Depression Prevalence and Other Checklist Limits

I finished reading a paper last night about estimating the prevalence of depression using the PHQ-9 (1). The paper had 76 authors including one of the most well recognized epidemiologists in the world. It was focused on the differences in estimating depression prevalence using a structured research interview specifically the SCID (Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders versus the PHQ-9 - a nine item checklist based on the DSM criteria for major depression. If you ever need a reference paper for how to write an epidemiology paper based on a literature search this is probably a good one to have.

The authors did an extensive literature review in the end found 44 (n=9,242) studies that looked at comparisons between the PHQ-9 and the SCID.  The result was that the pooled results showed that depression prevalence estimates with the PHQ-9 (total score ≥ 10) were about 25% and for the SCID it was 12%.  Modifying the criteria for the PHQ-9 to a score of ≥ 14 and using a separate PHQ-9 diagnostic algorithm resulted in a lower prevalence estimate but a wide margin of error.  The authors conclude that structured interviews are the best approach to prevalence estimates largely because they are closer to clinician style interviews and through clarification, they can limit confounding variables. Nobody ever seems to comment on the restrictive aspects of both checklists and structured interviews.  After all,  DSM criteria that are embedded in the matrix of questions and elaborations in the SCID are basically converted to nine unidimensional questions in the PHQ-9. It should be obvious that there would be a correlation between the two when the PHQ-9 is validated against the SCID, but instead it is accepted as an academic exercise.

The first thing I thought about when I saw these numbers and read the paper was “even the SCID prevalence figures are too high”.  I base that on numbers available in a standard textbook on psychiatric epidemiology (2).  Reviewing much larger sample sizes across 25 countries yields one-year prevalence figures for depression of 2.6-10.3% (median 5.3%) lifetime prevalence figures of 2 to 16.2% (median 8.6%). In that table the variation in very large community samples ranging from 5000 to 42,000 subjects in the United States seem to depend on the research methodology more than anything and structured interviews other than the SCID were used.

The selected samples from reference 1 are detailed in table 1 and very few of them are community samples. They are relatively small outpatient samples of identified medical patients or people seeking medical services for themselves or another person. Many of the conditions have known comorbidity with depression. The authors list this as a study limitation particularly “where the presence of transdiagnostic somatic symptoms and adjustment to illness or injury may have contributed to error variance”.  They also comment on the heterogeneity of the study settings and how that might affect the data. That is certainly my concern for post stroke patients, multiple sclerosis patients, Parkinson’s disease patients, epilepsy outpatients, and other neurological conditions for depression is a common comorbidity. The implicit message from this paper is that depression prevalence estimates from clinical samples will be higher than estimates from epidemiological community surveys.

But there is a much larger lesson here than differences in depression prevalence estimates based on methodology or clinical sample. For me the heart of the matter is the difference between a psychiatric interview, a structured clinical interview, and a checklist.  I have expressed my concerns over the years that checklists are currently surrogates for psychiatric interviews and I can confirm this on a weekly basis. Most the patients I see have seen primary care physicians or nonpsychiatrists and they tell me how they are given a PHQ-9, a diagnosis based on that rating scale, and a prescription. That model of care is promoted by some organizations as “evidence-based medicine”. In some cases it is called “measurement based medicine”. The state of Minnesota for example has a project were all PHQ-9 scores are collected from any clinic treating patients with a diagnosis of major depression. This was supposed to be some kind of quality measure even though an analysis of all the cross-sectional data has never been done.

When I talk with people who have taken these checklists and asked them about depression it is common to hear the question “What do you mean by depression? I am still not sure about what that means and the difference between depression and anxiety.” I hear those questions from people who have been filling out the rating scales and getting medications prescribed to them based on those scores and yet they are uncertain about the concept of depression. How can that happen?

The obvious way is by limiting choices. If a nine-item checklist is given to a person and they are told to answer a specific question as one of 4 choices, most people will check a box.  In the case of the SCID – there is more elaboration.  People are asked about whether there was a time in the last month when they felt “depressed or down most of the day nearly every day?”. They are asked to elaborate and whether or not it affected their interest or pleasure in activities. They are asked if it lasted as long as two weeks. At that point there is a qualifier that says the interviewer is not supposed to include symptoms “that are clearly due to a physical condition, mood-incongruent delusions or hallucinations, incoherence are marked loosening of associations, or that are clearly part of the residual or prodromal phases of schizophrenia”. Additional questions about symptoms of the depressive syndrome follow.

Many clinics use electronic health record (EHR) templates that include checklists about all of the major classes of psychiatric syndromes. They are a variation on the SCID but they generally result in more spontaneity and elaboration than a checklist but not as much as the structured interview. What is lost along the way?  I would suggest – a lot.

The rationale for structured interviews is reliability or consistency in responses.  If any population is given a matrix of the same questions to differentiate different conditions – no matter how exhaustive - there will be a pattern of responses that has internal consistency. Viewed from that perspective, the PHQ-9 is just a very abbreviated and less specific version of the SCID – hence the difference in prevalence estimates.

Although prevalence estimates are often the focus of criticism (too high, too low, just right) what is typically missed is that they really have limited application to good clinical psychiatry. Psychiatrists do not do SCID interviews on patients and the reasons may not be that apparent. Psychiatric diagnoses depend on a lot more than a symptom checklist and the total time to administer a SCID (2-3 hours) is prohibitive. There is also a question of efficiency.  In practice the psychiatrist has to be able to focus on all relevant aspects of the identified problem not areas that are not considered to be a problem.  Most importantly – the psychiatric interview needs to recognize that the person in the conversation has a unique conscious state that is interpreting their emotional, cognitive, and physical experience. The psychiatrists has to understand how that is happening.

There is probably no better discussion of this crucial aspect of the interview than that provided by Nordgaard, Sass and Parnas (3). These authors use the term “a conversational, phenomenologically oriented interview, performed by am experienced and reliability-trained psychiatrist.”  as the more optimal and preferred approach.  After reading their work, I realized that it is what I have been doing for the past 35 years.  In a more recent article, this group has compared American phenomenology to a simple study of signs and symptoms and suggested their use of the term is more consciousness based:

“It refers to a faithful exploration, description, and conceptualization of the patient’s contents and structures of subjective life and modes of existence (eg, not only the content of the delusion but its mode of emergence and articulation and ways of experiencing the delusion)” (4)

They suggest this requires an interview that maximizes self-description and a knowledgeable physician with a “rich conceptual repertoire”.  Since the DSM approach is intentionally atheoretical – it speaks to the need to be trained in a variety of psychopathological theories.  Andreasen (5) has previously written about the death of phenomenology as being an unintended consequence of the DSM approach.  In my experience it is easily approached in residency training as the need for a empathy based formulation that makes sense to the patient.  In their article (3) the authors provide a table comparing what is elicited with a structured interview as opposed to a phenomenologically based conversational interview.  In the table below I provide my own example for a patient with depression. I will add that in most electronic health records these days there are templates that are essentially structured interviews requiring brief responses and very little discussion about the process or content of those responses. Those templates are further limited by the fact that all of the information needs to be entered by the psychiatrist doing the interview - a further inefficiency.

