Categories
Consult-Liaison Education Medicine Policy Systems

Online Screening for Depression?

Inquisitve reader Amy asked me if I had any opinions about online screening for depression. The British Medical Journal recently published a debate on this issue.

What an excellent question, Amy! I read the opposing arguments and these are my thoughts:

First, I see two different issues. The first is whether the 9-question Patient Health Questionnaire (PHQ-9) is an appropriate tool to use to screen for depression. The second is whether the public should trust Google to administer the PHQ-9.

Before I do delve into that, though, let’s take a step back and consider the purpose of screening tools. Screening tools help physicians figure out how much more we should learn about a person. For example, asking for a person’s biological sex is a screening tool. The moment I learn that the person before me is female, I will ask her questions about menstruation and pregnancy history. I’ll skip those questions if the person is male. Similarly, if a person tells me that he smokes cigarettes, then I will ask more questions about how much and how often he smokes, what he gets out of smoking cigarettes, and if he thinks smoking causes him any problems. This helps me assess potential risks to his psychological and physical health. It also helps me assess if he has any interest in changing his smoking behaviors. Screening tools help us sort and gather information to generate diagnoses and interventions.

The literature states that the PHQ-9 was developed both to diagnose and measure the severity major depression. The PHQ-9 was modeled after the criteria for major depression in DSM-IV. Thus, the problems with the PHQ-9 for diagnosis are the same as the problems with the DSM for diagnosis: Context is completely missing. The authors of DSM argue that the situation and underlying causes of major depression don’t matter; they state that the presence of certain symptoms determine whether the diagnosis applies.

Long-time readers know my refrain: Context does matter. Major depression is “comorbid” with many other psychiatric conditions, meaning that someone experiencing the symptoms of major depression often experience symptoms of other psychiatric conditions. For example, bipolar disorder, by definition, includes episodes of major depression. People with diagnoses of post-traumatic stress disorder (PTSD) and schizophrenia often experience major depression. Some people who take drugs, whether prescribed or obtained from illict sources, experience symptoms of major depression. Sometimes the symptoms of major depression are actually due to a medical condition, such as certain cancers, infectious diseases, or thyroid conditions.

There are several papers that make the case that the PHQ-9 is a useful tool in the screening for and diagnosis of major depression. Given that major depression is comorbid with other conditions, a positive PHQ-9 result is useful to help get people into care. A professional can then help clarify symptoms, determine possible diagnoses, and suggest treatment and other interventions. Recall that the purpose of diagnosis is to guide treatment.

Here is where we get into the second issue as to whether the public should trust Google to administer the PHQ-9. Most task forces agree that there is no point in performing screening tests if you can’t do anything with the results. If you can’t refer someone with a positive PHQ-9 result to a professional who can clarify diagnosis and provide treatment, then why bother? You’re potentially causing more problems and distress for the person seeking help. Thus, the question is whether Google will direct people with positive PHQ-9 results to helpful resources.

There is a shortage of psychiatrists and other mental health professionals in the US. One wonders if an online depression screening tool will lead people to believe that they are “majorly” depressed, when they are not. They will then seek services that are hard to find. If these individuals are able to get into primary care services, those medical professionals may not be able to determine if someone has depression because of bipolar disorder, or depression due to the recent death of a loved one. Wrong diagnosis often results in wrong treatment or overtreatment. Recall that we should first do no harm.

However, it is clear that people seek information about depression and other psychological experiences on the internet. The questions on the PHQ-9 can educate the public about the differences between major depression and having a sucky day. The more information and education we can provide to the public, the more empowered the public can feel about not only what isn’t going well, but also what they can do to improve their health and wellness. I do not view my work as a psychiatrist as a guild secret. The more understanding and communication we have in our communities, the more we can address our psychological health on individual and societal levels.

The other reaction I had to that BMJ debate was related to a comment that Dr. Duckworth made under “attitudinal barriers”. He noted that a “key reason may be that people with mental health conditions perceive that they do not need treatment. Studies show that they report attitudinal barriers to seeking care much more often than structural or financial barriers.”

I don’t see how the PHQ-9 is related to “attitudinal barriers”. Screening tests don’t reduce stigma. Sure, people may avoid treatment for depression because they don’t know that they are depressed. However, I suspect that more people avoid treatment for depression because of the stigma associated with psychiatric conditions and treatment. If we want to reduce and remove “attitudinal barriers” related to depression, we must help share stories that remind everyone that people with depression are, first, people. The PHQ-9 is not a means to that end.

