hi all,
as a practicing community psychiatrist who works in primary care and community mental health settings let me see if i can bridge an apparent gulf in this conversation string.. inventing the neck, as it were...
actually the whole idea of the chronic care model has its roots in psychiatry. from the 1970s on, there are has been a growing appreciation in community psychiatry of what it takes to be useful to folks who have circumstances and syndromes that relapse and remit.. as well as syndromes and circumstances that just persist. the development in the 70s of the "assertive community treatment model" has almost all the ingredients of the chronic care model. but it lacked two elements that are now reshaping psychiatric practice.
first was the development of the consumer/expatient movement which has articulated an extraordinary vision of how consumers can pursue their recovery- with help from other consumer, attuned mental health professionals, and other resources. it has been building on the crosswalk between people with addictions and people with other psychiatric conditions. this movement is a much deeper notion then is currently articulated notion of the "activated patient" in the chronic care model. by the way, the use of the term "chronic" is anathema to recovery movement. the word implies lack of hope- as in "chronic mental patient". a better term for the chronic care model would be "wholelistic long term support for people with persisting illness or disability" WLTSPPID?
second is the development of a related movement by the families of persons with mental illness. here we see an effort to recognize the need to support people who are helping family and friends deal with difficult circumstances- and come out the other side.
in combination (along with the more medical approach of meds and genetics) these forces are reshaping psychiatry and, i suspect will begin to reshape the care of people with persisting illnesses in primary care..
which gets us back to the issue of the treatment of depression in primary care. i think the problem isnt the lack of an approach to depression as a persisting remitting and relapsing condition in psychiatry- we have such an approach and, while it is often overly focused on meds (and should be critiqued), it is not only focused on meds. but in primary care medicine, i see a model of practice that does much less in engaging patients and families in addressing the social circumstances of their illnessess and disabilities and the consequent social dilemas people face individually and as a group..
the chronic care model is not yet a vision of recovery. (and so we are clear, recovery does not necessarily mean making the illness/symptoms go away.. it means figuring out how to have a life that a person wants to live, despite their illness/disabilty. it means moving the system of supports and interventions that we call medicine to be useful in that pursuit...
ken thompson
pittsburgh
-----Original Message-----
From: Social Determinants of Health on behalf of Dave Cundiff
Sent: Fri 6/10/2005 8:40 PM
To: [log in to unmask]
Subject: Re: [SDOH] primary health care models
Graeme: I disagree with only one of your factual allegations. Every
diabetes treatment I know of, with the possible exception of WISELY PACED
weight loss and exercise, has a significant risk of unintended adverse
effects. Psychiatric drugs arenšt unique. EVERY drug has side effects,
without exception, and almost every drug (even those sold over the counter)
has potential to cause serious and/or permanent harm.
Compared with somatic diagnosis (diagnosis of the body), psychiatric
diagnosis really DOES seem primitive. The mind appears to be much more
complex than the rest of the body. It is much harder to sample brain tissue
than that of any other organ. And although most somatic organs/functions
have at least some closely analogous animal models, therešs no other species
known to have brains/minds anything like ours. So psychiatric research is
intrinsically slower than other medical research.
At first, I thought you were trying to trivialize the suffering of depressed
people. Many people do that, and depressed people often resist the idea of
treatment because of unproductive self-blame for the condition. After
reading both your messages carefully, I think youšre primarily trying to
find a different model with which to help alleviate the suffering. I hope
you succeed.
You have analyzed and publicized the shortcomings of other
diagnostic/treatment models. You know the dogmatism, arrogance, and profit
motivation of some of their proponents. Your adversaries have human
failings, but that doesnšt mean their observations are all wrong and it
doesnšt show their treatments are useless. Wešre stuck with the same old
scientific method: Observe what we can, theorize as cogently as we can,
argue as respectfully as emotions will allow, and accept the process of peer
review. The scientific method doesnšt AVOID error, but if we stick with it
the scientific process will CORRECT error.
Perhaps others, with more in-depth knowledge of neurochemistry than I, will
be able to contribute to this dialogue. Best wishes!
Dave Cundiff
***
On 6/10/05 4:18 PM, "Graeme Bacque" <[log in to unmask]> wrote:
> To elaborate why I believe it is ridiculous to equate bona fide medical
> conditions such as diabetes with the more common psychiatric perjoratives such
> as 'depression':
>
> Diabetes is a serious, chronic physical condition caused by a hormone
> deficiency (the hormone in question being insulin, which metabolizes glucose
> in the body). A clinical diagnosis is easily obtained by examining the
> patient's blood or urine for excessive glucose. Treatment may involve
> modification of diet to reduce glucose in the blood, oral medication, or
> replacement of the deficient hormone through regular injections of insulin,
> all of which are proven to be of benefit without causing additional
> physiological harm.