Structured Interview	Conversational Interview
She has been depressed all of her life with very few periods of neutral mood. The depression includes periods of extreme irritability.  The depression worsens from time to time.	She had had long term depression but it is clearly worsened in specific contexts. There are situations that specifically make her anxiety worse and when this happens, she “spirals down” into a depression and will often spend the entire weekend in bed. A lot of these episodes are associated with a stressful job and a specific interpersonal conflict at work.
She describes a motivational deficits and anhedonia.	During the episodes of worsening depression and isolation – she watches TV all day long. She is not motivated to exercise but occasionally will push herself to go for a jog. She was the high school state record holder in the quarter mile. Even though it is initially difficult she feels much better afterwards and the activity reminds her of the importance of exercise in her life and how she used to work out in high school.
Decreased concentration and memory problems	She has had life long concerns about her memory and at one point considered “getting tested” for ADHD. She got a degree in molecular biology and graduated summa cum laude. She is currently working in a professor's lab and thinking of applying for a PhD program. She has no problem reading and retaining information from highly technical journals and devising lab protocols or her favorite science fiction. She attends meetings where her mind wanders.
Depressing thoughts	“I am a perfectionist and am my own worst critic.” She was encouraged from an early age to get A grades in school and had a nearly catastrophic reaction when she got a B in high school.  She still remembers that teacher who told her that getting a B would be “good for her”. Her parents were always critical and she realized at some level she has internalized some of these criticisms especially when it comes to body image and weight: “I don’t think being petite and wearing the latest fashions makes me a better scientist”. Despite fairly constant self-criticism it never gets to the point where she feels worthless.
I have some suicidal thoughts but have never made a suicide attempt or an attempt to hurt myself.	“I read a journal article somewhere that looked at the prevalence of suicidal thoughts and they are fairly common.” She describes intrusive thoughts about suicide that are obsessional in nature. “I drive across this bridge every day.  If I am having a bad day, I think about cranking the wheel at the half way point and driving off. But I know I will never do it.  I am too chicken and I have too much going for me.  I want to hang around and see what happens.”

The conversational interview is information rich and allows for more extensive pattern matching.  The PHQ-9 and even the SCID describes a very limited pattern or as Kendler (6) describes indexing of major psychiatric disorders.  That is the primary (and limited) intent of the DSM.  But Kendler points out that it is really a jumping off point for the additional study of psychopathology.  I would also point out that it ignores what is the elephant in the room for psychiatrists – human consciousness.  Consciousness in psychiatry tends to be mentioned only when it is grossly impaired rather than existing as the every day moderator of everything.

When the additional pattern matching takes place, the only real limit is the interviewer’s ability to recognize it and what it means. In the ideal world that should lead to further elaboration of the patient’s concerns, education based on the psychiatrist’s understanding of the general problem and more specifically how it affects the unique patient, and specific treatments that have worked before.  It can extend to a unique approach to the associated DSM disorder that would not have been possible with a highly structured interview.  One of the best examples I can think of are life long sleep problems that become anxiety and depressive disorders as an adult – because the development of those disorders and the sleep disorder is not covered in detail.  There are a lot of examples.

In closing this post, prevalence estimates for psychiatric disorders vary greatly.  That is the expected result of the screening methodology that includes the instrument used, the population sampled, and the prevalence of the disorder being screened in the population. Very basic screens like checklists used as a proxy for diagnoses will have the highest prevalence estimates. More comprehensive structured interviews will be somewhat lower. The gold standard for epidemiological work (structured interview) is not the gold standard for clinical work (the semi-structured phenomenologically oriented interview).  It is also the reason psychiatrists need to know psychopathology, phenomenology, and case formulations based on those disciplines.

George Dawson, MD, DFAPA

References:

  

1:  Levis B, Benedetti A, Ioannidis JPA, et al. Patient Health Questionnaire-9 scores do not accurately estimate depression prevalence: individual participant data meta-analysis. J Clin Epidemiol. 2020;122:115‐128.e1. doi:10.1016/j.jclinepi.2020.02.002

2:  Hasin DS, Fenton MC, Weissman MM.  Epidemiology of depression disorders. In: Tsuang MT, Tohen M, Jones PB, editors.  Textbook of Psychiatric Epidemiology, Third Edition. West Sussex: Wiley Blackwell, 2011: 289-309.

3:  Nordgaard J, Sass LA, Parnas J. The psychiatric interview: validity, structure, and subjectivity. Eur Arch Psychiatry Clin Neurosci. 2013;263(4):353‐364. doi:10.1007/s00406-012-0366-z

4:  Parnas J, Zanderson M. Rediscovering disordered selfhood in schizophrenia. Psychiatric Times.   Jun 08, 2020

5:  Nancy C. Andreasen, DSM and the Death of Phenomenology in America: An Example of Unintended Consequences, Schizophrenia Bulletin, Volume 33, Issue 1, January 2007, Pages 108–112, https://doi.org/10.1093/schbul/sbl054

6:  Kendler KS. DSM issues: incorporation of biological tests, avoidance of reification, and an approach to the "box canyon problem". Am J Psychiatry. 2014;171(12):1248‐1250. doi:10.1176/appi.ajp.2014.14081018

Collaborative Care Just Gets Worse.....

I am a long time opponent to the expansion of the collaborative care model and have explained why in earlier posts on this blog.   At the Minnesota Psychiatric Society (MPS) conference last week, I learned that the collaborative care model had expanded to more than just the treatment of anxiety and depression.  The presenter discussed an expanded model to treating bipolar disorders based on questionnaires based screening for that disorder.  The overriding rationale for this model is that psychiatrists can't possibly see all of the patients with mental illness, therefore a more  hands off approach to care was acceptable.  The presenters were very explicit about the model not involving direct patient care in the primary care clinic.  The concern is the psychiatrist would start to to develop their own practice in the clinic and within several months their schedule would be full and they would have no capacity to see anyone else.  I can say from my experience that a primary care examination room is the wrong setting to do psychiatric consultation.  At the minimum a psychiatrist needs a service where they can take detailed notes.  Scribes are apparently on the rise these days.  I would be be very concerned about the training necessary for a scribe to record the details that I consider to be important and remain in the background during the interview.  I am a purist and believe that another person in the room produces a different interview.

The argument about expanding the collaborative care model fails at the level of the total number of psychiatrists and the total number of people needing care by psychiatrists.  Being medically trained I have always defined those people as having the most severe forms of mental illnesses.  That is the essence of having a defined number of physicians for any population and it works very well for other specialties.  The ones I have written about here include ophthalmology and orthopedic surgery.  Despite having fewer physicians available, both of these specialties cover a much larger spectrum of eye, bone, and joint disease and trauma.  They are seeing a larger number of patients and in many cases performing lengthy operative procedures on these patients.

