i have just had a patient suicide.
he was depressed, with all the hallmarks
he refused medication
he thought asking for help was a sign of weakness.
he was deeply shamed by social circumstances beyond his control
clearly prozac deficiency does not capture this.
but whatever it was, it was deadly serious..
ken
I've yet to hear of anyone dying because of a 'Prozac deficiency' (Or
any other drug).
Graeme
Maria Inęs Reinert Azambuja wrote:
> This is becoming a very interesting discussion...
>
>
>
> My point would be: are tipe 2 diabetes and depression very different
> kinds of "ailments" regarding approaches by primary health care teams
> at the community level?
>
>
>
> I would tend to say that they are alike, not because they are both
> easily diagnosable and manageable, but exactly the opposite. They are
> both complex conditions for which we are still far from understanding
> determinants and physiopathologic processes. Type 2 diabetes is not
> just lack of insulin production... It is one of the manifestations of
> a plurimetabolic syndrome which seems to be associated with a
> "pro-inflammatory" phenotype which, by its turn, might have evolved as
> a result of early (intrauterine) environmental exposures capable of
> canalizing metabolic profiles and their abilities to deal with further
> environmental challenges (including stress) to be met during the life
> course...
>
> The only difference that I see between them is that diabetes has some
> numbers attached to it that may give us the impression of objectivity
> in defining outcomes. However, it has been recognized that "the use
> of only measurable health outcomes in working with people with chronic
> conditions (eg, blood pressure, glucose levels,weight) could miss the
> patient's needs, and that outcomes need to be useful to both the
> person and the health care team." (1).
>
>
>
> I used the term "ailments" instead of diseases because I think that
> only a small part of people with "metabolic syndrome" and "depression"
> should be considered ill. For the most part, treating them as if ill
> they were may probably make them sicker. Approaches which have been
> proposed for dealing with "chronic diseases" result in excessive
> medicalization of health conditions. The main error, as I see it, is
> the emphasis in "early identification of cases". For what? If what we
> will offer is in no way different from what we should be doing for
> strengthening health in the community - advocacy of exercises and
> good nutrition, job opportunities, housing, education, leisure
> opportunities,. - why we should classify people in healthy and sick
> for this sake?
>
>
>
> On the other hand, the small proportion of people with depression and
> metabolic syndrome which need medical treatment would really need very
> skilful family doctors and health care teams. I believe that calling
> them "primary" disqualifies them in front of the peers and the
> community. Dealing with the complexity of a patient with chronic
> diseases requires much more skills than being a specialist.
>
>
>
> I believe that current terminologies and policies regarding health
> care models deserves further discussion.
>
>
>
> Maria Inęs Azambuja, MD
>
> Adjunct Professor
>
> Dep. Social Medicne
>
> School of Medicine
>
> Federal University of Rio Grande do Sul,
>
> Porto Alegre, RS - Brazil
>
> [log in to unmask]
>
>
>
>
>
> (1) - PEOPLE WITH CHRONIC CONDITIONS A Discussion Paper - New
> Zealand
> http://www.nhc.govt.nz/publications/PDFs/chronicconditions-discussionpaper.pdf
>
>
>
>
>
>
>
>
>
>
>
>
> ----- Original Message ----- From: "Thompson, Kenneth"
> <[log in to unmask]>
> To: <[log in to unmask]>
> Sent: Saturday, June 11, 2005 10:11 AM
> Subject: Re: [SDOH] primary health care models
>
>
> 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.
>>>>> >
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