Depression

\"depression\" The decreasing number of PCP\’s is well documented (perhaps too much).  This means job security for me (to some extent) and hopefully will eventually give physicians like me some leverage.

At this moment in time, this scarcity does not affect me nearly as much as the lack of good psychiatric physicians in our area.  I find that I spend a lot of my time trying to stabilize people in crisis and get them to as good of help emotionally as possible.  This is a huge portion of my workload that puts a big stress on me and my practice.

When I think about it, it only makes sense: people are much more comfortable coming to see me for anxiety and depression than to go to a psychiatrist.  They know me and are comfortable talking to me.  Coming to see me does not carry with it the "shame" of seeing a psychiatrist.  Besides, I am covered by insurance and much cheaper by the hour.

But I have not been trained to do psychiatry.  I am an amateur. But with the lack of psychiatrists, I don\’t have the option of downloading these on psychiatry.  The closest appointment with psych is usually several months in the future (unless I call in a favor and get them to see a patient sooner – which I don\’t do too often).  Plus, the level of depression people are dealing with when they come to me may not be high enough to merit visits to psychiatry – much in the same way that I manage most of my asthmatics without a pulmonologist. 

So I have had to develop my own style of handling things.  Several factors are in play when I deal with a psychiatric problem:

  • I have limited time – I have only 15-30 minutes to handle their problems.
  • I cannot do "therapy" with the patient.  I have not been trained to do this, and I should not pretend I can do something I have not done.
  • There are often psychiatric problems lurking behind physical complaints – either as the primary problem (e.g. palpitations caused by anxiety, fatigue caused by depression), or secondary to physical problems (e.g. chronic disease causing depression, an "abnormal x-ray" making patient worry about cancer).
  • There is a statistic that says that a high percent of patients who commit suicide have seen their doctor within the last week.  This is always a lurking fear that makes it hard to rush through these visits.  I don\’t want to miss a chance to avert suicide.
  • Some of my patients come from incredibly dysfunctional situations that I can do nothing about.

\"NorthProps\"How I have handled depression has changed over the years.  When I first started, I felt that any person who asked for an antidepressant should probably get one.  Why not make them feel better?  Why not help the emotion improve when you have the tools to do so?  The medications really do make people feel better, which is very gratifying.  It is very easy to just give a prescription and to not engage the person in conversation about the root problem, especially with my lack of time or training.

I approach depression differently now.  Having observed people over the 14 years I have practiced, I think that there are times when it is actually to the person\’s detriment to take medication.  I am not referring to the potential of adverse events or side effects, but more to the fact that it is not always good to avoid going through hard times.  This is difficult to get across to the patient, however, and runs the risk of coming off sounding patronizing. 

To help me get my message quickly to patients, I have developed several illustrations that explain depression and my approach to it.

  1. Medications for depression are like a prop that holds a wall up that is falling down.  If you hammer on the wall before you put the prop up, you may knock the wall over.  The prop is important to stabilize things.  Some people, however, are content to put the prop up and call the problem solved.  Taking medication alone makes it possible to do what needs to be done to find out what is really causing problems.
  2. If someone comes to my office with chest pressure, I don\’t simply give them pain medications to make their symptoms go away.  In fact, treating the pain may actually harm the person by giving them a false sense of everything being OK.  The pain is there for a reason, and finding out why it is there is more important than making it go away.

How do you tell when someone needs medications?  Once the anxiety or depression are so bad that it is not possible to face the difficult things in life that are causing the depression, then medications are a good idea.  The goal is not an elimination of pain, but a healing of the root problem. 

\"JUMP_FOR_JOY\" The irony of all of this is that the large number of anxious/depressed patients coming through the office causes me to be very anxious.  I often feel like I am flying by the seat of my pants.  I am the best care available for many people for these crises in their lives, yet I worry that missteps in this area can have significant consequences.  I am not able to make them emotionally whole when their past is full of trauma or their relationships are all dysfunctional.

So I am left to do my best, try to know where I need to send people on to psychiatry, and not make any huge mistakes.  It can make me feel pretty sucked-dry at the end of the day. 

Then there are those things in my own personal life to attend to….

It\’s a good thing that I am so emotionally secure and fulfilled.

18 thoughts on “Depression”

  1. Isn’t it a good thing to be emotionally secure and fulfilled? Scary to think we (I don’t treat patient’s depression, but sometimes see it when they come in asking for a cosmetic procedure) might miss something. At least, for me it is. Keep up the good work, thoughtful work.

  2. Isn’t it a good thing to be emotionally secure and fulfilled? Scary to think we (I don’t treat patient’s depression, but sometimes see it when they come in asking for a cosmetic procedure) might miss something. At least, for me it is. Keep up the good work, thoughtful work.

  3. When I was in Vietnam, I saw lots of guys who were stressed out. Normally I did what I could, but on one occasion I had a patient who seemed headed over the edge. There was only one shrink in Vietnam, in Saigon, and it took me three days to get hold of him. When I described the situation, he said “Look, I’m the only psychiatrist in the whole theater. I simply can’t see anyone unless they’re truly psychotic. You’ll have to deal with this guy yourself.” And that was that.
    A few weeks later, I had a patient who’d truly gone psychotic. After the usual three days, I finally got a call back from Saigon. When I told him about the patient, he said, “Well he sounds psychotic all right. Send him back to the States.”