The collaborative care model has rapidly evolved in the hands of the APA from the Diamond Project of about a decade ago.  The original Diamond Project involved collecting PHQ-9 scores in primary care setting and having case managers remain in touch with patients for supportive counseling and to review the progress of patients based on those scores with psychiatrist.  The psychiatrist recommended medication changes in order to improve treatment of the depression and improved PHQ-9 scores.  The state of Minnesota took this one step further and decided to implement widespread reporting of PHQ-9 scores from all primary care clinics as part of an accountability initiative called Minnesota Community Measurement.   Lacking any scientific or statistical merit did not slow down the politics of the least accountable (politicians) holding the most accountable (physicians ) - even more accountable.  At least one group of experts has come out against the idea of depression screening, because using the current models it eventually equates to more antidepressant exposure.  That has not slowed down health plans in the state of Minnesota or national organizations that essentially represent health plans. So far, I am unaware of any reporting of PHQ-9 changes.  I sent the project an e-mail about 5 years ago pointing out that their statistical approach was meaningless on a longitudinal basis - so it will be interesting to see what they eventually report.      

The course presented was Applying the Integrated Care Approach: Practical Skills for the Consulting Psychiatrist.  It was presented as an official American Psychiatric Association backed course and part of the Transforming Clinical Practice Initiative.  Since I have never heard of this initiative before I just assumed it was another in a series of top down decisions by an organization that I thought was supposed to support its members.  I would include the very unfavorably rated Maintenance of Certification initiative to be another in that series.

I will proceed to the end product to illustrate the general feel of this course for experienced psychiatrists.  Every psychiatrist has had on-call experience.  During those times it is common to be operating in a decision-making environment where there is either inadequate or partially adequate information to make a decision.  An example is being on call and admitting patients by some combination of phone calls or internet network connections or both.  A new patient comes in at 10 PM, it is impossible for the psychiatrist to get up and drive to the hospital to do a comprehensive admission evaluation on each patient, so temporary orders are given over the phone, until the staff psychiatrist can see the patient and refine the process in the morning.  In the uncomplicated process, this is an easy task.  The healthy patient comes in taking fluoxetine 20 mg.  The medication is continued until the next day.  But things can get much more complicated in a hurry.  What happens when you are asked to write the on-call orders for a bulimic patient with depression on bupropion who may be in alcohol and benzodiazepine withdrawal?  Or the patient who has been on escitalopram, using methamphetamine, and is complaining of some symptoms of serotonin syndrome?  What happens when a sixty year old patient comes in taking 10 different medications for hypertension,  diabetes mellitus, and atrial fibrillation?  Medications need to be modified or held and significant additional plans need to be implemented.  These are the kinds of calls that you will be making in the APAs integrated care model.  The only difference is that they will be strictly regarding psychiatric medications, but they will be all of the medications and more than just antidepressants and anxiolytics.  You must be prepared to treat bipolar disorder by proxy on partial information and assume the primary care physician has the skill set to take it from there.

 The screening instrument for bipolar disorder is the CIDI-3 developed by the World Health Organization for lay screening of large populations.  I had absolutely no luck in locating CIDI-3 anywhere on the Internet or the WHO website.  I was able to locate this Harvard site containing containing what appear to be numerous sections of the Comprehensive International Diagnostic Interview (CIDI).  To anyone familiar with structured interviews (DIS, SCID, SADS, etc) it is a the same technology.  The CIDI-3 screen described in the PowerPoint for the course had two stem questions - one for euphoria and one for irritability.  Neither of them matched my stem questions due to a lack of duration criteria and no rule outs for medical or substance use problems.  It is also not clear about how a consulting psychiatrist is going to learn about the pattern of illness from these screens.  The it seems that the precedent set by the PHQ-9 and GAD-7, that a positive screening equals diagnosis - also applies in this case.      

As I thought about all of the work that is involved in the quality treatment of bipolar disorder, I asked myself about whether all of that work and all of the necessary information transfer to the patient and family can be accomplished in a primary care setting.  There is also the idea that a medication cures the problem.  Although bipolar disorder is undoubtedly one of the most biologically based psychiatric disorders, it takes plenty of skill in managing side effects, associated symptoms (especially anxiety and sleep), and additional supportive psychotherapy.  There is also the issue of assessing suicide potential and generally functional capacity including risk for aggression but most importantly the ability to care for oneself.  In psychiatric practice - each of those dimensions amounts to an additional primary care visit.  All things considered, I don't see bipolar disorder or any type being assessed and managed well in primary care settings with a psychiatrist phoning it in.  The lecturer in this case had ample justifications - but to me that is all a reaction to excessive and continued rationing of psychiatric services.

And speaking of rationing - the money was discussed.  First - the psychiatrist in these consultations does not submit any billing.  The primary care clinic submits a collaborative care billing code and then they reimburse the psychiatrist.  At no point in my career as a physician employee have I ever seen an exchange like this occur where an administrative fee was not tacked on - just for the purpose of cutting the check I guess.  Second - there is all sorts of hype about how these arrangements save money in primary care settings.  Since managed care stole the field of medicine 30 years ago - there are ad nauseum articles written about cost-effectiveness.  To me it is just another buzz word for managed care.  There is no reason to expect that treating severe psychiatric disorders should be any more cost-effective than treating severe non-psychiatric medical disorders - in fact, one often leads to the other.  The lecturer in this case was very honest about that.  He pointed out the two studies that claimed costs savings and bluntly said that he doubted that would apply to clinical situations.

All things  considered, collaborative care continues to leave a bitter taste  in my mouth.  It translates to second class care for psychiatric patients based on managed care rhetoric.  The argument can be made that these are not psychiatric patients - but primary care patients who would never see a psychiatrist.  I don't know  if that is really a legitimate argument or not because it comes down to legal and political convention rather than professionalism.  In that case it depends what faction ultimately "wins."  The APA has clearly adopted it and it openly promoting it.  At the end of this course, there was the doubly ironic offer to enroll in an online collaborative care course that would result in both CME credits and also MOC credits for maintenance of certification.

I don't know how covering call suddenly becomes psychiatric innovation.


George Dawson, MD, DFAPA


Reference:

1:  John Kern.  Applying the Integrated Care Approach:  Practical Skills for the Consulting Psychiatrist.  Presented at the 2017 MPS Spring Scientific Meeting; Thursday June 15, 2017 at 1:00-5:00 PM.


Supplementary:

Above image is from National Severe Storms Lab (NSSL) web site and reproduced here per the NOAA intellectual property notice.

More Than 9 Questions About Sleep

I was just thinking about the PHQ-9 and it widespread use in managed care as a metric for depression.  The idea that 9 questions are all that is needed strike most psychiatrists as a gross oversimplification.  There has been plenty of debate over the years about the diagnostic criteria and waht should be included.  Kendler recently wrote an excellent paper on the fact that the diagnostic criteria as they stand in the DSM really indexes disorders rather than diagnosing them.  Some recent blog posts have looked at real patients and what is happening with them when they appear to have an elevated PHQ-9 score but are not depressed.  Past markers of psychiatric disorders like the dexamethasone suppression test had had to withstand more rigorous testing than the PHQ-9.  And lastly, the literature to support it seems to reflect the literature that justified managed care - a business concept with no basis in science or medicine.

