Category: Education

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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!

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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.”

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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).

Categories
Education Lessons Medicine Nonfiction Reflection Seattle

It’s Good to be Busy.

It was a busy day:

There was the guy who spoke with enthusiasm about his doctrine of RUL (“Righteous Unconditional Love”); the man who stared through me after I asked him about whether he had eaten that morning; the fellow who made no efforts to hide his nose-picking while expressing his frustration with the court system; the young man who wouldn’t let me inspect the wound on his hand, though I soon recognized that he had crafted the wound out of a packet of juice crystals; the man who hadn’t taken a shower in several months, though the odor bothered me more than it bothered him; the guy who boasted about his abilities to run a mile in two minutes; the man who refused to acknowledge my existence; the fellow who advised me that he would prefer to take his medications in the morning because that’s what his nurse practitioner told him to do; the man who apologized for masturbating, but argued that he is young and “that’s what young people do”; the fellow who said that after he used “bad heroin”, he realized that his parents aren’t actually his parents; the guy who found lithium energizing and was in the process of tapering off of methadone; and the man who simply said, “I’m not sick,” when I asked him why he hadn’t been taking medication that the state psychiatric hospital had prescribed to him. Nurses paged to ask for orders for medications to reduce the discomfort of heroin withdrawal, medications that patients had asked for three days ago, medications that patients took before they entered jail. The phone rang as callers shared information about diagnosis, treatment, and next steps.

I tipped my head back in the chair, stretched my arms up, and sighed.

“You okay?”

It was my second year of residency and I was the only psychiatrist in the hospital that night. My duties included addressing any issues that occurred in the psychiatric unit and providing care for any patients that came to the emergency department with psychiatric concerns.

My classmates had warned me about a particular emergency medicine attending physician who was working that night:

  • “Last week he told me I was useless.”
  • “He rolls his eyes at me all the time.”
  • “He’s just angry. He won’t ever thank you for anything you do.”

“Hi, Dr. Angry,” I said around 7pm. “I’m the psychiatry resident on call tonight.”

After glancing at me, Dr. Angry grunted.

Well, I guess that’s how it’s going to go tonight.

Less than three hours later, after Dr. Angry referred four patients to me, he muttered in my direction, “I’ve got another one for you.”

Shortly after midnight, a patient’s husband was pulling her out of the ED while she was screaming at me.

“I’M GOING TO GET YOU FIRED FROM HERE! YOU’RE A TERRIBLE DOCTOR! I KNOW THE PRESIDENT OF THE HOSPITAL! YOU CAN’T DO THIS TO ME!”

I was shaking, but I wasn’t going to admit her to the hospital. Dr. Angry caught my eye and nodded once. I wasn’t the only person who knew I was shaking.

It was close to 3am and I had already seen seven patients.

Dr. Angry had a slight smile on his face as he approached me while I was slogging through my notes.

“Dr. Yang, there’s another one for you to see.”

please make it stop

“Thank you. Who is it?”

As I was beginning my note around 6am for the ninth patient I saw, Dr. Angry stopped by.

“Dr. Yang, you did all right. Thank you.”

“You’re welcome, Dr. Angry.”

I tipped my head back forward in the chair in the jail and dropped my arms.

“Yeah, I’m fine,” I replied to my colleague. “It’s busy, but it’s good to be busy. And when I think about my intern year, this isn’t bad at all.”

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Education Lessons Medicine Reflection

Talking About Suicide.

I was recently asked to speak at a community event about youth suicide. Several young people in the area had killed themselves in the past few months to years. This was an opportunity for the community to learn and talk about suicide and suicide prevention.

My role was to provide a professional perspective on and information about suicide in young people. There was also a panel of people between the ages of 16 and 19 who shared their perspectives about suicide. The youth panel was the most compelling aspect of the evening.

The audience was comprised entirely of adults. Most were probably parents; others were adults who often interact with young people, such as school administrators and police. The youth panel encouraged the audience to talk to the young people in their lives about death, dying, and suicide. The panel also spoke about the importance of showing that they, as adults, care about young people. They shared their experiences in how talking about suicide with their peers has given others hope and saved lives.

One girl shared an anecdote that involved a teacher who inspected the wrists and arms of students prior to a test. He wanted to ensure that students didn’t have accoutrements on their arms that could contribute to cheating. This girl said that she felt anxious about rolling up her sleeves because of the scars on her wrists and arms from cutting. What would her teacher say or do?

When he inspected her arms, he undoubtedly saw the scars. His response? “Okay, good. Nothing on you that will lead to cheating.” And that was it. He never spoke to her about what he saw; he never asked her how she was doing or what the injuries were on her arms.

What did she take away from that? “He cared more about whether I was cheating than about me staying alive.”

The fresh candor of young people inspired some adults to comment on their own perspectives of suicide. One man, hands stuffed into the pockets of his jeans and voice deep and gruff, shared, “I’m a veteran. I also come from a generation of men who just don’t talk about suicide, even though a lot of veterans come home from war and commit suicide.”

The contrast was striking: The young people sat on the stage, the lights on their faces, and spoke about death and suicide without fear or self-consciousness. The adults sat in the shade of the auditorium and shifted with unease, gasped with sadness, or shook their heads when they heard the youth talk about their peers dying.

I do not believe that there was anything anomalous about this group of young people. Youth want to talk with adults about death, dying, and suicide. They want relationships with parents and other parental figures where they can ask questions, share their worries, and learn how to navigate the difficulties in life so that they can live another day. They also are sensitive to the burdens that adults already experience; sometimes they don’t share their thoughts, worries, dreams, and fears with us because they don’t want to cause us more distress. Because they automatically assume that any conversation about death and dying will cause distress in adults.

I created a short handout with suggestions about how to talk about suicide with young people (hint: these suggestions work with adults and older people, too). It also has phone numbers to call, online chats to access, and websites to view for more information about suicide prevention.

There is no evidence to support the fear that talking about suicide—particularly in a thoughtful, caring way—will increase the likelihood that people will kill themselves. In fact, talking about suicide directly can help people change their minds about taking their lives.

Here’s the requisite link to the National Suicide Prevention Lifeline, which is an excellent and literally lifesaving resource. However, I encourage all of us to talk with each other, within our own communities—even if it is “only” the community within our homes—about death, dying, and suicide. We don’t have to talk about it all the time; we don’t have to ask each other, “Are you thinking about killing yourself?” every day. The more comfort we have with talking about how we are doing, what we’re thinking about, and what death means to us, the more we can support each other when the difficulties, problems, and failures in life occur.