I don’t know the workings of Google well enough to comment more about whether we should trust Google to administer the PHQ-9. Others with more knowledge about online security, marketing, and data mining can say more about whether Google will use PHQ-9 results for good or evil… or both. There are likely other unintended consequences that I don’t know or understand.

Thanks for the question, Amy!

Categories
Nonfiction Observations Reflection

A Thousand Years.

I recently had the opportunity to visit two places in New Mexico: Chaco Culture National Historical Park and the Very Large Array.

The Chaco Culture National Historical Park features now ruined pueblos that people built over a thousand years ago. Construction started on Pueblo Bonito, a structure that archaeologists believe contained over 600 rooms, around 850 AD! Additions and revisions occurred on Pueblo Bonito for the next two hundred years. There are ruins of other pueblos in the area; some of them are now crumbling walls that have succumbed to the eroding powers of the desert winds and blazing sun.

Petroglyphs and the orientation of these ruined pueblos suggest that the people who lived in or visited Chaco appreciated their relationship with the celestial universe. A sun dial, located on a butte that is no longer open to the public, reflects their observations of the equinoxes and solstices. People, then and now, witnessed the directional relationships the buildings have with the stars.

The Very Large Array, on the other hand, was constructed over forty years ago. The 27 enormous dish antennae, arranged in a Y configuration, sense radio waves coming in from the universe. These antennae function as a giant “eye” and funnel the signals they receive to a supercomputer. Scientists analyze data from this supercomputer to describe events that have occurred in the universe: Stars exploding, the birth of new stars, and the location of black holes.

The antennae are arranged in straight lines, which are in stark contrast to the curves and shapes of the surrounding mountains and clouds. Such straight lines do not occur in nature—even trees are not so rigid.

What if Chaco and the Very Large Array serve the same purpose?

What if Chaco was an effort to better understand the universe and what was in it? The Very Large Array gathers data from invisible radio waves; Chaco collected data from visible waves from the sun, moon, and stars.

If people excavate the Very Large Array a thousand years from now, what will they think? Will they look upon the Very Large Array with the same wonder that we feel when we look upon Chaco?

I have noted before that death is the great equalizer. It puts everything in perspective.

In a thousand years, who will know your name? That thing you’re worried about now: Will it matter in a thousand years? Your creations—children, music, writings, meals, home improvements, tweets, laws, relationships—what impact will they have in a thousand years?

To be clear, I am not saying that what we do now has no importance or value.

There are things we do now that have huge significance and meaning. Sure, that kind act you do today won’t enter the annals of history. However, that same kind act will make the world an easier place for someone who is suffering now. Maybe the melody of that song you wrote will fall silent once you die, though it brings joy now to someone who delights in music. What you do now may not last forever, but that shouldn’t stop you from doing those things. What you do matters.

And maybe the remnants of something you create will still be around a thousand years from now. If that is the case, consider how your creations can inspire and humble the people of the future. The mysteries that you want to understand now may still be mysteries hundreds of years from now.

Someone said this a thousand years ago, and someone else will say this a thousand years from now. This is a reminder for us all today.

Categories
Medicine Observations Reflection

Dr. Handsy.

Note: I’ve felt pretty bummed out for the past two weeks, much of it related to the behaviors and opinions of the US federal government. Epictetus commented that

We are only enraged at the foolish because we make idols of those things which such people take from us.

which, yeah, is all fine and good, but I have yet to achieve a level of wisdom where I do not permit others to steal my peace. I find it hard to write when I’m unsettled.

A female friend, who is not a physician, recently asked me, “Do you find that, in your position, men treat you differently? Meaning, do they show you the same kind of respect that they show their male colleagues?”

The group of medical directors were seated around the table. The meeting was supposed to go on for six hours. While I was not the only female in the room, I was the only female medical director in that cohort.

Around hour two, the medical director seated to my right, a man with whom I had no relationship, made an emphatic statement to the group. While doing so, he leaned over and grasped my bare right arm with both hands. One hand gripped my bicep; the other hand wrapped around my forearm.

In my surprise, my eyebrows furrowed and I turned to look at him. Before I could ask him to let go, though, he had already released my arm and his palms were flat against the tabletop. The large gemstone on his left ring finger reflected the fluorescent lights overhead.

I smirked to myself. Did that just happen? Should I say something now? Maybe he won’t do that again. That was weird.

Around hour four, he used the back of his left hand to deliver a brisk tap to my right tricep.

“Hey, what does [acronym] mean?” he whispered as the group continued its discussion.

