On Monday, March 14, I woke up in the ICU after having been intubated for reasons that I won’t go into. The presenting problem had more to do with my chronic depression, but the subsequent lab work revealed massive electrolyte imbalances that could easily have induced seizures or a coma in someone not as chronically predisposed to them as I. Because of a history of depression that was the “main event” in the conversation, I was discharged with worse levels than I’d had in years (and for that matter, worse electrolytes than in previous hospitalizations for this issue... personally, I don't think the treatment effect of being surrounded by crucifixes helped).
It is not news that many Americans go to their primary care doctors first in seeking treatment for depression and other mental illness, whether because of persistent stigma attached to receiving mental health treatment or because of the greater difficulty access to services given relatively low numbers of providers and a markedly lower rate of providers accepting insurance relative to other medical practitioners.
In a sense, it’s all well and good to get that care from anyone – they have gone to medical school, done psychiatry rotations, encountered both medical and psychiatric cases in internal medicine residencies, and presumably continue to be competent physicians addressing a host of different issues (which is not to say that a physician friend in Westchester County doesn’t spent three fourths of his time addressing diabetes and high blood pressure, to which I respond in probabilistic terms given disease rates in the United States).
Deemed the “common cold of mental health,” depression leads to approximately 8 million doctors’ appointments a year, again whether because of comfort level or availability or insurance. The catch is that primary care doctors emphasize breadth over depth, whereas specialists are best equipped to address the nuances of more particular care. Thus, there are limitations in the care that even the most well-meaning practitioners can provide.
But there is a greater problem here, spanning all physicians and not just those in primary care (PCPs). What those experiencing mental illness – whether depression or anxiety – may well experience psychosomatic symptoms with which many even just having a stressful week can relate (heart palpitations, indigestion, perspiration, headache). The challenge is when we preemptively write off such symptoms in a patient who also happens to have a history of depression, especially considering that a number of those with depression also have medical illnesses as well (sometimes depression triggering worse self-care and thus issues such as type II diabetes, other times chronic illness and pain understandably contributing to depression or its worsening, and still other medical issues such as thyroid problems notoriously having the potential to induce depression in otherwise non-depressed patients. So in short, there are a lot of moving parts that make things both clinically interesting and diagnostically challenging.
And that is not necessarily doctors’ fault. Indeed, most are very well-meaning. I for one have been blessed by my doctors at New York Presbyterian. But it is not uncommon to find accounts – some anecdotal, others more systematic – of those with mental illnesses getting short shrift from physicians to whom patients are going for non-psychiatric conditions (whether reluctance to write prescriptions, being suspicious of whether it's "all in their head," etc). And again, there are reasons for those concerns, especially if there are risks of overdose in a depressed patient, even if the particular prescription is indeed valid.
The good news is that there are resources in place to facilitate productive discussions with doctors (of all specialties) about depression and its management. The bad news is that as depression spirals downhill, it becomes more and more difficult to advocate for oneself, and it’s easy to find oneself on the losing end of the battle. When at the lowest point, getting dressed can feel like a challenge in itself. Researching physician quality and medications and scheduling appointments goes beyond arduousness. (And given the noted high rates of depression and suicide among doctors themselves, this is not likely unnoticed by any parties). Having a good mental health provider is imperative if this is something with which you struggle or might be predisposed to struggle (whether from physical illness, a family history, a stressful job, such that a single trigger might be devastating). But having a good primary care provider to advocate when you cannot do so is at least as important, and it’s worth searching for one who doesn’t stigmatize reaching out, and who’s invested in treatment and feels like a safe person to go to if only in the interim until other resources are in place. We have already seen medical recommendations about depression screenings for all patients, which hopefully will reduce the stigma of acknowledging some of the symptoms on that list (that is, you’re not being singled out and asked, “You look tired today. Do you mind filling out this survey about your loss of interest and pleasure?”) and raise greater awareness to doctors of the prevalence of these symptoms in their patient populations, whether or not they meet DSM diagnostic criteria for depression (because as we can draw from pain management, it's easier to manage when caught earlier at a 6 as opposed to an all-consuming 9 or 10 ("but it goes to 11").
While doctors are – admittedly with much reason – told that when they hear hoofbeats, they shouldn’t assume zebras. That is, many ordinary diseases are in fact ordinary. But given the complexity and interconnectedness of the mind and the body, and the ways in which they can exacerbate ailments in the other, it is at least important to have more of a “zebra prevention strategy” in place (yes, I come from the San Francisco Bay Area, I have experienced one major earthquake in 1989, and you bet my bookshelves were bolted and I had an earthquake supply kit) so that doctors will be less likely to write of symptoms as physiological manifestations of depression when there could be something more at work (or to undergo expensive tests instead of making a referral to a therapist). So is the solution to run expensive batteries of tests on a mere hypochondriac? Surely not. But would it hurt is to make more open the discussion across the country (and not just major metropolitan areas where services are more available and information more easily acquired) discussions to disentangle the medical from the psychological, and their potentially numerous interactions? Surely not.