And then I had the thought: "During an evaluation I ask more than 9 questions about sleep on the average."  By comparison the PHQ-9 has one question.  That question is:

3. Trouble falling or staying asleep, or sleeping too much?  
[Not at all] [Several Days] [More than half the days] [Nearly every day]


There are more complex sleep questionairres.  The Pittsburgh Sleep Quality Index (PSQI) and Functional Outcomes of Sleep (FOSQ, FOSQ-10) are good examples.  I thought I would tabulate my questions here.  Sleep disturbance can be a primary disorder independent of any psychiatric problem.  Sleep is also comorbid with many if not most psychiatric problems.  Most people do not recover from a priamry psychiatric disorder as long as their sleep is disturbed.  Sleep disorders can antedate the onset of mood and anxiety disorders by years and for that reason I think it is important to determine if the sleep disorder is primary rather than part of the mood or anxiety disorder.  That cannot be determined by a brief cross sectional look that considers all current symptoms as part of a mood disorder.  So during my standard evaluation I ask people the following questions about their sleep not necessarily in the following order:

When you were a kid in middle school or high school did you have trouble sleeping?
Did you have nightmares back then?
Did they occur early in the night or later in the early morning hours?
Did you sleepwalk?
Did anyone ever tell you that you had sleep terrors?
Did your sleep problems from childhood ever resolve - have you ever slept normally since then?


Do you work at night?
Do you do shift work where the work time changes?
Do you currently have sleep problems?
Do they occur when you try to fall asleep?
Tell me your experience of trying to fall asleep - what gets in the way?
Any idea how long it takes you to fall asleep?
Have you had sleepless night where you could not sleep at all?
Do you wake up off and on all night long?
Do you wake up early in the morning - like 4 or 5 AM and find that you can't fall asleep?
Is your sleep restorative - do you feel rested the next day?
Do you snore?
Have you ever had a sleep study?
Have you been diagnosed with a sleep disorder?
Do you take alcohol or any medication to help you fall asleep?
Do you take in many caffeinated beverages during the day as coffee, soda, tea, or energy drinks?

That is about 20 fairly basic questions about sleep.  It is a framework that requires elaboration.  Just the issue of sleep studies these days can lead to details about parasomnias, related surgeries, sleep disordered breathing diagnoses, restless leg syndrome, and all of the associated treatments.  For the pupose of this post that is about 18 questions or twice as many as the total on the PHQ-9. It should be apparent that severe sleep problems can lead to a score considered in the depressed range on the PHQ-9 by adding up the scores of questions 1, 3, 4, 7 and 8.  Critical distinctions need to be made between sleep problems, anxiety disorders, mood disorders, addictions, and also the excessive use of an adult attention deficit-hyperactivity disorder diagnosis.

This brief exploration should point out the problems with a screening versus a diagnostic evaluation.  If you are given a PHQ-9 or GAD-7 (for anxiety) in your primary care clinic that score alone is insufficient as a basis for a treatment plan for depression.  A person repeating the questions as confirmation does not constitute a diagnostic evaluation.  By itself it does not mean that an antidepressant prescription is indicated.

Ask that person how they know that you have depression and not a sleep disorder or something else.


George Dawson, MD, DFAPA

"Good News - Your Care Today Was Free"

"The bad news - we don't know how to make this diagnosis".

I woke up on Monday morning with a 2 inch diameter bright red rash on the inside of my right ankle.  It was mildly pruritic (itchy).  I could not recall any exposure to insects or trauma of any kind and it did not appear to be infected, so I applied some topical corticosteroid cream and went to work.  That night at home the rash seemed very mildly improved but it still itched.  I decided to get some medical input at that point.  The usual choices in my area are the Emergency Department or Urgent Care, but recently my health plan started to offer online consultation through a combination of limited diagnoses and procedures,  an algorithmic set of questions, the ability to upload images, and consultation with a nurse practitioner.  I looked at the list of conditions they were set up to diagnose and treat, noted that "rash" was one of them and logged on.

Health care IT is still in its infancy so nobody should be surprised that it took me much longer than expected to log in to the appropriate interface.  At first the program suggested I could just use my existing login and that would also integrate previous test results and conditions into the current evaluation.  After needing to call them I established a separate login and password for this episode.  Rather than the expected details up front, the program started to ask me all of the usual questions about the rash.  There were 28 screens in all, including some that forced an answer.  That question was "What do you think is causing the rash?".  Possible answers were: insect bite, infection, allergy exposure, poison ivy, etc.  There was nothing on that list that seemed likely.  That was after all the reason I was calling in.  I could not proceed past that point without giving an answer so I clicked "insect bite".  After completing 28 screens there was a text field and I entered: "Even though I answered "insect bite" on question #8, I only did that because I could not proceed if I did not provide an answer."

Next came the expected demographic data.  I live in a town that the U.S. Postal Service never gets right.  If I list a Zip Code the wrong town name pops up.  This software was no exception.  It took me extra time to enter and reenter data that was already there somewhere in my healthcare company's database.  The final screen was the billing and financial data including credit card information.  More data that my healthcare company has know for the last five years.  At this point I am about 20 minutes into the process and it is time to upload the photos.  I had 4 photos of the ankle and the program accepted 3 of them.  Sign off occurred at the 25-30 minutes mark.  As I waited for the return e-mail or call,  I marvelled at how health care companies have transferred all of this clerical work to physicians over the last 20 years and now they are transferring it to the patient.  I just did the work of the intake person and financial person in any clinic or hospital.

In 20 minutes I got a call from the nurse practitioner.  She said that although it was clear that I had a rash, it was not a rash they could diagnose in the system.  I told her that I was applying a potent corticosteroid and she said to just keep doing that but to go into a primary care clinic and get it checked out by my primary care physician.  Within 2 minutes, I got an e-mail from them:

Dear George,

Thanks again for taking the time to talk with us on the phone. Your health and safety is our top priority. Based on the information you shared with us, we think that an in-person visit is the best way to handle this specific condition. And, please know that you will not be charged for your visit today.

We're sorry we couldn't help you this time, but please keep us in mind the next time you're feeling ill. Thanks for choosing us.


Good to know I guess, but no diagnosis or specific treatment plan.  I continued the corticosteroid and the next night after work I stopped into an urgent care clinic after work.  I saw a family medicine physician who inspected and palpated the rash, took my pulses and determined that they were good in the area, and asked me clusters of questions that were clearly designed to rule in/out various pathological processes.  His conclusion:  "Well it's not an infection and its not due to trauma, but it clearly is an inflammatory process like atopic dermatitis.  So at this point I would keep applying the corticosteroid."  He asked me for questions.  My mind was preoccupied with tales of devastating spider bites lately so I blurted out:  "This does not in any way look like a brown recluse spider bite does it?"  He laughed and said: "Absolutely not."

So what have I learned from all of this and how do those lessons apply to psychiatry?  First off, it appears that human diagnosticians are safe for now.  Keep in mind that the system is set up to diagnose and treat a restricted list of conditions that are considered to be the least complicated in medicine.  Second,  the human diagnostician's superior capabilities depend on pattern matching and that in turn depends on experience.  It reminded me of a course I taught for 15 years on how to avoid diagnostic errors and pattern matching was a big part of that.  The two examples were rashes and diabetic retinopathy.  Dermatologists were much faster and much more accurate in classifying rashes from pictures than family physicians.  Ophthalmologists are much more accurate using indirect ophthalmoscopy than family physicians using direct ophthalmoscopy in diagnosing diabetic proliferative retinopathy.  In fact, the family physicians were slightly better than chance.