With urgency I pulled my arm into my lap. After murmuring my answer, I scooted my chair away from him.

It’s too late again for me to say something. Boo.

Around hour five, he rested his bejeweled left hand onto my right forearm while finishing his gallant comment, “… as Dr. Yang said earlier.”

Another man had already begun to speak as I yanked my arm away. Glancing at Dr. Handsy, I summoned forth the Ice Queen and hissed, “Please stop touching me.”

Oh, the look that Dr. Handsy shot at me! It was as if I had kicked his pet dog or spit in his beverage.

I smiled at my friend. “Do they show me the same kind of respect? Many do, but not all.”

Categories
Consult-Liaison Education Lessons Reflection

Being Right vs. Being Effective.

“It’s best to avoid confirming their beliefs,” they said, “but you can validate the underlying emotion.”

She was dabbing her eyes with a crumpled tissue already streaked with mascara.

“It’s been two years and I still can’t believe he’s gone. I thought we would grow old together, that he’d get to see his kids graduate from high school.”

“The sadness still feels overwhelming.”

“Yes,” she whispered before bursting into tears. “When will I stop feeling so sad?”

He avoided eye contact while his leg bobbed up and down.

“I feel so anxious, like I’m paranoid. It used to be that I only felt paranoid when I was high on crystal meth, but now it’s all the time. It’s like people are watching me all the time, like they want to know all my business or something.”

“It’s exhausting to feel so anxious all the time.”

“Oh my God, YES. I’m so tired, but I can’t relax.”

“I didn’t know what to say to my wife. She didn’t deserve any of this. I tried to stop, and I did for a few weeks, but then I’d download more of it. My wife was the one who answered the door when the police came to seize my computer. I would do anything to not have this problem; I know how many people it hurts.”

“You feel a lot of shame about looking at child porn.”

His face flushed and his voice quivered.

“Yeah.”

She heard every word, but her gaze was fixed to something on the other side of the room.

“I can’t. I’ve already said too much. I can’t. I can’t. They know, they will know, they already know everything. I can’t. It’s in the lights, it’s in the ceiling, it’s in the sky. It’s everywhere. I can’t. They will know and they will know through the lights—”

“You’re scared that something bad will happen if you tell me the story.”

“Yes! And I want to be strong, I don’t want to be scared.”

“The whites are better than the Asiatics—”

“Let me ask something else—”

“—and there will come a day when all the races will submit to us—”

“—I’m going to walk away if you keep talking about this—”

“—even people who went to a lot of school like you. I’ll remember that you were helpful, but you are still just an Asiatic—”

“—okay, I’m going now.”

“But Doctor! You know what I say is true! C’mon! Why won’t you talk to me about this? You’re not being a good doctor….”

“You also have to respect your own limits,” they said. “Sometimes you want to show that just how right you are, but it’s much more helpful to be effective. And sometimes it’s best for everyone if you end the conversation when you’re no longer effective. You can always try again later.”

Categories
Education Medicine Nonfiction Reflection

A Week in School!

I spent the past week at a health care ethics seminar. Here are some reflections:

How lucky was I to spend a week in school? The last time I sat in a classroom for five consecutive days was about 15 years ago. Prior to starting my clinical rotations in medical school, I was a professional student: There were 18 years between kindergarten and my second year of medical school. I got really skilled at sitting in classrooms, listening to people talk at me, and organizing the information for either tests or real-world application.

I’ve recognized the privilege of attending school. I don’t think I appreciated the depth of this privilege until this past week.

Different perspectives makes for rich learning. Most of the students in this seminar came from three professions: Chaplains, nurses, and physicians. There were some social workers, as well as an attorney or two.

There were further divisions within those groups: Some people were professionals within the military; others came from Catholic hospitals; multiple medical specialties were present. Most of the people there were already participating in ethics committees.

The different perspectives that each profession, specialty, and individual brought were useful. Decisions by committee can be onerous (cf. the pain of some meetings), but discussing and learning within committees is often humbling and fascinating. My classmates brought up ideas and arguments that I would not have considered.

One wonders if these rich discussions occur because we know our time together as a group is limited. In standing meetings in our usual jobs, we sometimes get accustomed to who says what and why. We might also face formal or informal consequences for speaking up (or not speaking up). In a week-long seminar, what have you got to lose by sharing your thoughts?

