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From:
Maria Inês Reinert Azambuja <[log in to unmask]>
Reply To:
Social Determinants of Health <[log in to unmask]>
Date:
Sat, 11 Jun 2005 11:49:16 -0300
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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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