Dr Robert London

Who's Treating Depression?

Clinical Psychiatry News - Volume 35, Issue 1, Page 18 (January 2007)

Depression screening is becoming a mainstay in general medical evaluations, and this is a positive development, considering its prevalence and power. Depression is one of the four leading causes of disabilities and disease throughout the world, and it is associated with serious medical conditions and mortality across the lifespan (Nat. Neurosci. 2005;8:701–3).

More hospitals and outpatient clinics are aware of depression as a major health care problem. Our colleagues in primary care do recognize the prevalence of this often debilitating and catastrophic illness. Often, however, they are not fully aware of the dimensions and treatment protocols of depression. Furthermore, the time demands of their practices make it difficult for them to provide sensitive, effective treatment.

We all know the DSM definition of depression, but over the last 100 years, depression has had an ever expanding definition, from transient feelings of sadness to unhappiness—not to mention the depression that occurs in bipolar disorders, physical illnesses, perinatal depressions, anhedonic and anergic symptoms in thought disorder patients, personality disorders, and those associated with the anxiety disorders.

When we add this up, and factor in the huge direct-to-consumer advertising campaigns on depression, we see that the definition and potential treatment have expanded exponentially.

All of this is happening against the backdrop of an unfortunate trend: There are not enough psychiatrists to go around.

Now we have these wonderful medications such as Prozac, Zoloft, and Wellbutrin—sort of the penicillin of mental health—that work magic in certain depressions. But they are not the sole modality.

Think of the implications of these trends for primary care and other specialties. I don't mean to minimize the importance of primary care doctors—their significance in the differential diagnosis and treatment of stomach pains, sore throats, fevers, and countless other physical illnesses cannot be overemphasized. But should they do hip replacements or bypass surgeries to fill their days in this managed care environment? Should those who see 30–40 patients per day be treating a major psychiatric illness on their own?

A recent New York Times article described the gravitation of family physicians, obstetricians, dentists, and emergency room physicians to the lucrative beauty business (“More Doctors Turning to Business of Beauty,” Nov. 30, 2006; p. 1). They're using Botox and Restylane as if they were trained for years in plastic surgery.

I asked a colleague and plastic surgeon, Dr. Alfred Culliford IV, about this trend, and his response came as no surprise.

“It can be a nightmare out there for patients—who are potentially subjected to physicians who are not formally trained in facial anatomy and the proper techniques of using injectibles,” said Dr. Culliford, who is affiliated with Staten Island (N.Y.) University Hospital and spent 10 years training to become a plastic surgeon.

“Plastic surgeons, otolaryngologists, and dermatologists certainly should have the appropriate background and training to safely perform such procedures, but many health care professionals do not,” he said.

He went on to express concern about those patients for whom complications arise.

“Unfortunately, I feel the American public may have a perception that injectables are simple procedures that [nearly] everyone can perform,” Dr. Culliford said. “That may true if you are appropriately trained, but buyer beware.”

After reading the Times article and talking with Dr. Culliford, I realized that clinicians in many medical specialties are treating patients without the “best of the best qualifications,” as we in America have come to expect.

Getting back to the serious illness of depression, we psychiatrists know better than anybody that depression is difficult to treat.

With all of the challenges facing primary care physicians called on to treat our patients, we psychiatrists must develop a plan of action essentially educating our colleagues about the nature of depression, its dimension, multiple therapies, and how to use and not use them, and the need for regular guidance.

One such program that aims to educate and consult primary care physicians about depression—perinatal depression, in this case, is the University of Illinois' Perinatal Depression Project.

The program has trained more than 3,000 providers in the last 2 years, according to Dr. Laura Miller, an expert in women's mental health who serves as director of the project at the University of Illinois, Chicago.

Dr. Miller pointed out that, ideally, all primary care physicians should have a psychiatrist with whom to consult, but the resources are simply not there.

“There are not enough mental health professionals to serve all women who have perinatal depression,” Dr. Miller said, “so we need realistic and cost-effective models to figure out which patients can reasonably be cared for by their prenatal or primary care providers, and which should be referred to a mental health professional.

“By properly educating primary care providers, giving them stepped-care models, and providing easy access to ongoing consultation, we can accomplish this.”

Dr. Miller said her project has become so successful that an 800 number and a Web site have been established to provide expert mental health consultation to prenatal and primary care providers.

Much of the project's value is tied to its stepped-care models, which help prenatal and primary clinics create systems for identifying which patients to treat themselves and which patients to refer, said Dr. Miller, whose project not only helps Illinois patients but those in other states as well.

Clearly, recognizing the importance of depression as an illness and screening for it routinely is a major step forward in health care. The question I raise here is: How should this be done?

My view is that mental health professionals need to be part of any treatment program for a mental health/mental disorder problem.

By training primary care physicians who are truly interested in and willing to spend the time learning about depression and linking them with psychiatrists or other mental health providers like psychologists or psychotherapists, we are developing good programs for this group of disorders.

If, on the other hand, primary care providers continue to treat depression simply by using selective serotonin reuptake inhibitors—knowing their basic safety—we as psychiatrists will lose the battle in treating depression and give up treatment for the major disorder in our specialty.

I have trained medical students and residents, and lectured nonpsychiatric physicians for more than 25 years. This is my advice:

? If you want to treat a patient of yours who develops depression, learn about depression.

? Don't go beyond a single antidepressant.

? Be willing to give a great deal of time to a depressed patient.

? Be willing to refer to a mental health professional for ongoing talk therapy, which has shown to be the preferred mode of care when combined with medications.

Let me know your thoughts on depression and depression screening, and I will try to pass those thoughts along to my readers.

PII: S0270-6644(07)70021-8


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