On not speaking up. As both a student and physician, I continue to receive feedback that I should talk more. (Given how much I blather here, one might find this surprising.) When I was a student, sometimes teachers thought I didn’t care about the topic. (Usually untrue.) Sometimes they thought I was shy. (I’m not, though people who haven’t gotten to know me might think otherwise.)

These days, sometimes people wish I would speak up to demonstrate my expertise. Sometimes I get the impression that some people want to know what I’m thinking, but when I don’t speak, they believe I’m withholding information on purpose. (Rarely true.)

There was plenty of dialogue that occurred between teacher and student and between students during the lectures. I said little. The admonitions from my past (and present) echoed in my ears: “You’re not talking! You’re not contributing to the group! Why don’t you say something and help out?”

Honestly, I think I’m just a slow thinker. It’s not that I don’t have opinions; I just find myself thinking about multiple perspectives at the same time. This muddles my thoughts. Muddled thoughts often leads me to produce incoherent speech. While I’m slowly clarifying a single line of thought, others who are able to organize their thoughts faster have raised their hands and are ready to speak.

Health care ethics isn’t limited to death and dying. Most of the discussions we had during the seminar surrounded death and dying. For example: A child is in a coma in the intensive care unit. The medical team wants to proceed with further interventions and treatment that has a 50% chance of recovery. The parents of the child want to withdraw treatment, which means imminent death. Discuss.

I imagine that most ethics consultations in the hospital are related to death and dying. But what about all the other ethical quandaries that are not as “glamorous”, but occur more frequently?

Like informed consent for medications. How much informing is “enough”? How much detail of the risks, benefits, and alternatives should we offer? If someone doesn’t want the information, but wants the treatment, is that a valid consent?

When I was a resident, one of my attendings commented in half-jest, “A common problem with informed consent is that by the time someone is truly informed, they are not able to provide consent… and when someone consents, they are not truly informed. Consider someone who is experiencing CPR: The chest compressions, the mouth-to-mouth breathing, the ribs breaking. That person is completely informed about CPR now… but he can’t consent. But when we obtain consent about CPR, that person usually has no idea what happens during CPR.”

Involuntary treatment is a big deal in psychiatry (as it should be). Sometimes we don’t seem to devote sufficient attention to all of its ethical issues.

The value of teachers showing vulnerability. Some of the speakers at this seminar take care of patients. They offered real clinical examples of ethical quandaries (e.g., a patient who doesn’t want to know her diagnosis, even though the physician believes that the patient should know). Those discussions were the most compelling because these teachers had opinions about what to do, but were not sure and still are not sure if they did the “right” thing.

I admired the thoughtfulness and humility of these speakers. Ambiguity is present in all of medicine. Sometimes we—all of us, regardless of our role—want a clear, concrete answer, but it doesn’t exist. Sometimes people craft an answer to reduce the motion sickness they feel while floating on the sea of ambiguity. It takes courage to recognize that sometimes there is no anchor, that the clouds are blocking the stars, that we don’t know where we are or what to do next. We just do the best we can with the information we have at the moment.

The value of pithiness. Several of the instructors seemed to speak solely in aphorisms. It didn’t matter how muddled or disorganized our questions were; they reformulated our questions with wisdom and clarity and provided concise answers.

I wish I could do that all the time.

Each instructor highlighted the importance of clarifying the ethics consultation question. This idea was also drilled into our minds as psychiatry residents when we were learning how to do hospital consults. What is the question? It doesn’t matter how great the answer is if it doesn’t actually address the question. And sometimes we don’t know what we’re asking.

Pithiness comes from clear thinking. Clear thinking comes from understanding the issue at hand. We don’t understand the “issue at hand” unless we ask questions.

Of course, these instructors have been thinking about ethics for years. They have likely heard our questions or some variant of them before. The various moral frameworks (e.g., utilitarianism, deontology, virtue ethics, etc.) are novel to us, but not to them.

It also takes time to think clearly. The time pressures inherent in clinical medicine contribute to muddled thinking or, in the worst case scenario, not thinking at all. This is yet another reason why I was grateful to attend this seminar: There was time to think, reflect, and consider the “bigger” picture of the work we do.

As I’ve noted before, the more experience I get, the more I realize how much I don’t know. (It’s disturbing.) This is why I now value more how to think, rather than what to think. The content changes over time as psychiatry makes (slow) advances. Knowing how to apply this information in the service of caring for patients is paramount.

For those of you interested in health care ethics, the primary paradigm this seminar used is called the “four boxes“. Look over my Twitter timeline for more comments about the seminar (though I stopped sharing much after day three, only because my mind felt full).