at baseline, duration and specific number of treatment failures.  Treatment resistance is a biological psychiatry based term that is not applied to psychotherapy.

Looking at what is available, there should be concerns about people being able to recall that level of detail.  I prompt people with a list of all known medications.  A substantial number of people cannot recall medication names, even when prompted.  Unless the medication regimen has been uncomplicated like: "I took fluoxetine for 10 years and then changed to venlafaxine" specific duration will not be recalled (the ESM has 5 specific intervals of treatments demarcated in weeks). Unless medical records are available for review by researchers, I would be skeptical of a large population of research subjects being able to provide the information necessary to make these classifications.

I generally try to reconstruct the history from late childhood and adolescence through adulthood.  That allows for the determination of global subtypes of depression from persistent depressive disorder or what used to be called dysthymia to discrete episodes of major depression.  When I was trained we had an entity of double depression or episodes of major depression superimposed on dysthymia.  In DSM-5 parlance that would be called persistent depressive disorder with intermittent major depressive episodes with or without current episode.  Since the diagnostic criteria for persistent depressive disorder involves having at least two of six symptoms that results in a total of 15 combinations of two symptoms.

In focusing on how to determine if the depression is gone most clinicians like myself are looking at binary outcomes.  We are treating depression until the symptoms are gone.  Research studies depend more on metrics like rating scales that are done directly by the research subjects or researchers.  Remission or partial remission is based on the scores of those rating scales.  For example, a typical psychopharmacological study would look at either the amount of decrease on a depression rating scale or where the rating scale score is relative to the established cutoff.  For example, treatment resistance could be defined as less than a 50% reduction in depression rating scale scores after a course of treatment.  It could also be defined as a failure to attain the require responder score or remission score after an adequate course of antidepressant therapy.  In primary care these days, a lot of people are diagnosed and treated with a depression rating scale - the PHQ-9.  Their PHQ-9 scores are tracked and their depression is classified as remitted if their score is 5 or less (the total score ranges from 0-27).

For the purpose of this post consider the following scenario.  I see a person back after they have been treated with an antidepressant.  In reviewing whether the medication has been working the patient reports his sleep has normalized, he is eating and exercising well, he has gone back to enjoying his previous activities, and most of his depressogenic thinking has resolved.  He no longer has any hopelessness or suicidal thinking - the original reason for the referral.  For further clarification, the discussion proceeds to the issue of dysthymia:

MD:  "Do you remember the first time we talked and you told me that you had been depressed since middle school and it had never gone away?  With the improvement you are noticing right now - do you feel like it has gone away?"
Pt:  " I am a lot better but I still feel depressed.  I would say that I am about 60-70% better."
MD:  "We have covered pretty much all of the critical symptoms for depression.  Let me ask you - what else would need to clear up right now in order for the depression to be completely gone?"
Pt:  "I guess my wife and family would need to treat me better.  I know that you can't do much about that - but that is a big problem.  If that happened I would be feeling a lot better?"

What to do about what seems to be an external factor affecting our neat little conceptualization of depression?  A typical formulation considers this to be an external factor.  A factor amenable to environmental engineering or adaptation.  Either way, the patient is still depressed despite what appears to have been a significant treatment effect.  On dichotomous analysis of depressive symptoms appear to have resolved for the most part.  He could be handed a rating scale and score in the mild to moderate range.  But the most important part of the assessment is that he still feels subjectively depressed.  In the 1970s or 1980s general systems theorists proposed that the brain is able to develop models of the environment so well that becomes an important part of any central nervous modulated process.  Motor activity provides the most obvious models.  A person walking with a cane has a much different cortical representation of what walking with a cane is than before they walked with a cane.  The cane is an actual extension of the CNS process.  You can easily demonstrate this by going through the motions of brushing your teeth without the tooth brush.  Within seconds it is obvious that you are not engaged in the same process and the parts are much more than the weight and feel of the toothbrush.  Can this exist in depression?  Can there be brain representations of relationships that are disturbed and lead to chronic depression?

I don't see why not.  Many psychiatrists would see this as a bad thing.  Many critics of psychiatry would see this as a good thing.  I see it as a brain thing.  A person would have to be fairly naive to believe that the most complex object in the universe could be parsed into a couple hundred diagnoses based on verbal criteria.  That is why psychiatrists are extensively trained.  Trained psychiatrists should be able to do much more than read the DSM-5.  I think that this is where Kendler's idea about indexing is valuable.  These are ballpark estimates of problems that need further refinement both over the course of treatment and by active research.  Formulations of these estimates can allow for successful medical treatment as well as successful psychotherapy.

These formulations can also suggest when active treatment can stop and a person can pick up the ball and start to make a lot of discoveries on their own - whether they consider themselves to be chronically depressed or not.

There is more to life than a score on a rating scale.

      

George Dawson, MD, DFAPA



References:



1: Carvalho ACCF, McIntyre RS. Treatment-resistant mood disorders. Oxford: Oxford University Press; 2015.

2: Greden JF, Riba MB, McInnis MG. Treatment Resistant Depression, A Roadmap for Effective Care. American Psychiatric Pub; 2011.

