I’d love to talk to you about how you feel about all the mental health depression anxiety suicide education being given to children in public government schools- without their parents knowledge that’s now having an iatrogenic affect. If doctors like you would speak out and understand education people like me wouldn’t be fighting two political parties- they’re killing our children and people won’t do anything
this doctor using a case study to drive his emotional Opinion in my view and then looks for reasons to back it up. Then nitpicks studies in order to justify. Just my $.02 as to what's happening here
Unfortunately I don't think this third-year resident has enough experience because he's basically Letting perfect be the enemy of the good by saying we don't have any great studies and then he discounts a meta-analysis, Then implies that SSRIs have harm which is true but overall they reduce suicidal thoughts and the last time we Reduced their prescribing, suicides increased when we black boxed Prozac. When you screen ffor depression here can find it more often and then you have to differentiate what it isBut he is saying we are going to find the depression anyway which is not really true
After my PCP recommended 'Depression Screening' I took the self administered tests, the results were interesting:
My score was identical for every test I took - it was ZERO. This is problematic. There is no category for people with a ZERO score (GOD FORBID anyone is allowed to be happy!!!) and some of the wording demands an answer that can only be interpreted as a sign of depression.
Have I EVER been depressed? yes - I was devastated at age 22 when my 63 year old father died, feelings were much different at the age of 56 when my 97 your old mother died. Depression for me was situational and transient.
The rush to medicate in many instances is unconscionable.
Dr. Gibson, below, rightly notes that we screen for things we might not be aware of. And we certainly don't want to miss cancer. Or hypertension. Or renal failure. The expanding use of screening for psychiatric symptoms among so many others, however, includes the similarly evidence-lite assumptions that depression or anxiety (also now recommended by the USPSTF) are pathologic - we have named disorders after them, after all, and as noted by many - have so many pharmacologic treatments targeting these symptoms.
Depression is a normal response to life. Depression to the point of contemplating suicide - or at the very least having the thought that I might not want to wake up and go through the same shit tomorrow - is something most people I know have experienced. By aligning depression with a faulty a/c compressor that might be leaking or need replacement altogether, we miss the inherent value in experiencing life to its fullest... which absolutely and necessarily involves sometimes feeling depressed, stressed, and anxious. Those symptoms, that do not have anything like the consistent appearance of cancer cells under a microscope, are part of the process of learning to manage our response to whatever comes our way today... some the consequences of our own doing, some random curveballs thrown by an indifferent universe.
I always have to consider whether I should treat someone's depression or anxiety pharmacologically in the context of both the limitations of our medical treatments, but more importantly potentially subverting the normal process of human development and resilience. In much the same way that our cancer screenings highlight false positives in the search for something truly harmful - leaving many recipients of additional scans and biopsies with a new assumed (and false) identity and association with cancer - so, too, one of the profound potential harms in depression and anxiety screening is that we now label ourselves and one another as henceforth suffering from these disorders.
One of the first young men I saw in my current position had a minimal medical and behavioral health history. He presented with, "I think I'm depressed."
"Why do you think you're depressed?"
"Well, I was with this girl for the last four years and we were about to get married, and she just broke up with me. And my Mother just died of cancer."
Those are GREAT reasons to feel depressed! For most people, that would be the normal response, right? Indeed if he had been overjoyed (although there could be good reasons for that, too), I might have considered some real pathology. Again, if that grief, loss, and sadness manifest in the cognitive blinders that lead us to the conclusion that ending our life in response is the best or only solution - then our actions might be more interventional.
But a PHQ screening that led to a medication could artificially limit the vital work we need to do as we all know such losses, disappointments, unexpected life changes are sure to come throughout our lives. Many of our patients describe the effect of SRI's or other pharmacologic treatments for anxiety and depression as dulling their feelings in general - feelings that provide information about our present moment, our thoughts, our values (much less the physiologic and other common side effects all drugs may have).
I agree that screening tools can have value, especially in the context of knowing the dangers as yet unknown. But we can know our patients without the real and potential harms this adds to our computer-driven checklist that itself removes us from fully entering into our patients' lives in the few moments we have with them.
