Category: Systems

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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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Education Informal-curriculum Lessons Medicine Observations Reflection Systems

Thoughts on the Movie “Get Out”.

Have you seen the movie Get Out? If you haven’t, what follows might spoil part of the movie for you. You might want to watch it before reading this.

If you have seen Get Out, this post ponders the role of psychiatry in the movie. (Full disclosure: I enjoyed and recommend the movie.)

We learn early on in the movie that Rose’s mother is a psychiatrist. Chris, Rose’s boyfriend, asks something like, “She’s a psychologist?”

The response Chris receives is something like, “No, she’s a psychiatrist.”

While I can’t know for sure, I believe that the writer of the film, Jordan Peele[1. If you are not familiar with Jordan Peele, please go watch some clips of Key and Peele.], wanted to highlight the difference between the two. Psychiatrists are physicians. And some physicians, under the guise of expertise, have promoted racist ideas.

Dr. Samuel Cartwright was a physician who practiced in Alabama, Mississippi, and Louisiana in the years leading up to the American Civil War. He defended slavery and wrote pieces that argued that blacks were inferior to whites.

One of his articles, “Diseases and Peculiarities of the Negro Race“, describes “drapetomania, or the disease causing Negroes to run away”. Because he describes drapetomania “is as much a disease of the mind as any other species of mental alienation”, it is clear that this is a psychiatric condition, such as kleptomania (compulsive stealing), pyromania (compulsive fire-setting), and dipsomania (the old name for alcohol use disorders).

In this article Dr. Cartwright asserts that God has ordained blacks as “submissive knee-bender[s]” and are “intended to occupy… the position of submission”. To support that blacks were destined to be “submissive knee-benders”, he states that “in the anatomical conformation of his knees, we see [it] written in the physical structure of his knees, being more flexed or bent, than any other kind of a man.”

To prevent the development of drapetomania, he states:

if his master or overseer be kind and gracious in his hearing towards him, without condescension, and at the same time ministers to his physical wants, and protects him from abuses, the negro is spell-bound, and cannot run away.

In Get Out, Chris (plus Georgiana, Walter, and Andrew) becomes obviously “spell-bound” through the hypnotic powers of the porcelain cup and silver spoon. One could argue that Rose is demonstrating faith in this practice as she was initially “kind and gracious”, “without condescension”, “ministers to his physical wants”, and “protects him from abuses” (remember the police officer who pulled them over?).

Dr. Cartwright comments that, in the course of drapetomania, slaves become “sulky and dissatisfied” before they run away. He advises that “the cause of this sulkiness and dissatisfaction should be inquired into and removed, or they are apt to run away or fall into the negro consumption.” However, if slaves were “sulky and dissatisfied without cause,” he states that the treatment was “in favor of whipping them out of it, as a preventive measure against absconding, or other bad conduct. It was called whipping the devil out of them.”[2. Wikipedia also comments that another treatment for drapetomania included “removal of both big toes”, which makes running difficult.]

Chris becomes understandably “sulky and dissatisfied” with his time at the Armitage home and seeks to flee. Though he wasn’t whipped to treat his drapetomania, it’s not a hard stretch to argue that the plan to remove most of his brain (“coagula”) is essentially whipping the devil out of him so that only his body remains.

Dr. Cartwright apparently published these ideas in the New Orleans Medical and Surgical Journal (as well as De Bow’s Review, a magazine of “agricultural, commercial, and industrial progress and resource” in the American South). This publication came from his work as the chairman Louisiana State Medical Convention committee. One of their tasks was to “examine the diseases peculiar to the Black slaves of the antebellum South”.[3. From a Lancet article called “Drapetomania“.] This was a professional medical opinion!

To be clear, not all physicians agreed with Dr. Cartwright’s opinion. Dr. Hunt, a physician who practiced in Buffalo, New York—that is, North of the Mason-Dixon line—lampooned Dr. Cartwright’s concept of drapetomania. He rightly wondered why drapetomania seemed to only exist in the South. He made wry remarks that drapetomania seems to affect the neurons of slaves so that they only flee in a northerly direction. He also pointed out that drapetomania resembled the condition of schoolchildren who ran away from school to play.

In essence, Dr. Hunt shouted, “Context matters!”

Dr. Cartwright sincerely believed that drapetomania was an inherent quality of black people.[4. Dr. Cartwright also described “dysaethesia aethiopica“, or “hebetude or mind and obtuse sensibility of body” that only occurred in blacks in the South.] As he was a fish in the sea of Southern slaveowning culture, he either could or would not believe that social and political context affects the definitions of psychiatric conditions. (He also could not believe that his ideas were wrong.) Maybe Jordan Peele was thinking about Dr. Cartwright and drapetomania when he created the characters in Get Out. Maybe he wasn’t; maybe he was pointing out the consequences and longevity of racism.