The lessons for psychiatry are two fold.  Remember the idea of a restricted list of conditions that are not considered complex?  It turns out that depression and anxiety are on that list.  Even though there is no call center where you can call and complete the paperwork like I did,  it would probably not be much of a stretch to say that many if not most primary care clinic diagnoses of depression and anxiety are keyed to some rating scale.  Like the studies of Dermatologists and Ophthalmologists, there are no expert pattern matchers looking at the patient.  That can result in a diagnosis that is essentially dialed in.

The second aspect here is the design of the algorithm and its implications.  My rash algorithm had a forced choice paradigm.  I could not proceed to the end unless I picked an answer that was clearly wrong.  That is the way it was set up.  That is the problem with so-called "measurement based" care.  There is the appearance of a quantitative result.  The Joint Commission called the 10-point pain scale "quantitative" in the year 2000 with their pain treatment initiative in the year 2000.  I have spent a good deal of my adult life talking with patients about their moods, sleep and appetite patterns, and other symptoms.  The most important part of my job is coming up with a plausible scenario for their current distress.  I can say without a doubt that over half of the people I see cannot describe discrete episodes of mania or depression.  The usual description of depression I get is that it is life long with no remissions.  Certain personality characteristics predict descriptions of symptom severity in the initial interview.  Some people completely minimize symptoms and other people will flat out tell me that they do not want to discuss their inner thoughts even if they are experiencing thoughts that may place them in danger.  Map those response patterns onto a psychiatrist and hopefully that will result in a diagnostic formulation and a plan to deal with the nuances.  Map those response patterns onto a PHQ-9 and suddenly you have a number that somebody believes has meaning.   Looking only at Question 9:

"Thoughts that you would be better off dead or of hurting yourself in some way."  

Suddenly people are alarmed with the person with a personality disorder and chronic suicidal thinking or chronic obsessions involving suicidal thinking endorses "nearly every day" as their response.  We are falsely reassured when the patient who has a significant personality change and depression endorses "not at all".  We have forced them to make a choice and they have, rather than using all of the information necessary to make an evaluation.

As a discipline - we should be moving in the direction of using all of the relevant information in clinical situations and not less.  My rash today is an example of what can happen in an organ governed by much less genetic, metabolic and signalling information than the human brain.  Even in that situation a diagnosis with no clear etiology or diagnostic features can present itself.

Forcing choices reduces the information flow rather than facilitating it.  If primary care physicians find this checklist approach to diagnosing anxiety and depression useful I would see no problem with that, but it might be useful to look at the medications being used based on the PHQ-9 and the kind of impact this approach is having on medication utilization.  It also might be useful to have a seminar or two on the problem of over prescribing medications.  The correlation between overprescribing opioids and the use of a "quantitative" scale to measure everyone's pain is undeniable.

The question that applies in all of these circumstances is whether a number on a subjective rating scale is ever enough of a reason to prescribe a medication.

You already know what I have to say about that.

George Dawson, MD, DFAPA

More on Geriatric Depression and Overprescribing Antidepressants in Primary Care

A recent article in the New England Journal of Medicine adds some more epidemiological data to the issue of the treatment of geriatric depression.  The centerpiece of the article by Ramin Mojabai, MD is a graphic that is a combination of data from the National Survey on Drug Use and Health or NSDUH and the U.S. National Health and Nutrition Examination Survey or NHANES.  His central point is that the majority of people diagnosed with depression in primary care clinics do not meet diagnostic criteria for major depression.  The actual numbers for the elderly are 18% of those diagnosed with depression and 33% of those diagnosed with major depression actually have a diagnosis of major depression as assessed by rating scales or structured interviews.  The bar graphs in the A panel illustrate that most people over the age of 35 who are taking antidepressants do not meet criteria for major depression.  The opposite is true for the 18-34 year olds where antidepressant prescriptions are less than the prevalence of depression.  Panel B illustrates that the prevalence of people who were told by their clinician that they had depression and did or did not meet criteria for major depression.  In all cases the clinicians involved estimated non-major depression as being more prevalent than major depression.  Can we learn anything from these graphs?

The striking feature in Panel A is the dissociation of the total number of people taking antidepressants from the people with a diagnosis of major depression.  I can see that happening for a couple of reasons.  I would expect the number of people who are stable on antidepressant therapy to accumulate over time.  Most of them would have major depression in stable remission and would no longer meet the criteria.  A related issue is the atypical presentations of depression with increasing age.  I have seen many cases of depression presenting as pseudodementia, Parkinson's syndrome, and polyarthritis or a similar chronic pain syndrome.  In all cases, the symptoms responded to antidepressant medication but they would not meet criteria for major depression and most often the evaluation would resemble an evaluation for a medical problem.  There is also the problem of depression in the aging population who have a form of dementia.  At the upper end of this age distribution that may involve as many as 5% of the 65 year old population and they are likely overrepresented in primary care settings.  Lastly there is the problem of suicide in the elderly.  I reviewed a recent paper in the American Journal of Geriatric psychiatry that documented a decreased risk for suicide in elderly men and women who were taking antidepressants and the increased suicide risk in that group.  It is likely that many primary care physicians are concerned about that higher level of risk and this may influence prescribing for this group.  The other interesting comparison is that using different methodologies the ballpark antidepressant use in the elderly in Denmark approximates the antidepressant use on the US.  It is probably a few percentage points lower, but the study in Denmark used a more robust marker of antidepressant use (refilling the actual prescription) rather than survey questions.

The author addresses the issue of antidepressants being used for other applications like headaches and chronic pain chronic pain and states from an epidemiological perspective that two thirds of the prescriptions are for "clinician diagnosed mood disorder."  The standard used in this study of DSM major depression criteria is too strict to use as a marker for antidepressant use since there are other valid psychiatric indications that primary care physicians are aware of and treat.  Panic disorder, generalized anxiety disorder, social anxiety disorder and dysthymia are a few.  There are also more fluid states like adjustment disorders that seem to merit treatment based on severity, duration, or in many cases by the fact that there are no other available treatment modalities.  These are all possible explanation for the author's observation that the majority of people diagnosed with depression in primary care clinics do not meet criteria for major depression.

Diagnostic complexity is another issue in primary care settings.  Patients are often less severely depressed, have significant anxiety, may have an undisclosed problem with drugs or alcohol, and have associated medical comorbidity.  In an  ideal situation, a diagnosis of depression is not necessarily an easy diagnosis to make.  It takes the full cooperation of a patient who is a fairly accurate historian with regard to symptom onset and dates.  They are harder to find than the literature suggests.  The epidemiological literature often depends on lay interviewers using structured interviews like the DIS or SADS to make longitudinal diagnoses.  This approach will not work for a large number of patients and a significant number will not be able to recall events, dates, medications or prior treatments with any degree of accuracy.  With that level of uncertainty, antidepressant prescription often comes down to a therapeutic trial so that the patient and physician can directly observe what happens between them as the only available reliable data.