The enormous quantity of screening questions my MAs have to go through to room a patient often determines whether I can squeeze the ear pain or elderly UTI patient in for a visit. The options are to treat without seeing or to send to urgent care, neither as good as just seeing them for the three minutes these kinds of problems should take.
I've been reluctant to push back on this kind of stuff because I don't wish to be seen as insensitive or uncaring about mental illness. I assumed there was a good reason we were doing these things, although I cannot think of a time screening has turned up useful information, now that I *am* thinking about it.
The decisions about who and how often to screen for what are made at levels far above anyone I have ever met and by people who have never struggled to get patients roomed on time for overwhelmed doctors.
I wish I knew how to influence a re-thinking of all the stuff that looks like useless nonsense that we do before we room a patient (and in the exam room, too). Every thing that we do means that we cannot do something else because the health care system and the providers and staff who work in it are finite.
Thank you for raising this issue. I had assumed that universal depression screening was an evidence-based idea and a beneficial practice. However, after reading this piece, I would like the USPSTF to review its 22-year-old recommendation.
In general, screening takes away time and attention from the problem the patient came in with that may have an evidenced based solution. Any screening used in medicine should have to prove its efficacy AND providers should seek permission, stating the risks and benefits like any other intervention
Thanks for this. I'm not an advocate for screening, but I view the Sarah vignette as more of an example of inappropriate treatment than a rationale not to screen. I suppose the argument against screening would be that because it doesn't result in appropriate treatment, therefore screening is bad? But the failure is not in the screening process per se it's in the treatment process. For an effective screening program you need an effective intervention, and you chose an ineffective one! Nowhere do you mention therapy for Sarah, which would be my go-to, I'd be reluctant to initiate SSRIs unless in severe depression and only as an adjunct to therapy. Depression that has psychosocial causes needs a psychosocial solution.
I agree with you about screening, I'm not a fan, but think there are better arguments against it than an example of an inappropriate response to a screening-identified condition. If you had offered Sarah therapy, I can see this story having the completely opposite ending... screening facilitated her "cure"... but that wouldn't convince me of the benefits of screening either.
I had the same impression: while screening in general population feels at the minimum pointless and potentially a cause of iatrogenic harms (not to even go towards the realm of undesirable cultural shifts) much of the argument does seem to speak better against automatic medication of any identified depression than against screening as such.
Awesome 👍. Throwing away the good for the few to treat the functional depressive is lunacy. This bracket creep is pushed by pharma to get more drugs to more cattle aka humans. Trying to stop statins in the elderly is pushing it uphill. Literally zero benefits and huge impacts on their cognition and musculoskeletal strength and coordination. Yet we're all beaten over the head with "falls prevention" and "keep them out of hospitals" it's truly madness. Medicine has it's head so far up pharma's wallet patients would near get better care from a vending machine. With AI on the rise and human intelligence and integrity on the slide we are all headed for oblivion.
This is great! You have renewed my faith in the future of medicine. I have recently spent a lot of time reflecting on why our default is to always do “something.” Something is not always better than nothing and often it at best has unintended negative consequences or worse causes actual harm.
The crazy part about the current annual exam is that it doesn’t include an exam in which the patient can say they have this spot on their chest and they don’t know if it’s cancerous or if something is wrong because the doctor will tell them they’re only allowed to ask all the questions, including the depression screening questions that the insurance pays for on the regular annual exam and that your insurance requires you to come in for a separate visit to ask about that spot on your chest. Doctors say it’s even worse for Medicare. Doctors are not allowed to refill a prescription during a regular well check exam now. It seems like the insurance companies are just collecting data.
Depression is not a disease by any reasonable definition and is well outside the bounds of competence and training that goes into medical education. I am old enough to remember when the "chemical imbalance" mantra was first put forward and became the basis for all the pharmaceutical "treatments" that have turned this into a disaster area for kids and adults. I was skeptical at the time and nothing has come along to change my mind since then.
I heard today that the 10 year old daughter of a friend had become "anxious". So she's now on some psych med, quite possibly the escitalopram mentioned in this article. You know, the one that increases the risk of suicide by a significant factor. And no one in that family sees a problem with this.