I am an academic. We are constantly learning. Doctors are constantly learning. The more that we can remind ourselves that yes we have our expertise, but we can also grow and evolve and improve (and that shortcomings in a patient case present opportunities to learn for future reference), the better off both doctors and patients will be.
It is not news that many Americans go to their primary care doctors first in seeking treatment for depression and other mental illness, whether because of persistent stigma attached to receiving mental health treatment or because of the greater difficulty access to services given relatively low numbers of providers and a markedly lower rate of providers accepting insurance relative to other medical practitioners.
In a sense, it’s all well and good to get that care from anyone – they have gone to medical school, done psychiatry rotations, encountered both medical and psychiatric cases in internal medicine residencies, and presumably continue to be competent physicians addressing a host of different issues (which is not to say that a physician friend in Westchester County doesn’t spent three fourths of his time addressing diabetes and high blood pressure, to which I respond in probabilistic terms given disease rates in the United States).
Deemed the “common cold of mental health,” depression leads to approximately 8 million doctors’ appointments a year, again whether because of comfort level or availability or insurance. The catch is that primary care doctors emphasize breadth over depth, whereas specialists are best equipped to address the nuances of more particular care. Thus, there are limitations in the care that even the most well-meaning practitioners can provide.
But there is a greater problem here, spanning all physicians and not just those in primary care (PCPs). What those experiencing mental illness – whether depression or anxiety – may well experience psychosomatic symptoms with which many even just having a stressful week can relate (heart palpitations, indigestion, perspiration, headache). The challenge is when we preemptively write off such symptoms in a patient who also happens to have a history of depression, especially considering that a number of those with depression also have medical illnesses as well (sometimes depression triggering worse self-care and thus issues such as type II diabetes, other times chronic illness and pain understandably contributing to depression or its worsening, and still other medical issues such as thyroid problems notoriously having the potential to induce depression in otherwise non-depressed patients. So in short, there are a lot of moving parts that make things both clinically interesting and diagnostically challenging.
And that is not necessarily doctors’ fault. Indeed, most are very well-meaning. I for one have been blessed by my doctors at New York Presbyterian. But it is not uncommon to find accounts – some anecdotal, others more systematic – of those with mental illnesses getting short shrift from physicians to whom patients are going for non-psychiatric conditions (whether reluctance to write prescriptions, being suspicious of whether it's "all in their head," etc). And again, there are reasons for those concerns, especially if there are risks of overdose in a depressed patient, even if the particular prescription is indeed valid.
The good news is that there are resources in place to facilitate productive discussions with doctors (of all specialties) about depression and its management. The bad news is that as depression spirals downhill, it becomes more and more difficult to advocate for oneself, and it’s easy to find oneself on the losing end of the battle. When at the lowest point, getting dressed can feel like a challenge in itself. Researching physician quality and medications and scheduling appointments goes beyond arduousness. (And given the noted high rates of depression and suicide among doctors themselves, this is not likely unnoticed by any parties). Having a good mental health provider is imperative if this is something with which you struggle or might be predisposed to struggle (whether from physical illness, a family history, a stressful job, such that a single trigger might be devastating). But having a good primary care provider to advocate when you cannot do so is at least as important, and it’s worth searching for one who doesn’t stigmatize reaching out, and who’s invested in treatment and feels like a safe person to go to if only in the interim until other resources are in place. We have already seen medical recommendations about depression screenings for all patients, which hopefully will reduce the stigma of acknowledging some of the symptoms on that list (that is, you’re not being singled out and asked, “You look tired today. Do you mind filling out this survey about your loss of interest and pleasure?”) and raise greater awareness to doctors of the prevalence of these symptoms in their patient populations, whether or not they meet DSM diagnostic criteria for depression (because as we can draw from pain management, it's easier to manage when caught earlier at a 6 as opposed to an all-consuming 9 or 10 ("but it goes to 11").
While doctors are – admittedly with much reason – told that when they hear hoofbeats, they shouldn’t assume zebras. That is, many ordinary diseases are in fact ordinary. But given the complexity and interconnectedness of the mind and the body, and the ways in which they can exacerbate ailments in the other, it is at least important to have more of a “zebra prevention strategy” in place (yes, I come from the San Francisco Bay Area, I have experienced one major earthquake in 1989, and you bet my bookshelves were bolted and I had an earthquake supply kit) so that doctors will be less likely to write of symptoms as physiological manifestations of depression when there could be something more at work (or to undergo expensive tests instead of making a referral to a therapist). So is the solution to run expensive batteries of tests on a mere hypochondriac? Surely not. But would it hurt is to make more open the discussion across the country (and not just major metropolitan areas where services are more available and information more easily acquired) discussions to disentangle the medical from the psychological, and their potentially numerous interactions? Surely not.
I am an academic. We are constantly learning. Doctors are constantly learning. The more that we can remind ourselves that yes we have our expertise, but we can also grow and evolve and improve (and that shortcomings in a patient case present opportunities to learn for future reference), the better off both doctors and patients will be.
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