The  author notes that the primary intervention for depression in primary care is the prescription of antidepressants.  He talks about the ethical concerns about exposing patients especially the elderly to antidepressant drugs if it is not warranted, but he is using the major depression diagnosis here as the standard for treatment.  He makes the same observation that I have made here that mass screening for depression is not warranted based on the concern about false positives.  That stance is supported by the Canadian Task Force on Preventive Health Care.  The U.S. Preventive Services Task Force recommends screening "when staff assisted depression care supports."  My position is that screening, especially in medical populations is problematic not only from the false positive perspective but also because the screening checklist is often used as the diagnosis and an indication for starting antidepressant medications.  Screening checklists are also political tools that are used to manipulate physicians.  The best example I can think of is using serial PHQ-9 scores as a marker of depression treatment in primary care clinics even though it has not been validated for that application. As an extension of that application the PHQ-9 is used as a quality marker in clinics treating depression over time even though there is no valid way to analyze the resulting longitudinal data.

The author makes recommendations to limit the overuse of antidepressants and uses the stepped care approach with an example from the UK National Institute for Clinical Excellence or NICE.  These guidelines suggest support and psychoeducation for patient with subsyndromal types of depression.  A fuller assessment is triggered by very basic inquiries about mood and loss of interest.  Amazingly the PHQ-9 is brought up as an assessment tool at that point.  More monitoring and encouragement is suggested as a next step with a two week follow up to see if the symptoms remit spontaneously.  Medications are a third step for longstanding depressions or those that do not remit with low level psychosocial interventions.  An expert level of intervention is suggested for patient with psychosis, high risk of suicide, or treatment resistance.  That seems like a departure for NICE relative to their guideline for the treatment of chronic neuropathic pain.  In that case the referral for specialty care was contingent on a specific prescribing consideration (opioids) and the pain specialist was considered the gatekeeper for opioid prescriptions in this situation.  Antidepressants are seen as overprescribed drugs but no gatekeeper is necessary.  I suppose the argument could be made that there are not enough psychiatrists for the job, but are they really fewer than pain specialists who prescribe opioids for chronic neuropathic pain in the UK?  

This model is only a slight variation on the Minnesota HMO model of screening everyone in a primary care clinic with a PHQ-9 and treating them as soon as possible with antidepressants.  The driving factor here is cost.  With a month of citalopram now costing as little as $4.00 - there is no conceivable low level psychosocial intervention that is more "cost effective".  I have also been a proponent of computerized psychotherapy as a useful intervention and it is not likely that the Information Technology piece needed to deliver the psychotherapy would be that inexpensive.  Another well known correlate of depression in the elderly is isolation and loneliness.  I was not surprised to find that there were no interventions to target those problems since it would probably involve the highest cost.  In the article standard research proven psychotherapies were recommended on par with the medical treatment of depression, but the question is - does anyone actually get that level of therapy anymore?  My experience in assessing patients who have gone through it is that it is crisis oriented and patients are discharged at the first signs of improvement.  That may happen after 2 or 3 sessions.

I doubt that the stepped care approach will do very much to curb antidepressant prescribing.  This study suggests that overprescribing is a problem using a strict indication of major depression.  There are always problems with how that is sorted out.  I have not seen any studies where a team of psychiatrists goes into a primary care clinic and does the typical exhaustive diagnostic assessment that you might see in a psychiatric clinic.  It would probably be much more relevant to the question at hand than standardized lay interviews or checklists.  There is also a precedent for interventions to curb over prescribing of medications and that is the unsuccessful CDC program to reduce unnecessary antibiotic prescriptions.  If clear markers of a lack bacterial infection can be ignored, what are the chances that an abstract diagnostic process will have traction?

And finally the stepped care interventions seem very weak.  This is a good place for any number of professional and public service organizations to intervene and directly address the psychosocial aspects of depression in the elderly.  Public education on a large scale may be useful.  The psychoeducation pieces can be included in relevant periodicals ahead of time rather than as a way to avoid the use of medications.  Environmental interventions to decrease isolation and loneliness is another potential solution.  From a medical perspective, if the concern is medication risk every clinic where antidepressants are prescribed should have a clear idea of what those risks are and how to assess and prevent them.  Patients who are at high risk from antidepressants should be identified and every possible non medication intervention (even the moderately expensive ones) should be exhausted before the prescription of antidepressant medication.   Primary care prescribing patterns that potentially impact the patient on antidepressants should also be analyzed and discussed.  A focus on risks and side effects can have more impact on the prescription of antidepressants than psychosocial interventions and waiting for the depression to go away.


George Dawson, MD, DFAPA


Supplementary 1:  Permission and credit for the graphic:

"From New England Journal of Medicine, Ramin Mojtabai, Diagnosing depression in older adults in primary care. Volume No 370, Page No. 1181, Copyright © (2014) Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society."

Psychotherapy Has No Image Problem - Psychotherapy Has a Managed Care Problem

There was an opinion piece in the New York Times a few days ago entitled "Psychotherapy's Image Problem".  The author goes on to suggest that despite empirical evidence of effectiveness and a recent study showing a patient preference for psychotherapy - it appears to be in decline.  He jumps to the conclusion that this is due to an image problem, namely that primary care physicians, insurers, and therapists are unaware of the empirical data.  That leads to a lack of referrals and for some therapists use of therapies that are not evidence based - further degrading the field.  He implicates Big Pharma in promoting the image of medications and that the evidence base for medication has been marketed better.  He implicates the American Psychiatric Association in promoting medications and suggests that the guidelines are biased against psychotherapies.

I am surprised how much discussion this post has received as though the contention of the author is accurate.  Psychotherapy has no image problem as evidenced by one the references he cites about the fact that most patients prefer it.  It wasn't that long ago that the famous psychotherapy journal Consumer Reports surveyed people and concluded that not only were psychotherapy services preferred, they were found as tremendously helpful by the majority of people who used them.  That study was not scientifically rigorous but certainly was effective from a public relations standpoint.

The idea that psychiatry is promoting drugs over psychotherapy seems erroneous to me.  The APA Guidelines certainly suggest psychotherapy as first line treatments and treatments that are part of selecting a therapeutic approach to the patient's problems.   Psychopharmacology is also covered and in many cases there are significant qualifications with the psychopharmacology. Further there are a number of psychiatrists who lecture around the country who are strong advocates for what are primarily psychotherapeutic approaches to significant disorders like borderline personality disorder and obsessive compulsive disorder.  Psychiatrists have also been leaders in the field of psychotherapy of severe psychiatric disorders and have been actively involved in that field for decades.   Even psychopharmacology seminars include decision points for psychotherapy either as an alternate modality to pharmacological approaches or a complementary one.  What is omitted from the arguments against psychiatry is that many payers do not reimburse psychiatrists for doing psychotherapy.