>
> OTOH, so-called 'depression' is generally diagnosed on the basis of a brief
> verbal interview alone - no physical exam or lab procedure exists that will
> confirm this 'diagnosis' simply because, like all things psychiatric, it is a
> subbjective value assessment of a person's behavior, feelings, and perceptions
> of the world, made outside of any clear physiological context or without any
> consideration given to what is going on in the patient's personal life that
> might be causal.
>
> As well, there are well-documented hazards associated with the more common
> antidepressants, ranging from an increased risk of heat-related illnesses (see
> http://www.toronto.ca/health/pdf/medicationsheat.pdf) to an increase
> possibility of suicidal ideation or violent behavior. The FDA in the United
> States has issued 'black box' warnings on most common antidepressant drugs due
> to this risk, and the U.K. has banned their use outright for anyone under
> eighteen years of age. Similar but much milder cautions have been issued by
> Health Canada but no actual restriction on the prescribing of these drugs.
>
> In a nutshell, there is little benefit and much potential harm involved in
> feeding people happy pills instead of addressing the very real, pervasive
> personal or social issues that likely lie at the root of what they are
> feeling. Even the non-medical approach of 'cognitive therapy' can be perceived
> as a form of victim-blaming because it focuses on changing the 'patient'
> rather than addressing broader social issues. In the long run, the only people
> to benefit from the medical model approach are the pharmaceutical companies,
> who make literally billions of dollars from the sale of antidepressants.
>
> Graeme
>
> Carlson, Marie wrote:
>> RE: [SDOH] primary health care models
>>
>> Dr. Dundiff .. I appreciated your thoughtful and well informed reply. Would
>> you kindly also fax the 3 page summary of Dr. Gredin's talk on "What if we
>> Really Cared about Depression" to me as well?
>>
>>
>> Thank you.
>>
>>
>> Marie
>>
>>
>> **********************
>> Marie S. Carlson
>> Population Health Consultant
>> Capital Health
>> Suite 300, 10216 - 124 St.
>> Edmonton, AB. T5N 4A3
>> Phone (780) 413-7786
>> Fax: (780) 482-5358
>> [log in to unmask]
>>
>>
>>
>>> ----------
>>> From: Social Determinants ofHealth[SMTP:[log in to unmask]] on behalf of Dave
>>> Cundiff[SMTP:[log in to unmask]]
>>> Reply To: Social Determinants of Health
>>> Sent: Thursday, June 09, 2005 5:28 PM
>>> To: [log in to unmask]
>>> Subject: Re: [SDOH] primary health care models
>>>
>>>
>>> Graeme: As you know, there iscontroversy about the origins of depression,
>>> which is probably an aspect of severalgenetically and environmentally
>>> mediated dysfunctions.
>>>
>>>
>>> Several aspects of depression wouldlend themselves to a "chronic disease
>>> management model", as Jennifer inquires.
>>>
>>>
>>> First, treatment makes adifference. Under the right circumstances, both
>>> cognitive psychotherapy and drugtreatment can help. They can help even
>>> more when used together.
>>>
>>>
>>> Second, relapse is common. Somerelapses may occur because of recurring
>>> adverse events. Others may occurbecause the brain's capacity to remove
>>> cortisol and other stress hormonesbecomes imperfect. Too much psychic
>>> stress may overwhelm the body'sshort-term and long-term mechanisms for
>>> biochemical coping. Many peoplerecover completely from major depressive
>>> disorder, but many more do not -- andthe resulting disability is immense.
>>> (I believe I've seen a WHO statementthat depression causes more lost
>>> workdays than any other singledisabling condition.)
>>>
>>>
>>> Third, whether you subscribe to apurely biochemical model or a purely
>>> psychosocial model, the patient'senvironment interacts with the patient's
>>> innate attitudes and medical treatmentto create the patient's experience --
>>> and it does so over a period of time.
>>>
>>>
>>> One respected writer on thechronicity and treatability of depression is
>>> John F. Greden, MD, at the Universityof Michigan Department of Psychiatry.
>>> I can fax a three-page summary of his2000 lecture, "What if We Really Cared
>>> About Depression?", within NorthAmerica on request. (It was distributed as
>>> an Audio-Digest program in 2001, but isno longer available for purchase.)
>>> Consider checking "Diagnosing andtreating depression earlier and preventing
>>> recurrences: still neglected after allthese years." (Curr Psychiatry Rep.
>>> 2004 Dec;6(6):401-2.) That's one ofthe more recent references found in a
>>> PubMed search for Dr. Greden'spublications.
>>>
>>>
>>> Chapter 13 of _ComprehensiveTextbook of Psychiatry_ (Lippincott, Williams &
>>> Wilkins, 2005) discusses diagnostic andtreatment strategies for
>>> depressive-spectrum disorders. Itappears to me to cite historical and
>>> current theories in a well-balanced way-- but the writing is a bit dry.