Well did she did she have increase in suicidal thoughts in the 1st week or 2? Because if she didn't and It loweredHer anxiety she shouldn't stop it as that would causeMore harm
It's true that once you start those meds you're in a bind. She wasn't suicidal BTW, just had some quack diagnose her as OCD and anxious. Now if her mom wants her off the meds she'll have to taper very carefully because the withdrawal symptoms can trigger suicide. I think she's been medicated because it made life easier for her mother. But now she's in a corner. And pharma has another customer for life.
That's a shame. It is bad enough that adults are subjected to this but it is criminal to inflict medication and psychological "therapy" on children who are experiencing the normal ups and downs of childhood.
And risking "post-ssri syndrome" into the bargain, with a 10 year old who will not know what normal ever was.
I know a psych NP who tells me most of the parents he deals with who have children diagnosed with ADHD want nothing to do with non-pharmaceutical treatment. They prefer to use pills on their kids.
When I was teaching at a local state university campus students would come to me with accommodations for ADHD. Almost always male. The most striking thing about these students was their lack of a sense of humor, the part of us that's such a big part of being human in the first place.
In my opinion ADHD is one of those made-up disorders that can be applied to lots of young males during their growth and development. Instead of working through it in normal fashion with parental guidance and tolerance, they are now put on medication that stunts normal psychological development and gives them a life long excuse for failure.
And I know a few young men who know how to answer the questions in order to score a script for Adderall or Vivance. They tell me they don't use it "chronically", merely "acutely", so that they can get stuff done. What a clown show.
I never bought into the concept that the way to treat a hyperactive kid who had difficulty focusing was to give him amphetamines. Seems rather counterintuitive.
Just so everyone not in primary care is aware, these are the “quality metrics” for my company at present (which follow many HEIDIS and medicare metrics): —
Tobacco screening (with counseling if pos)
- BMI screening ( with counseling if > 30)
- anxiety screen
- depression screen (PHQ2, 9 if needed)
- HgA1C control < 8 for diabetics
- eye exam note in our chart for diabetics (not just the patient saying they had it)
- nephropathy screening, diabetics
- foot exam documented, diabetics
- hypertension control- <140/90 in diabetics and anyone with HTN diagnosis
-colon cancer screening (actual test in chart, not patient say so)
- breast cancer screening
- cervical cancer screening
- and an individual NPS score > 85 minimum and > 92 to get full credit
- notes closed/ locked within 72 hrs
————-
They hold back part of our pay unless meet certain % of these OR pay less and give “bonus” if meet them.
Another thing is insurance companies and various health websites give ratings on how well you do on these and can make you a nonpreferred provider/ make you look like a “bad” doctor if you do not meet them.
And another is if you work for a big system, it is a reason to be “let go”.
Many incentives to do many things that may or may not actually help individual patients.
(Reposted here so maybe more people see, not sure how much the non- primary care/ non medical folks are aware of this behind the scenes stuff)
I was going to smash “like”, because I am glad you shared this. But then I realized, I don’t like this at all. Not one bit. I am sad that primary care has come to this for many of you.
And “nephropathy” screening in diabetics??? Last time I checked, there aren’t really any treatments for that…
My boss asked me yesterday why I needed 40 minutes to do a CPE on a healthy 80 year old. I don't knw if there is anywhere within commuting distance that still allows people to do medicine with humans at the center, but I plan to find out.
I agree with Zade. My last physical was almost nothing but these questions, and me saying, "no" over and over again. I feel like I'm at a car dealership... "window tinting?" No "rust-proofing?" No
Once these metrics get institutionalized, how can we get them undone?
Your note explains a lot about the questions/pestering I now get at my annual physical. Seems like something changed about 5-10 years ago. No one is happy about this.
It’s a pleasure to read such a good article by someone so young. Wish he were in our program.
I am old enough to have missed “the guidelines” and can proudly say I have never performed a depression screen nor do I intend to. (I don’t do OB.) In a very long career I have had only one suicide and that was likely a homicide!