Survey-Centric Versus Customer-Centric Versus Patient-Centric

Over the past decades of managed care we have evolved from a medical model that mandated specific behaviors toward the patient to a business model that is supposedly based on customer satisfaction.  After all, the business theory is basically that satisfied customers are more likely to come back and do additional business. As any customer knows that model does break down in a number of ways.  My recent post illustrates a marked difference in the level of customer assistance available through many Internet companies over the past 15-20 years.  And yet, large managed care companies and other health care companies continue to adopt the customer satisfaction approach even when it can be demonstrated that this approach can result in increased mortality and morbidity for the satisfied patients.

It recently came to my attention that there is another variable in play that would have never been an issue in the days of patient centric care.  The best way to point it out is with the example.   Two separate people recently talked with me about their experience buying new cars.  I am going to maintain their anonymity because it could be traced back to the salesperson and have repercussions as you will see in a few lines.  New cars are high tech vehicles with an impressive array of electronics.  All of these electronics require more than a manual or a DVD.  The salesperson generally gives you an orientation to the vehicle and helps you with the preliminary setup.   In both cases that occurred taking about an hour each time.  At the end of the hour the salesperson approached with the customer satisfaction survey and said something like this:

"This is the customer satisfaction survey.  It is rated on a scale of 1 to 10.  1 is the worst and 10 is the best.  I have  to tell you that if you liked my service I would really appreciate it if you could rate me a 10.  If you rate me a 9 or lower I am out of here!  They will replace me in a month."

The first time I heard that, I thought "Incredible - this is just like the scripting that occurs at major hospitals and clinics."  Scripting is basically an exit interview set up to capture the elements of the customer satisfaction survey and inflate the scores.  The best way to get a high rating on a question about whether or not your nurse provided you with information on how to take your medication, is to have that nurse go through a standardized protocol about that right before he or she hands you the satisfaction survey.  What can you do at that point?  It just happened and it matches the survey question.  In compiling that kind of information, it should not surprise anyone when you find that all of the facilities in your area are in the 90th percentile.

I had a second thought.  I remembered the times that a patient was clearly satisfied with my work and said so right during the appointment.  Having been "scripted" about the importance of customer satisfaction at a recent staff meeting I had the thought: "Well if you really feel that way, it would greatly help me if you said that on the survey that they will send out to you on your satisfaction with my care."  I admit to thinking about it, but never said it.   I would never say it because I consider it to be a boundary violation.  Since when is it proper to suggest to a patient that they do something to advance your interests?  To my way of thinking (and the thinking of psychiatrists who preceded me) - never.  It is such a natural thought that it would not surprise me if it happens.  I think it is more likely to happen with clinicians schooled in business model of medicine.  If it was ever disclosed I can imagine that there are any number of administrators waiting to jump on it.  I can recall a physician telling me that his administrator insisted that he tell all patients coming in to see him that they need to bring in their insurance card.  He was actually reprimanded for not doing it a few times.  It only took a couple of complaints about that physician being too focused on the insurance card to get him fired by the same administrator who insisted that he should ask about it in the first place.

It is internally consistent that the MBAs who currently run America's healthcare system with seemingly little input from physicians would force the customer satisfaction issue.   They consider it a tool even though I would question its validity these days.  It seems like customer service is just common sense - why shouldn't it be rated?  There are a number of reasons.  Many ratings appear to have an unusual level of complexity.  Does it really take 10 or 20 different Likert scales or is a simple "yes" or "no" global rating better?  Clinical trials technology would suggest that there is an important role for both.  What about the manner in which the data was collected?  Should a rating that was coached by the subject who is being rating have the same validity as the rating that was not coached?  I would say no - again based on clinical trials technology.  Data needs to be collected in the same way to be comparable.  Either everybody uses scripting or nobody uses it.  There could also be a correction factor for ratings where scripting occurs.  It may result in a more realistic look at health care resources in local communities.  We also know that the way health care companies are managed has nothing to do with customer satisfaction.  One of the leading texts in how MBAs are taught shows very clearly that profitability counts and mental health services are considered the "dog" quadrant.   Are you really going to pay much attention to ratings of providers in the "dog" quadrant?  Only if you need it for leverage with those providers.  And finally does everything have to be rated?  If I am desperately searching for a way to fix my computer so that I can complete a document for a deadline, are pop-ups asking me to rate whether or not suggested fixes that did not work were helpful?  Probably not.   On the clinic or hospital rating from those questions focus on services that are peripheral to the provision of care.  How does the lack of parking or an ATM machine affect a patient's attitude toward their doctor when it comes to those ratings?

The most important consideration that nobody seems interested at all in - what is lost when we apply business ratings to physicians.  It allows us to consider that physicians are just like any other group of hucksters bound only by their ability to separate you from your money.  Caveat emptor right?  It neglects an entire system of checks and balances that have evolved over centuries from the professional relationship between patients and their physicians.  It also neglects a massive bureaucratic structure that regulates physicians and demands certain behaviors and concessions when they engage in certain types of business transactions.  Rating physicians, even with multiple Likert scales seems to put them on the same plane as the pizza delivery guy.

With the current business emphasis in medicine,  it may be that some day physicians will have the same level of responsibility as the pizza delivery guy especially if governments and business interests succeed in their efforts to erode professionalism.  Until then, I think it pays to remember that your physician is obligated to treat you in a certain way - irrespective of any rating systems.

That includes not requesting a certain rating.  



George Dawson, MD, DFAPA


Supplementary 1:  No offense to pizza delivery guys everywhere and I hope you don't have to hand out customer satisfaction surveys with the pizza.