>>>
>>>
>>> ***
>>>
>>>
>>> To answer Jennifer's question verybriefly:
>>>
>>>
>>> On the medical side, there aremyriad examples. The best I know is the
>>> "Diabetes Collaborative" approach asoutlined and taught by the Institute
>>> for Healthcare Improvement (http://www.ihi.org). Most of them stay within
>>> the "healthcare system" paradigm,rather than challenging broader social
>>> conditions. But some programs haveexperimented with the boundaries of what
>>> the "healthcare system" can do toaffect the social conditions.
>>>
>>>
>>> On the mental health side, I am notas familiar. My impression is that the
>>> application of chronic disease modelsto mental health may be less well
>>> developed than that for chronicphysical diseases. But that may just
>>> reflect my own orientation and practicehistory. I'd start with resources
>>> such as www.ihi.org <http://www.ihi.org> and the MacColl Institute for
>>> healthcare innovation at
>>> Group Health Cooperative in Seattle.
>>>
>>>
>>> Be prepared for a difficult timewhen researching the application of chronic
>>> disease models to depression, becausethere appear to be fewer funding
>>> sources for system innovation in mentalhealth. However, the
>>> less-publicized field may have equal orgreater opportunities to make a
>>> difference in the public's health.
>>>
>>>
>>> I won't be able to participate inprolonged discussion on this topic, but
>>> I'd welcome the insights of others andI'd like to know the results of
>>> Jennifer's inquiries.
>>>
>>>
>>> Best wishes!
>>>
>>>
>>> Dave Cundiff, MD, MPH
>>> Olympia, Washington, USA
>>>
>>>
>>> ***
>>>
>>>
>>> On 6/9/05 1:31 PM, "Graeme Bacque"<[log in to unmask]>
>>> <mailto:[log in to unmask]> wrote:
>>>
>>>
>>>> > Jennifer Boyko wrote:
>>>> >
>>>>> >> I am wondering if anyone knowsof any examples of primary medical care
>>>>> >> settings that have applied achronic disease management model (for lack
>>>>> of a
>>>>> >> better term) to address aparticular health issue (e.g. depression,
>>>>> >> diabetes). Within thesetting, which might be a community health
>>>>> centre or
>>>>> >> family medical practice, thiswould mean having an information system
>>>>> in
>>>>> >> place e.g. electronic medicalrecord, evidence based practice,
>>>>> >> reo-orientation of services,self-care supports, as well as efforts to
>>>>> >> improve community healththrough involvement in policies that create
>>>>> >> supportive envioronments,address determinants of health and enable
>>>>> community
>>>>> >> devleopment.
>>>>> >>
>>>>> >>
>>>> > 'Depression' is asituational-based state of mind, not a 'chronic
>>>> > disease'. Lumping it in withmedical conditions such as diabetes is
>>>> > ridiculous.
>>>> >
>>>> > -------------------
>>>> > Problems/Questions? Send it toListserv owner: [log in to unmask]
>>>> >
>>>> >
>>>> > To unsubscribe, send the followingmessage in the text section -- NOT the
>>>> > subject header -- [log in to unmask]
>>>> > SIGNOFF SDOH
>>>> >
>>>> > DO NOT SEND IT BY HITTING THEREPLY BUTTON. THIS SENDS THE MESSAGE TO THE
>>>> > ENTIRE LISTSERV AND STILL DOES NOTREMOVE YOU.
>>>> >
>>>> > To subscribe to the SDOH list,send the following message to
>>>> [log in to unmask]
>>>> > in the text section, NOT in thesubject header.
>>>> > SUBSCRIBE SDOH yourfirstnameyourlastname
>>>> >
>>>> > To post a message to all 1000+subscribers, send it to [log in to unmask]
>>>> > Include in the Subject, itscontent, and location and date, if relevant.
>>>> >
>>>> > For a list of SDOH members, send arequest to [log in to unmask]
>>>> >
>>>> > To receive messages only once aday, send the following message to
>>>> > [log in to unmask]
>>>> > SET SDOH DIGEST
>>>> >
>>>> > To view the SDOH archives, go to:
>>>> https://listserv.yorku.ca/archives/sdoh.html
>>>
>>>
>>> -------------------
>>> Problems/Questions? Send it to Listservowner: [log in to unmask]
>>>
>>>
>>>
>>> To unsubscribe, send the followingmessage in the text section -- NOT the
>>> subject header -- [log in to unmask]
>>> SIGNOFF SDOH
>>>
>>>
>>> DO NOT SEND IT BY HITTING THE REPLYBUTTON. THIS SENDS THE MESSAGE TO THE
>>> ENTIRE LISTSERV AND STILL DOESNOT REMOVE YOU.
