Depression is the poster child of mental health. It is everywhere: we all have a relative or friend or co-worker that suffers from depression. It is understandable: like a blue day -- but 50 times worse and it won't go away. Celebrities, authors, and athletes tell us tales of their depression. It is historical: melancholia dates back to Hippocrates. It is universal: no race, ethnicity, or country is spared; it strikes along the age spectrum from youth to old age. And it is treatable.
Depression is painful, disabling and a major driver of suicide. It reduces the productivity of our businesses through absenteeism and presenteeism (showing up but not being able to do much). It appears all the time, an unwelcome intruder, in people with diabetes, heart disease, cancer, Parkinson's and asthma, and impairs their ability to recover from their medical problems. Depression escalates health care spending for other diseases unless it is detected and treated. For all its prevalence and impact on our society -- and one in five Americans will have a depression in their lifetimes -- depression just doesn't get the respect it deserves.
My evidence for that claim is not its popularity in the media but its second class status in medical care. Most people with depression do not go to see psychiatrists, psychologists and social workers; they go to their primary care physician complaining of some vague set of problems or show up frequently because their heart disease or diabetes just doesn't get better. Those who go and say they feel depressed are frequently inadequately treated or told it's because of age or illness (75 percent of seniors who kill themselves were in their primary care doctor's office in the month before they took their lives). Reliable studies indicate that 75 percent of those afflicted with this treatable and too often debilitating or fatal illness do not receive effective care. One highly noted national study reported that 13 percent of people treated in the general medical sector get "minimally adequate" mental health care.
This is not because there are bad doctors (though there are some of those). This is because depression has not gained a foothold in the standard operations of your doctor's office. When we go to our doctor we get a set of numbers: we are weighed, our blood pressure taken, pulse too -- all numbers we have come to understand. We know it is really bad to have a BP of 170/110, and if we tell someone who cares about us they say "what are you doing about that?" Then we get more numbers: labs are drawn for sugar, good and bad cholesterol, iron in our blood cells, PSA in men, and on and on. We know it is really bad to have a sugar of 400 and pretty good to have a total cholesterol below 200. Doctors and patients (and families) understand numbers and manage to numbers.
But for the longest time mental health conditions, like depression, did not have a number. Chart records might say mood was "pretty low" or "about the same" or "discouraged" or "crying a lot". Quality medical care is hard to achieve with just descriptive terms; it relies on quantitative measures, principally numbers. What's more, there is not much chance to compete for a doctor's precious time if she is busy fixing the numbers for sugar and BP. Mental health has been losing in the competition for fair time and proper management without a numerical measure of a disease. How about starting with its poster child disease -- depression -- to remedy that?
The good news is that there is a simple, nine item questionnaire called the PHQ-9 that someone can fill out in the waiting room, before seeing the doctor or nurse, that provides a highly reliable number that tells the doctor the likelihood (almost 90 percent sensitive) that you have a depression. The PHQ-9 gives a score from 0-27 and over 10 is the line in the sand that says depression is likely present; over 20 means it is severe. The patient, once diagnosed by the doctor, has a number -- say 18 -- which goes in the medical record and the patient, family, and doctor have the job of getting that number below 10. Just like the person with the BP of 170/110 needs to get that number to (or below) 120/80.
Doctors are good learners. If they need to do something they will learn to do it. If you measure their performance they learn how to do better. We see this with rates of immunization, mammography, surgical complications, and the treatment of a host of common and serious diseases like diabetes, asthma, and heart disease. But they have not yet had to tackle depression, even though it is ubiquitous in their practice, because it has not been systematically measured and monitored. Clear treatment care paths exist that doctors can follow that make for success in treating depression, just as they do with other prevalent conditions that carry great suffering and disability. Improvement rates seen from well studied depression treatments are in the 70-80 percent range -- as good as or better than treatment responses to diabetes and heart disease.
One hundred percent of primary care practices that see adolescents through adults of all ages should be screening for depression and using standardized treatment guidelines. New York City began a journey toward that goal in 2005 (see New York Times April 13, 2005, p1). Initial progress was good when the City's municipal hospitals, which care for one in six New Yorkers, decided to make the PHQ-9 a standard screen to be completed in the electronic medical record. Other care systems have begun to adopt the practice but change has been slow. Some selected health systems around the country are using it, but to my knowledge no state, county or municipality has made depression screening and management a standard of care.
When we ran the public relations campaign for depression screening in NYC our tag line was: HAVE YOU ASKED YOUR DOCTOR ABOUT A SIMPLE TEST FOR DEPRESSION?
Have you? For yourself or your loved one? Why not? Are you not giving depression the respect it deserves?
The opinions expressed herein are solely my own as a psychiatrist and public health advocate.
Lloyd I Sederer, MD
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