The author's action plan to politically promote the idea that psychotherapy is evidence based and deserves more utilization is doomed to fail because the premises of his argument are inaccurate.  There is no image problem based on psychiatry - if anything the image is enhanced.  There is definitely a lack of knowledge about psychotherapy by primary care physicians and it is likely that is a permanent deficit.  Primary care physicians don't have the time, energy, or inclination to learn about psychotherapy.  In many cases they have therapists in their clinic and just refer any potential mental health problems to those therapists.  In other cases, the health plan that primary care physicians work for has an algorithm that tells them to give the patient a 2 minute depression rating scale and prescribe them an antidepressant or an anxiolytic.

And that is the real problem here.  Psychotherapists just like psychiatrists are completely marginalized by managed care and business tactics.  If you are a managed care company, why worry about insisting that therapists send you detailed treatment plans and notes every 5 visits for a maximum of 20 visits per year when you can just eliminate them and suggest that you are providing high quality services for depression and anxiety by following rating scale scores and having your primary care physicians prescribe antidepressants?.  The primary care physicians don't even have to worry if the diagnosis is accurate anymore.  The PHQ-9 score IS the diagnosis.  Managed care tactics have decimated psychiatric services and psychotherapy for the last 20 years.

It has nothing to do with the image of psychotherapy.  It has to do with big business and their friends in government rolling over professionals and claiming that they know more than those professionals.  If you really want evidence based - they can make up a lot of it.  Like the equation:

rating scale + antidepressants = quality

If I am right about the real cause of the decreased provision of psychotherapy, the best political strategy is to expose managed care and remember that current politicians and at least one federal agency are strong supporters of managed care.

George Dawson, MD, DFAPA

Brandon A. Guadiano.  Psychotherapy's Image Problem.  New York Times September 29, 2013.

Why A Checklist is Not A Psychiatric Diagnosis

I was inspired by a post by Massimo Pugliucci on his excellent philosophy blog Rationally Speaking, to start using concept mapping software to describe some of the things that psychiatrists do and rarely get credit for.  There is the associated problem (as I have posted here many times) of checklists being seen as the equivalent of a psychiatric diagnosis.  That has been carried to the extreme that some have said rating scales are actual "measurements" or validating markers of psychiatric diagnosis.  Any cursory inspection of the combination of parallel and sequential processes that actually occur during an interview will demonstrate that is not remotely accurate.

Click on this link for the actual concept map.  A click on the diagram will zoom it for viewing.  Another click will zoom out.  Navigate by mouse wheel or scroll bars.  It should print out onto one standard sheet of paper in a landscape view.

I am interested in feedback from psychiatrists on what aspects they would modify.  If you have suggestions about what should be modified post them in the comments section or send me an e-mail.

Concept Map

The concept map may also be useful for explaining some findings that are commonly held up as "problems" with the diagnosis such as low reliability.  A common ( and purely hypothetical) example would be the 35 year old patient with a clear diagnosis of depression as a teenager, no history of remission of symptoms and multiple antidepressant trials who develops a polysubstance dependence (alcohol, cocaine, heroin) problem who is being seen in various states of withdrawal for the treatment of depression, insomnia and suicidal ideation. At this point does the patient have major depression, dysthymia, substance induced depression, or depression due to withdrawal symptoms?  What would tell you more about this patient's problems - a psychiatric diagnosis or a PHQ-9 score?  What would be more helpful in developing a treatment plan?

This answer to that question is the difference between medical quality and a term that is frequently substituted by governments and managed care companies.  That term is "value".  Governments and managed care companies apparently believe that giving someone an antidepressant medication for a PHQ-9 score is a better value than a psychiatric evaluation.

George Dawson, MD, DFAPA

Collaborative Care Model - Even Worse Than I Imagined

I wrote a previous post about the APA backing the so-called collaborative care model and provided a link to the actual diagram about how that was supposed to work.  I noted a more elaborate model with specific descriptions of roles in the model in this week's JAMA.  The actual roles described on this diagram are even more depressing and more predictive of why this model is doomed to fail in terms of clinical care.  It does succeed in the decades long trend in marginalizing psychiatry to practically nothing and providing the fastest route to antidepressant prescriptions.

Wait a minute - I thought psychiatrists were the Big Pharma stooges who wanted to over prescribe antidepressants and get everyone on them?  Well no - it turns out that there are many government and insurance company incentives to assure that you have ultra rapid access to antidepressants even when psychiatry is out of the loop.  You don't need a DSM-5 diagnosis.  You don't need to see a psychiatrist.  If you pulled up the diagram in JAMA, you would discover that the consulting psychiatrist here has no direct contact with the patient.  In fact, about all that you need to do is complete a checklist.

Copyright restrictions prevent me from posting the diagram here even though I am a long time member of both organizations publishing them.  I do think that listing the specific roles of the psychiatrist, the care manager and the primary care physician in this model is fair and that is contained in the table below:

Roles in Collaborative Care Model

Care Manager	Monitors all patients in the practice Provides education Tracks treatment response May offer brief psychotherapy Describes patient symptoms and response to treatment to psychiatrist. Informs Primary care Physician of treatment recommendations from the psychiatrist
Primary Care Physician	Makes initial diagnosis and prescribes medication Modifies treatment based on recommendations from psychiatrist
Psychiatrist	Makes treatment (medication) recommendations. Provides regular psychiatric supervision. Has no direct contact with the patient.

  

see JAMA, June 19, 2013-Vol 309, No. 23, p2426.

As predicted in my original post, the psychiatrist here is so marginalized they are close to falling off the page.  And let's talk about what is really happening here.  This is all about a patient coming in and being given a PHQ-9 depression screening inventory.  For those of you not familiar with this instrument you can click on it here.  It generally takes most patients anywhere from 1 - 3 minutes to check off the boxes.  Conceivably that could lead to a diagnosis of depression in a few more minutes in the primary care clinic.  At that point the patient enters the antidepressant algorithm and they are they are officially being treated.  The care manager reports the PHQ-9 scores of those who do not improve to the "supervising" psychiatrist and gets a recommendation to modify treatment.

This is the model that the APA has apparently signed off on and of course it is ideal for the Affordable Care Act.  It is the ultimate in affordability.  The psychiatrist doesn't even see the patient - so in whatever grand billing scheme the ACA comes up with - they won't even submit a billing statement.  The government and the insurance industry have finally achieved what they could only come close to in the past - psychiatrists working for free.  Of course we will probably have to endure a decade or so of rhetoric on cost effectiveness and efficiency, etc. before anyone will admit that.

Keep in mind what the original government backed model for treating depression was over 20 years ago and you will end up shaking your head like I do every day.  Quality has left the building.

George Dawson, MD, DFAPA

A Valentine from the President

I caught the link to this fact sheet from President Obama a couple of days ago on the APA's Facebook feed.  In the post immediately before it, the current President of the APA is seen rubbing elbows with Bradley Cooper.  My first thought is that these initiatives are always a mile wide and an inch deep.  They provide a lot of cover for politicians who have enacted some of the worst possible mental health policy, but also for professional organizations who have really not done much to change mental health policy in this country.  These are basically non-events as in we applaud the President and he applauds us.  In the meantime, patients and psychiatrists are never given enough resources for the job and the necessary social resources keep drying up.

