I appreciate the opportunity to discuss different explanatory models of
this illness. As such, I would provide my perspective as an urban
physician.
As it has been discussed, there are no specific procedures or tests to
identify depression as is the case with diabetes or other conditions; it
is a diagnosis of exclusion. However, when patients present with
multiple symptoms, many of which are somatic, others emotional, and
others real physical complaints, my duty as a primary care doctor is
first: "do no harm", second: eliminate the other *physical*, biological,
and physiological causative possibilities, third: confirm (if possible)
that these are not present, and lastly build trust with patients to be
able to discuss the more deeply rooted emotional or mental circumstances
, whether internal or external that impact on the presenting physical
conditions, as may be the case of depression.
The treatment of depression has evolved tremendously. There is
extensive literature about the effectiveness of medications, especially
the newer SSRIs. The black box warning came about particularly because
of the potential side effect no so much on the truly depressed patient,
but on those specially young people misdiagnosed with depression when in
reality they may have bipolar disorder, leading to an overexpression of
the violence, manic behavior and subsequent increase risk of suicide.
there are many variables both external and internal that impact on the
emotional status of a person. Where I work, "life gets in the way"
(poverty, SES, education, poor environment, inadequate housing, etc).
But when the pressures of life become so strong, and the person becomes
overwhelmed to the point of affecting their physical health and well
being, they need help. Medications, psychological help, social support,
and social services are all very effective, together. I agree that
more work should be done to change the social circumstances that affect
people. Until then, I will continue treating my depressed (chronically
ill) patient with a multidisciplinary approach and will do what ever it
takes to make them feel emotionally better to tackle the difficult life
in which they live.
Ana
>>> [log in to unmask] 6/10/2005 7:18:47 PM >>>
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:
> 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 of Health[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 is controversy about the origins
of
> depression,
> which is probably an aspect of several genetically and
> environmentally
> mediated dysfunctions.
>
> Several aspects of depression would lend themselves to a
> "chronic disease
> management model", as Jennifer inquires.
>
> First, treatment makes a difference. Under the right
> circumstances, both
> cognitive psychotherapy and drug treatment can help. They can
> help even
> more when used together.
>
> Second, relapse is common. Some relapses may occur because of
> recurring
> adverse events. Others may occur because the brain's capacity
> to remove
> cortisol and other stress hormones becomes imperfect. Too
much
> psychic
> stress may overwhelm the body's short-term and long-term
> mechanisms for
> biochemical coping. Many people recover completely from major
> depressive
> disorder, but many more do not -- and the resulting disability
> is immense.
> (I believe I've seen a WHO statement that depression causes
more
> lost
> workdays than any other single disabling condition.)
>
> Third, whether you subscribe to a purely biochemical model or
a
> purely
> psychosocial model, the patient's environment interacts with
the
> patient's
> innate attitudes and medical treatment to create the patient's
> experience --
> and it does so over a period of time.
>
> One respected writer on the chronicity and treatability of
> depression is
> John F. Greden, MD, at the University of Michigan Department
of
> Psychiatry.
> I can fax a three-page summary of his 2000 lecture, "What if
We
> Really Cared
> About Depression?", within North America on request. (It was
> distributed as
> an Audio-Digest program in 2001, but is no longer available
for
> purchase.)
> Consider checking "Diagnosing and treating depression earlier
> and preventing
> recurrences: still neglected after all these years." (Curr
> Psychiatry Rep.
> 2004 Dec;6(6):401-2.) That's one of the more recent
references
> found in a
> PubMed search for Dr. Greden's publications.
>
> Chapter 13 of _Comprehensive Textbook of Psychiatry_
> (Lippincott, Williams &
> Wilkins, 2005) discusses diagnostic and treatment strategies
for
> depressive-spectrum disorders. It appears 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 very briefly:
>
> On the medical side, there are myriad examples. The best I
know
> is the
> "Diabetes Collaborative" approach as outlined 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 have experimented with the
> boundaries of what
> the "healthcare system" can do to affect the social
conditions.
>
> On the mental health side, I am not as familiar. My
impression
> is that the
> application of chronic disease models to mental health may be
> less well
> developed than that for chronic physical diseases. But that
may
> just
> reflect my own orientation and practice history. I'd start
with
> resources
> such as www.ihi.org and the MacColl Institute for healthcare
> innovation at
> Group Health Cooperative in Seattle.
>
> Be prepared for a difficult time when researching the
> application of chronic
> disease models to depression, because there appear to be fewer
> funding
> sources for system innovation in mental health. However, the
> less-publicized field may have equal or greater opportunities
to
> make a
> difference in the public's health.
>
> I won't be able to participate in prolonged discussion on this
> topic, but
> I'd welcome the insights of others and I'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]> wrote:
>
> > Jennifer Boyko wrote:
> >
> >> I am wondering if anyone knows of any examples of primary
> medical care
> >> settings that have applied a chronic disease management
model
> (for lack of a
> >> better term) to address a particular health issue (e.g.
> depression,
> >> diabetes). Within the setting, which might be a community
> health centre or
> >> family medical practice, this would mean having an
> information system in
> >> place e.g. electronic medical record, evidence based
practice,
> >> reo-orientation of services, self-care supports, as well as
> efforts to
> >> improve community health through involvement in policies
that
> create
> >> supportive envioronments, address determinants of health
and
> enable community
> >> devleopment.
> >>
> >>
> > 'Depression' is a situational-based state of mind, not a
'chronic
> > disease'. Lumping it in with medical conditions such as
> diabetes is
> > ridiculous.
> >
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