Psychiatry has been and can easily become an agent of social control. The moment we begin to think that we’re too good or too smart or too sophisticated to become agents of social control, we and the people under our care are doomed.

It is paramount that we remember this always in the current political climate. May we have the wisdom and courage of Dr. Hunt.

Categories
Medicine Nonfiction Observations Policy Systems

Disappointment.

My cohort graduated from our psychiatry residency almost ten years ago. The level of frustration and disappointment we’ve all experienced within the past two years is striking.

Some have taken leadership roles, only to relinquish them because of fatigue from fruitless discussions with administrators. Others have tried to alert senior managers about dangerous and irresponsible clinical practices. Their efforts were unsuccessful because concerns about finances trumped concerns about clinical services. With a bad taste in their mouths they resigned from their positions. Still others have tried to convince senior administrators about why certain clinical services are necessary. Though these clinical services save money across systems, they do not generate revenue for any specific organization.

“Just keep quiet and keep doing what you’re doing,” they hear from a few senior managers who are sympathetic to their efforts. “Maybe you can stay under the radar that way.”

One had the job duties of three positions. This physician asked for help after recognizing that this workload wasn’t sustainable. The administrators repeatedly said no. And, yet, when this physician finally resigned, the administrators split the single position into three.

“It’s like no one cares about about human suffering. It’s always about money.”

Some have become medical directors, only to learn that senior leadership expect a rubber stamp of agreement from them as figureheads to help change the behaviors of medical staff. Many of their clinical recommendations go unheeded because mandates from policy advisors and economists have primacy. For-profit corporations value profit over patients and seek the counsel only of their shareholders.

They have noticed that administrators often value the “medical doctor” credential for their reports over the clinical expertise of the person with the credential. They recognize that they are often not invited to certain meetings because some administrators do not want to hear what they have to say. They thought that they could offer specialized knowledge to proactively improve systems, but they learned that systems only react to audits.

We all sit around the table, the occasional fork clinking against plates holding desserts. No one talks because no one knows what to say. If we’re all experiencing this across different clinical settings and organizations, what encouragement could we offer?

What do we say to our patients?

Categories
Observations Reflection Systems

Race.

No one was sitting near us at the fast food chain, but my dad lowered his voice anyway.

“You were three or four years old,” he said. “We were watching an NBA game on TV. You asked, ‘Where are the white people who play?’ Even little kids notice these things.”

“How did you answer my question?”

“I didn’t.”

About 5% of inmates in the jail are in psychiatric housing at any given time. My current post assignment is with males who demonstrate acute symptoms, which comprises about 2% of the entire jail population. A small team works with this 2%.

To be clear, not all people with psychiatric conditions are put in psychiatric housing. Sometimes people start there and, as their condition improves, they move on to general population housing. Some people with psychiatric conditions never come to psychiatric housing. How one behaves, not one’s diagnosis, determines where one is housed.

I don’t know if the racial mix of my patients is proportional to the racial mix of all the people in jail. It’s rare that the patients I care for are comprised of only one race. I have yet to ask, “Where are all the white people?” However, I’ve certainly asked that before in another correctional setting.

I’ve often framed the processes of clinical work as a game. Maybe this is a product of clinical training: When working in hospital services, you’ve “won the game” if you were able to discharge all of your patients. You make informal wagers as to the duration of rounding: “Oh, our attending is Dr. So-and-So, so we’ll finish in less than an hour, tops,” or “Dr. Blah-Blah is on service now. You think three hours? Four? Five?!”

It’s probably just one way of coping.

While on various outreach teams, the objective of the game was to keep all of my patients out of the hospital. When working in a clinic in a medical center, it was to get all my patients well enough so that I could send them back to primary care. Now, the game is to get them out of the most acute unit and prevent them from returning. (The object of the game really should be how to keep people out of jail. That requires coordinated efforts across space and time, particularly for people with complex psychiatric conditions.)

Sometimes my patients are young black males. Sometimes they talk about problems they’ve had with officers or other inmates in the jail.

“I don’t want you to come right back to this unit if we send you out.” That’s how I usually start it. “If someone else gives you a hard time or starts being a jerk to you, what are you going to do to help you stay there and not get sent back here?”

People are often doing much better by the time we’re able to have this conversation. They usually provide reasonable answers.

Even though no one else is sitting near us, I then lower my voice.

“You’re a young black man. Some people here—not everyone, but some of them—react to you in certain ways just because of the color of your skin. That’s not fair, but, sometimes, that’s what happens. You know this much better than I do.”

I remain struck with how their faces soften. Jail is a hard place to be and people adopt hard expressions on their faces. When this coversation happens, these young black men invariably smile, but not from joy.

“So if something happens, you have to figure out how to respond so that you’re not the one who comes back here. Does that make sense?”

Sometimes they thank me for talking about race; sometimes they tell me that they already know what they need to do; sometimes they simply assert, “Don’t worry, I won’t come back here.”