I’d love to talk to you about how you feel about all the mental health depression anxiety suicide education being given to children in public government schools- without their parents knowledge that’s now having an iatrogenic affect. If doctors like you would speak out and understand education people like me wouldn’t be fighting two political parties- they’re killing our children and people won’t do anything
this doctor using a case study to drive his emotional Opinion in my view and then looks for reasons to back it up. Then nitpicks studies in order to justify. Just my $.02 as to what's happening here
Unfortunately I don't think this third-year resident has enough experience because he's basically Letting perfect be the enemy of the good by saying we don't have any great studies and then he discounts a meta-analysis, Then implies that SSRIs have harm which is true but overall they reduce suicidal thoughts and the last time we Reduced their prescribing, suicides increased when we black boxed Prozac. When you screen ffor depression here can find it more often and then you have to differentiate what it isBut he is saying we are going to find the depression anyway which is not really true
After my PCP recommended 'Depression Screening' I took the self administered tests, the results were interesting:
My score was identical for every test I took - it was ZERO. This is problematic. There is no category for people with a ZERO score (GOD FORBID anyone is allowed to be happy!!!) and some of the wording demands an answer that can only be interpreted as a sign of depression.
Have I EVER been depressed? yes - I was devastated at age 22 when my 63 year old father died, feelings were much different at the age of 56 when my 97 your old mother died. Depression for me was situational and transient.
The rush to medicate in many instances is unconscionable.
thats normal grief in the DSM no one would give you SSRIs for that unless you had SI or sevee neurovegatative sx energy motivation concentration.
Dr. Gibson, below, rightly notes that we screen for things we might not be aware of. And we certainly don't want to miss cancer. Or hypertension. Or renal failure. The expanding use of screening for psychiatric symptoms among so many others, however, includes the similarly evidence-lite assumptions that depression or anxiety (also now recommended by the USPSTF) are pathologic - we have named disorders after them, after all, and as noted by many - have so many pharmacologic treatments targeting these symptoms.
Depression is a normal response to life. Depression to the point of contemplating suicide - or at the very least having the thought that I might not want to wake up and go through the same shit tomorrow - is something most people I know have experienced. By aligning depression with a faulty a/c compressor that might be leaking or need replacement altogether, we miss the inherent value in experiencing life to its fullest... which absolutely and necessarily involves sometimes feeling depressed, stressed, and anxious. Those symptoms, that do not have anything like the consistent appearance of cancer cells under a microscope, are part of the process of learning to manage our response to whatever comes our way today... some the consequences of our own doing, some random curveballs thrown by an indifferent universe.
I always have to consider whether I should treat someone's depression or anxiety pharmacologically in the context of both the limitations of our medical treatments, but more importantly potentially subverting the normal process of human development and resilience. In much the same way that our cancer screenings highlight false positives in the search for something truly harmful - leaving many recipients of additional scans and biopsies with a new assumed (and false) identity and association with cancer - so, too, one of the profound potential harms in depression and anxiety screening is that we now label ourselves and one another as henceforth suffering from these disorders.
One of the first young men I saw in my current position had a minimal medical and behavioral health history. He presented with, "I think I'm depressed."
"Why do you think you're depressed?"
"Well, I was with this girl for the last four years and we were about to get married, and she just broke up with me. And my Mother just died of cancer."
Those are GREAT reasons to feel depressed! For most people, that would be the normal response, right? Indeed if he had been overjoyed (although there could be good reasons for that, too), I might have considered some real pathology. Again, if that grief, loss, and sadness manifest in the cognitive blinders that lead us to the conclusion that ending our life in response is the best or only solution - then our actions might be more interventional.
But a PHQ screening that led to a medication could artificially limit the vital work we need to do as we all know such losses, disappointments, unexpected life changes are sure to come throughout our lives. Many of our patients describe the effect of SRI's or other pharmacologic treatments for anxiety and depression as dulling their feelings in general - feelings that provide information about our present moment, our thoughts, our values (much less the physiologic and other common side effects all drugs may have).
I agree that screening tools can have value, especially in the context of knowing the dangers as yet unknown. But we can know our patients without the real and potential harms this adds to our computer-driven checklist that itself removes us from fully entering into our patients' lives in the few moments we have with them.