>>>
>>>
>>> To subscribe to the SDOH list, sendthe following message to
>>> [log in to unmask] in the text section, NOT in the subject header.
>>>
>>>
>>> SUBSCRIBE SDOH yourfirstnameyourlastname
>>>
>>>
>>> To post a message to all 1000+subscribers, send it to [log in to unmask]
>>> Include in the Subject, its content,and location and date, if relevant.
>>>
>>>
>>> For a list of SDOH members, send arequest to [log in to unmask]
>>>
>>>
>>> To receive messages only once a day,send the following message to
>>> [log in to unmask]
>>> SET SDOH DIGEST
>>>
>>>
>>> To view the SDOH archives, go to:
>>> https://listserv.yorku.ca/archives/sdoh.html
>>>
>>>
>> ------------------- Problems/Questions? Send it to Listserv owner:
>> [log in to unmask]
>>
>>
>>
>> To unsubscribe, send the following message in the text section -- NOT the
>> subject header -- to [log in to unmask] SIGNOFF SDOH
>>
>>
>> DO NOT SEND IT BY HITTING THE REPLY BUTTON. THIS SENDS THE MESSAGE TO THE
>> ENTIRE LISTSERV AND STILL DOES NOT REMOVE YOU.
>>
>>
>> To subscribe to the SDOH list, send the following message to
>> [log in to unmask] in the text section, NOT in the subject header. SUBSCRIBE
>> SDOH yourfirstname yourlastname
>>
>>
>> To post a message to all 1000+ subscribers, send it to [log in to unmask] Include
>> in the Subject, its content, and location and date, if relevant.
>>
>>
>> For a list of SDOH members, send a request to [log in to unmask]
>>
>>
>> To receive messages only once a day, send the following message to
>> [log in to unmask] SET SDOH DIGEST
>>
>>
>> To view the SDOH archives, go to:
>> https://listserv.yorku.ca/archives/sdoh.html
>
> ------------------- Problems/Questions? Send it to Listserv owner:
> [log in to unmask]
>
> To unsubscribe, send the following message in the text section -- NOT the
> subject header -- to [log in to unmask] SIGNOFF SDOH
>
> DO NOT SEND IT BY HITTING THE REPLY BUTTON. THIS SENDS THE MESSAGE TO THE
> ENTIRE LISTSERV AND STILL DOES NOT REMOVE YOU.
>
> To subscribe to the SDOH list, send the following message to [log in to unmask]
> in the text section, NOT in the subject header. SUBSCRIBE SDOH yourfirstname
> yourlastname
>
> To post a message to all 1000+ subscribers, send it to [log in to unmask] Include
> in the Subject, its content, and location and date, if relevant.
>
> For a list of SDOH members, send a request to [log in to unmask]
>
> To receive messages only once a day, send the following message to
> [log in to unmask] SET SDOH DIGEST
>
> To view the SDOH archives, go to: https://listserv.yorku.ca/archives/sdoh.html
-------------------
Problems/Questions? Send it to Listserv owner: [log in to unmask]
To unsubscribe, send the following message in the text section -- NOT the subject header -- to [log in to unmask]
SIGNOFF SDOH
DO NOT SEND IT BY HITTING THE REPLY BUTTON. THIS SENDS THE MESSAGE TO THE ENTIRE LISTSERV AND STILL DOES NOT REMOVE YOU.
To subscribe to the SDOH list, send the following message to [log in to unmask] in the text section, NOT in the subject header.
SUBSCRIBE SDOH yourfirstname yourlastname
To post a message to all 1000+ subscribers, send it to [log in to unmask]
Include in the Subject, its content, and location and date, if relevant.
For a list of SDOH members, send a request to [log in to unmask]
To receive messages only once a day, send the following message to [log in to unmask]
SET SDOH DIGEST
To view the SDOH archives, go to: https://listserv.yorku.ca/archives/sdoh.html
-------------------
Problems/Questions? Send it to Listserv owner: [log in to unmask]
To unsubscribe, send the following message in the text section -- NOT the subject header -- to [log in to unmask]
SIGNOFF SDOH
DO NOT SEND IT BY HITTING THE REPLY BUTTON. THIS SENDS THE MESSAGE TO THE ENTIRE LISTSERV AND STILL DOES NOT REMOVE YOU.
To subscribe to the SDOH list, send the following message to [log in to unmask] in the text section, NOT in the subject header.
SUBSCRIBE SDOH yourfirstname yourlastname
To post a message to all 1000+ subscribers, send it to [log in to unmask]
Include in the Subject, its content, and location and date, if relevant.
For a list of SDOH members, send a request to [log in to unmask]
To receive messages only once a day, send the following message to [log in to unmask]
SET SDOH DIGEST
To view the SDOH archives, go to: https://listserv.yorku.ca/archives/sdoh.html
|