Since the 1970s, the political climate in the US has focused on being as pro-business as possible.  Congress practically invented the credit reporting industry and in turn that industry made it easy for businesses to change your fees based on a credit report number.  What you have to pay for home and auto insurance can be based solely on your credit rating and independent of whether or not you have ever missed a payment.  It turns out that competitiveness is little more than political hyperbole.  But the politicians in Washington did not stop there.  The financial services industry is currently a multi-trillion dollar enterprise with little regulation or oversight that has essentially placed all Americans at financial risk.  There is no better proof than the fact that there are currently no safe investments and that some advisors are suggesting that prospective retirees need as least $1 million dollars in savings and $240,000 for medical expenses in addition to whatever is available in Medicare and Social Security.   Congress's retirement invention the 401K has surprisingly few accounts with that kind of money.

How can a government that puts all of its citizens at financial risk all of the time manage the health care of those same citizens?  It is a loaded question and the answer is it cannot.  The idea that an administration has an initiative to "increase understanding and awareness of mental illness"  at this point in time is mind numbing in many ways.  We  have had over two decades of National Depression Screening Day, we have Mental Illness Awareness Week, and we have had the Decade of the Brain.  There seem to be endless awareness initiatives.  I don't think the problem with mental health care is the lack of awareness or screening initiatives.  From what you can see posted on this blog so far, it might be interesting and productive to have some media awareness events that look at the issue of media bias against psychiatry and the provision of psychiatric services.  I don't think it is possible to destigmatize mental illness, when the providers of mental health care are constantly stigmatized.

What about the issue of screening at either a national level or at the level of a health plan?  A fairly recent analysis commented that there have been no clinical trials to show that patients who have been screened have better outcomes than those who are not.  Further, that weak treatment effects, false positive screenings, current rates of treatment and poor quality of treatment may contribute to the lack of a positive effect of the screening.  The authors also refer to a study that suggests that more consistent treatment to reduce symptoms and reduce relapse would lead to a greater treatment effect than screening.  A subsequent guideline by the Canadian Task Force on Preventive Health Care agreed and recommended no depression screening for adults at average or increased risk in primary care setting, based on the lack of evidence that screening is effective.  Why in the President's fact sheet are the AMA and APA recommending screening?  Why are there people advocating for "measurement based care" and the widespread use of rating scales and screening instruments?  Why does the State of Minnesota demand that anyone treating depression in the state send them PHQ-9 scores of all of the patient they treat?

The answer to that is the same reason we have political events that add no resources to the problem and make it seem like something is happening.  Screening everywhere makes it seem like somebody is concerned about assessing and treating your depression.   It makes it seem like we are destigmatizing mental illness and making diagnosis and treatment widely available.  The Canadian papers noted above suggest otherwise.  Nothing is happening, except people are being put on antidepressants at a faster rate than at any time in history.  In a primary care clinic, medications are the first line treatment and psychotherapies - even psychotherapies that are potentially much more cost effective than medications are rarely offered.

My professional organization here - the APA has chosen to advocate for an "integrated care" model that is managed care friendly.  A model like this can use checklist screening and essentially have consulting psychiatrists suggesting medication changes on patients who do not respond to the first medication.  I obviously do not agree with that position.  Only a grassroots change here will make a difference.

If you are concerned that you might have significant depression, you can't depend on your health plan or the government when they are both advocating for a screening procedure that has no demonstrated positive effect.  If somebody hands you a screening form for depression or anxiety or sleep or any other mental health symptom, tell them that you want  to be interviewed and diagnosed by an expert.  Tell them that you want the same approach used if you come to a clinic with a heart problem.  Nobody is going to hand you a screening form that you can complete in 2 minutes.  You are going to see a doctor.  Tell them that you want that expert to discuss the differential diagnoses, the likely diagnoses and the medical and non-medical approaches to treatment including counseling or psychotherapy.

Do not accept a cosmetic or public relations approach to your mental health and spread that word.

George Dawson, MD. DFAPA

The Day the Quality Died

I don't know when it happened exactly but if I had to guess it was somewhere in the mid-1990's.  That was the time when quality changed from a medically driven dimension to a business and public relations venture. The prototypical example was this depression guideline promulgated by AHCPR or the  Agency for Health Care Policy and Research.  The guideline was written by experts in the field and there was consensus that it was a high quality approach to treating depression in primary care settings. One of my colleagues used this guideline in its original form to teach family practice residents for years about how to treat depression in their outpatient clinics. The actual treatment algorithm is listed below:

Managed care companies had a different idea about treating depression not only in primary care settings but also in psychiatric clinics. In less than a decade the standard of care had devolved to the point where antidepressants were started on the initial visit and the standard outpatient follow-up was at one month. In addition, even though cognitive behavioral therapy was proven to be effective for the treatment of depression the standard course recommended in those research studies was never used. It was common then and even more common now for depressed patients to see a therapist and be told that they seem to be doing well after two or three sessions and there is probably no need for further psychotherapy. They typically did not receive the research proven approach.

The latest innovation is to assess and treat depression in outpatient clinics on the basis of a PHQ-9 score, and have psychiatrists follow those scores and additional information from a case manager in recommending alterations in therapy for patients with depression.  Although it was never designed to be a diagnostic or outcome measure the PHQ-9 is used for both.

The current model of maximizing medical treatment of depression in managed care clinics is an interesting counterpoint to psychiatrists bearing the brunt of criticism for over treating depression with ineffective antidepressants. The recent FDA warning about prolonged QTc syndrome from citalopram is another variable that suggests there are potential problems in maximizing antidepressant exposure across a primary care population where the number of people responding to psychotherapy alone is not known but probably significant.

There is another aspect of treating depression in primary care clinics that illustrates what happens when you think you are treating a population of people with depression. The new emphasis by politicians and managed care companies is screening for early identification of problems. The political spin on that is early intervention will reduce problem severity and of course save money.  Various strategies have been proposed for screening primary care populations for depression. It reminds me of the initiative to ask everyone about whether or not they have pain when their chief complaint has nothing to do with pain.

In the Canadian Medical Journal earlier this year, Thombs, et al, concluded that the evidence screening is beneficial and the benefit outweighs the potential harm is currently lacking and that study should be done before depression screening in primary care clinics is recommended. A recent op-ed by H. Gilbert Welch, M.D. in the New York Times is more accessible in the discussion of the risks of screening.

The irony of these approaches to depression in primary care clinics can only be ignored if the constant drumbeat of managed care companies about how they are going to save money and improve the quality of care is ignored. Despite the frequently used buzzword of "evidence-based medicine" this has nothing to do with evidence at all. It is all smoke, mirrors and public relations.  It makes it seem like managed care companies can keep you healthy when in fact they have all they can do to treat the sick and make a profit.

That is the true end result when medical quality dies and politicians and public relations takes over.

George Dawson, MD, DFAPA

Thombs BD, Coyne JC, Cuijpers P, de Jonge P, Gilbody S, Ioannidis JP, Johnson BT, Patten SB, Turner EH, Ziegelstein RC. Rethinking recommendations for screening for depression in primary care. CMAJ. 2012 Mar 6;184(4):413-8.

H. Gilbert Welch.  If You Feel O.K., Maybe You Are O.K.  NY Times February 27,2012.