The enormous quantity of screening questions my MAs have to go through to room a patient often determines whether I can squeeze the ear pain or elderly UTI patient in for a visit. The options are to treat without seeing or to send to urgent care, neither as good as just seeing them for the three minutes these kinds of problems should take.
I've been reluctant to push back on this kind of stuff because I don't wish to be seen as insensitive or uncaring about mental illness. I assumed there was a good reason we were doing these things, although I cannot think of a time screening has turned up useful information, now that I *am* thinking about it.
The decisions about who and how often to screen for what are made at levels far above anyone I have ever met and by people who have never struggled to get patients roomed on time for overwhelmed doctors.
I wish I knew how to influence a re-thinking of all the stuff that looks like useless nonsense that we do before we room a patient (and in the exam room, too). Every thing that we do means that we cannot do something else because the health care system and the providers and staff who work in it are finite.
(For full context, I work at an FQHC)
Thank you for raising this issue. I had assumed that universal depression screening was an evidence-based idea and a beneficial practice. However, after reading this piece, I would like the USPSTF to review its 22-year-old recommendation.
In general, screening takes away time and attention from the problem the patient came in with that may have an evidenced based solution. Any screening used in medicine should have to prove its efficacy AND providers should seek permission, stating the risks and benefits like any other intervention
Thanks for this. I'm not an advocate for screening, but I view the Sarah vignette as more of an example of inappropriate treatment than a rationale not to screen. I suppose the argument against screening would be that because it doesn't result in appropriate treatment, therefore screening is bad? But the failure is not in the screening process per se it's in the treatment process. For an effective screening program you need an effective intervention, and you chose an ineffective one! Nowhere do you mention therapy for Sarah, which would be my go-to, I'd be reluctant to initiate SSRIs unless in severe depression and only as an adjunct to therapy. Depression that has psychosocial causes needs a psychosocial solution.
I agree with you about screening, I'm not a fan, but think there are better arguments against it than an example of an inappropriate response to a screening-identified condition. If you had offered Sarah therapy, I can see this story having the completely opposite ending... screening facilitated her "cure"... but that wouldn't convince me of the benefits of screening either.
I had the same impression: while screening in general population feels at the minimum pointless and potentially a cause of iatrogenic harms (not to even go towards the realm of undesirable cultural shifts) much of the argument does seem to speak better against automatic medication of any identified depression than against screening as such.
Awesome 👍. Throwing away the good for the few to treat the functional depressive is lunacy. This bracket creep is pushed by pharma to get more drugs to more cattle aka humans. Trying to stop statins in the elderly is pushing it uphill. Literally zero benefits and huge impacts on their cognition and musculoskeletal strength and coordination. Yet we're all beaten over the head with "falls prevention" and "keep them out of hospitals" it's truly madness. Medicine has it's head so far up pharma's wallet patients would near get better care from a vending machine. With AI on the rise and human intelligence and integrity on the slide we are all headed for oblivion.
This is great! You have renewed my faith in the future of medicine. I have recently spent a lot of time reflecting on why our default is to always do “something.” Something is not always better than nothing and often it at best has unintended negative consequences or worse causes actual harm.
Thank you so much.
The crazy part about the current annual exam is that it doesn’t include an exam in which the patient can say they have this spot on their chest and they don’t know if it’s cancerous or if something is wrong because the doctor will tell them they’re only allowed to ask all the questions, including the depression screening questions that the insurance pays for on the regular annual exam and that your insurance requires you to come in for a separate visit to ask about that spot on your chest. Doctors say it’s even worse for Medicare. Doctors are not allowed to refill a prescription during a regular well check exam now. It seems like the insurance companies are just collecting data.
Depression is not a disease by any reasonable definition and is well outside the bounds of competence and training that goes into medical education. I am old enough to remember when the "chemical imbalance" mantra was first put forward and became the basis for all the pharmaceutical "treatments" that have turned this into a disaster area for kids and adults. I was skeptical at the time and nothing has come along to change my mind since then.
I heard today that the 10 year old daughter of a friend had become "anxious". So she's now on some psych med, quite possibly the escitalopram mentioned in this article. You know, the one that increases the risk of suicide by a significant factor. And no one in that family sees a problem with this.