Why do I lower my voice when I talk about this? Would I bring this up if I were a white female? a white male? Does the fact that I look obviously Asian work in my favor? Do I need to bring up something that they already know? Am I just being rude? Do good intentions matter when people find the intentions condescending?

Am I actually helping them when I frame things this way? Or am I only making myself feel better?

It’s a small sample size and completely anecdotal: After we have this conversation, they don’t return to the unit.

Maybe they were never going to come back, anyway.

Categories
Consult-Liaison Education Medicine Nonfiction Reflection Systems

Reflections While Writing About Psychiatry

I know I haven’t posted in a while. Someone presented me with the opportunity to write a section on psychiatry for medical students. This is wonderful (an opportunity to influence future physicians!!!) and terrible (GAAAAH there’s so much in psychiatry!!!). Between thinking about psychiatry at multiple levels at work and thinking about the foundations of psychiatry while writing the section, I’ve felt cognitively impaired when thinking about what I should write here.

But the thinking never stops… and here are some reflections I’ve had over the past two months while writing:

The differences between what physicians and patients want. Many medical students choose medicine because of the opportunity to help people in a very real way: In helping people improve their health, physicians help people experience a better quality of life. This is rewarding for both patient and physician. Right?

As physicians go through training, they learn the heartbreaking lesson, often repeatedly, that it’s not that simple.

Sometimes people want physicians to help them in ways that physicians can’t or won’t. Some people want medicine that will make the cancer go away and never come back. Other people want pain medicine or sedatives for short-term relief, though the long-term consequences are problematic and potentially devastating.

Other times, people reject the best help that physicians offer. Some people will not take insulin, even though it will prevent prevent worse outcomes from diabetes. Other people don’t want to see any physicians, even though medical interventions for their conditions are simple and effective.

Many medical students assume that patients will only be grateful for and accepting of the help physicians offer. That assumption is wrong.

But this is part of the “art” of medicine, right? How do physicians and other medical professionals help people when we don’t have an intervention that “works”? How do we help people who don’t want the help that we know “works”?[1. There are, of course, strategies we learn as psychiatrists to address how to help people who don’t want the help physicians offer. The problem is that the issue then gets cast as a “psychiatric problem”, when it, in fact, is a “human relations problem”. Psychiatrists often feel frustrated when some physicians either want us to have the doctor-patient relationship in their stead or, worse, when some physicians assume that a Disagreeing Patient is a Mentally Ill Patient.]

The psychiatric conditions that psychiatrists don’t encounter. I’ve worked in a variety of settings—in clinics, hospitals, a crisis center, a jail, homeless shelters, housing, and on the street—and, despite all that exposure, I have never met with someone with a diagnosis of somatic symptom disorder or factitious disorder. While both conditions are rare, my colleagues in primary care and emergency departments see people with these conditions more frequently. Those same people don’t want to see a psychiatrist.

When we think about systems that take care of patients, sometimes we need to remember that the patient isn’t always the actual patient. Sometimes the best way psychiatrists can help these patients is to help the physicians who actually see them. If we wipe our hands and say, “Well, they won’t see me, so that’s not my problem,” what are we doing? If there are barriers in the system that prevent us from helping our colleagues, how can we work together to remove them to increase the likelihood we can help them?[2. This is an argument for “integrated care”, which refers to the integration of physical and behavioral health services. Unfortunately, how these services are paid for often creates barriers… which is exactly why we need more physicians involved in advocacy and leadership.]

Conversations on what is “wrong” instead of the experience of being ill. While in training, physicians learn how to diagnose and treat conditions based on what is “wrong”. We learn the characteristics of the condition, its underlying causes, and the treatments that often correct it. However, we don’t spend a lot of time learning just how much the condition afflicts people.

To be fair, there is so much to learn in medical school and beyond. Furthermore, physicians, as a population, like to solve problems. This temperament was likely present in all of us even before we went to medical school. If talking and listening won’t actually fix the problem, but doing Something actually will, why don’t we just do the Something and get on with it?

Because of this focus on Fixing the Problem, some people assume we are uncaring. That assumption is often wrong, too.

There are also other forces at work: Physicians often don’t have as much time with patients as they would like to listen, provide education, and offer encouragement. Those are Receptive skills and, while complementary to, are often not as glamorous (or billable) as Problem-Solving skills. All of us—in health care or otherwise—often forget that healing occurs with both Receptive and Problem-Solving skills.

I’m grateful for many reasons to have this opportunity to write for medical students. A major reason is the chance to explicitly go back to the basics. Examining the foundation reminds me why I chose to go into psychiatry in the first place, highlights (again) just how much I don’t know, and challenges me to consider what is actually important in my clinical work. And let me tell you, knowing the doses of various medications is not actually important. That’s stuff you can look up. As Dr. Edward Trudeau said, what is actually important is “to comfort always”.[3. The full aphorism attributed to Dr. Trudeau is “To cure sometimes, to relieve often, to comfort always.”]