Well did she did she have increase in suicidal thoughts in the 1st week or 2? Because if she didn't and It loweredHer anxiety she shouldn't stop it as that would causeMore harm
It's true that once you start those meds you're in a bind. She wasn't suicidal BTW, just had some quack diagnose her as OCD and anxious. Now if her mom wants her off the meds she'll have to taper very carefully because the withdrawal symptoms can trigger suicide. I think she's been medicated because it made life easier for her mother. But now she's in a corner. And pharma has another customer for life.
That's a shame. It is bad enough that adults are subjected to this but it is criminal to inflict medication and psychological "therapy" on children who are experiencing the normal ups and downs of childhood.
And risking "post-ssri syndrome" into the bargain, with a 10 year old who will not know what normal ever was.
I know a psych NP who tells me most of the parents he deals with who have children diagnosed with ADHD want nothing to do with non-pharmaceutical treatment. They prefer to use pills on their kids.
When I was teaching at a local state university campus students would come to me with accommodations for ADHD. Almost always male. The most striking thing about these students was their lack of a sense of humor, the part of us that's such a big part of being human in the first place.
In my opinion ADHD is one of those made-up disorders that can be applied to lots of young males during their growth and development. Instead of working through it in normal fashion with parental guidance and tolerance, they are now put on medication that stunts normal psychological development and gives them a life long excuse for failure.
And I know a few young men who know how to answer the questions in order to score a script for Adderall or Vivance. They tell me they don't use it "chronically", merely "acutely", so that they can get stuff done. What a clown show.
I never bought into the concept that the way to treat a hyperactive kid who had difficulty focusing was to give him amphetamines. Seems rather counterintuitive.
edwin.goldstein@va.gov is retiring on Friday, May 31, 2024. Please reroute e-mail notifications to: efgold2@aol.com.
Thank you.
Just so everyone not in primary care is aware, these are the “quality metrics” for my company at present (which follow many HEIDIS and medicare metrics): —
Tobacco screening (with counseling if pos)
- BMI screening ( with counseling if > 30)
- anxiety screen
- depression screen (PHQ2, 9 if needed)
- HgA1C control < 8 for diabetics
- eye exam note in our chart for diabetics (not just the patient saying they had it)
- nephropathy screening, diabetics
- foot exam documented, diabetics
- hypertension control- <140/90 in diabetics and anyone with HTN diagnosis
-colon cancer screening (actual test in chart, not patient say so)
- breast cancer screening
- cervical cancer screening
- and an individual NPS score > 85 minimum and > 92 to get full credit
- notes closed/ locked within 72 hrs
————-
They hold back part of our pay unless meet certain % of these OR pay less and give “bonus” if meet them.
Another thing is insurance companies and various health websites give ratings on how well you do on these and can make you a nonpreferred provider/ make you look like a “bad” doctor if you do not meet them.
And another is if you work for a big system, it is a reason to be “let go”.
Many incentives to do many things that may or may not actually help individual patients.
(Reposted here so maybe more people see, not sure how much the non- primary care/ non medical folks are aware of this behind the scenes stuff)
I was going to smash “like”, because I am glad you shared this. But then I realized, I don’t like this at all. Not one bit. I am sad that primary care has come to this for many of you.
And “nephropathy” screening in diabetics??? Last time I checked, there aren’t really any treatments for that…
My boss asked me yesterday why I needed 40 minutes to do a CPE on a healthy 80 year old. I don't knw if there is anywhere within commuting distance that still allows people to do medicine with humans at the center, but I plan to find out.
I agree with Zade. My last physical was almost nothing but these questions, and me saying, "no" over and over again. I feel like I'm at a car dealership... "window tinting?" No "rust-proofing?" No
Once these metrics get institutionalized, how can we get them undone?
Your note explains a lot about the questions/pestering I now get at my annual physical. Seems like something changed about 5-10 years ago. No one is happy about this.
It’s a pleasure to read such a good article by someone so young. Wish he were in our program.
I am old enough to have missed “the guidelines” and can proudly say I have never performed a depression screen nor do I intend to. (I don’t do OB.) In a very long career I have had only one suicide and that was likely a homicide!