  4. When I was in Vietnam, I saw lots of guys who were stressed out. Normally I did what I could, but on one occasion I had a patient who seemed headed over the edge. There was only one shrink in Vietnam, in Saigon, and it took me three days to get hold of him. When I described the situation, he said “Look, I’m the only psychiatrist in the whole theater. I simply can’t see anyone unless they’re truly psychotic. You’ll have to deal with this guy yourself.” And that was that.
    A few weeks later, I had a patient who’d truly gone psychotic. After the usual three days, I finally got a call back from Saigon. When I told him about the patient, he said, “Well he sounds psychotic all right. Send him back to the States.”

  5. Such a shame so many are hurting. #2 in your post says it perfectly, “The pain is there for a reason, and finding out why it is there is more important than making it go away.”
    We are all so busy, and continually in motion these days that people barely have time to process how their day went, let alone calm the wounds that have taken root over time.

  6. Such a shame so many are hurting. #2 in your post says it perfectly, “The pain is there for a reason, and finding out why it is there is more important than making it go away.”
    We are all so busy, and continually in motion these days that people barely have time to process how their day went, let alone calm the wounds that have taken root over time.

  7. Great post, Rob.
    I appreciate a lot of your sentiment. I too am becoming a little less likely to pick up the pen as soon as I see a chief complaint of “crying all the time” or “really stressed out”.

    I think that it is equal parts being more comfortable in assessing depression and being more familiar with my patients. Some of them are looking for me to say “You can deal with this without medication,” and it helps them to have courage to carry on. Of course, I always see them back in a few weeks to assess if my instincts were right. And some of them I feel really need the pharmacologic help. I’m much more likely to prescribe to people I don’t know well.

  8. Great post, Rob.
    I appreciate a lot of your sentiment. I too am becoming a little less likely to pick up the pen as soon as I see a chief complaint of “crying all the time” or “really stressed out”.

    I think that it is equal parts being more comfortable in assessing depression and being more familiar with my patients. Some of them are looking for me to say “You can deal with this without medication,” and it helps them to have courage to carry on. Of course, I always see them back in a few weeks to assess if my instincts were right. And some of them I feel really need the pharmacologic help. I’m much more likely to prescribe to people I don’t know well.

  9. Excellent post Rob!
    I actually wrote you a post size comment but was already getting blogger’s remorse at the size of it. So I may do it as a post sometime or not.

    I think using medications can be like putting a bandaid on a festering wound allowing the cause of infection to spread and do more damage. Cleaning it out hurts but chance for best recovery. And then there are times it can be a lifesaver.

    I think your analogies are excellent too.

    Again…your patients are blessed to have you.

    Just remember to keep your balance so you don’t get burned out because then you won’t be able to help all you want to. I’m glad you have your wonderful support system.

    And of course Zippy the Lobster probably keeps you in line too because he wants you up and running to attend to his needs. Promoting a rubber (sorry Zippy) Lobster can be time consuming, especially as his popularity and ego grows. 🙂

  10. Excellent post Rob!
    I actually wrote you a post size comment but was already getting blogger’s remorse at the size of it. So I may do it as a post sometime or not.

    I think using medications can be like putting a bandaid on a festering wound allowing the cause of infection to spread and do more damage. Cleaning it out hurts but chance for best recovery. And then there are times it can be a lifesaver.

    I think your analogies are excellent too.

    Again…your patients are blessed to have you.

    Just remember to keep your balance so you don’t get burned out because then you won’t be able to help all you want to. I’m glad you have your wonderful support system.

    And of course Zippy the Lobster probably keeps you in line too because he wants you up and running to attend to his needs. Promoting a rubber (sorry Zippy) Lobster can be time consuming, especially as his popularity and ego grows. 🙂

  11. I think it would be a good idea to refer your patients to therapists. Psychologists or licenced clinical social workers etc…. They are usually better trained therapists than psychiatrists. They also usually have a bunch of psychiatrists on speed dial if needed. However, every person is different. I was recently diagnoses as being bipolar. My primary doctor referred me to a psychologist who spent a half a day a wek at their office. He then referred me to a psychiatrist.
    Just my thoughts. I agree that many people are just having distressing life issues that should not be medicated.

    Just a word of advice…if anyone admits to suicidal thoughts and tries to convince you that they are “fleeting.” That may be a huge red flag.

  12. I think it would be a good idea to refer your patients to therapists. Psychologists or licenced clinical social workers etc…. They are usually better trained therapists than psychiatrists. They also usually have a bunch of psychiatrists on speed dial if needed. However, every person is different. I was recently diagnoses as being bipolar. My primary doctor referred me to a psychologist who spent a half a day a wek at their office. He then referred me to a psychiatrist.
    Just my thoughts. I agree that many people are just having distressing life issues that should not be medicated.

    Just a word of advice…if anyone admits to suicidal thoughts and tries to convince you that they are “fleeting.” That may be a huge red flag.

  13. Some patients are open to this, and to those I do recommend therapists. It is only the very difficult patients I refer to psychiatry. Still, even those patients I refer, many will not go for either the cost or pride on their part. It is hard to send them there. I note that I have tried, but cannot force the issue.

  14. Some patients are open to this, and to those I do recommend therapists. It is only the very difficult patients I refer to psychiatry. Still, even those patients I refer, many will not go for either the cost or pride on their part. It is hard to send them there. I note that I have tried, but cannot force the issue.

  15. I think that primary care physicians should routinley screen new patients for mental illness. I think it might be pretty easy to pick out a problem in their regular patients. I think that Psychiatrist should have some guidlines they could distribute to GPs; when to treat, when to refer, when to call the ER.

  16. I think that primary care physicians should routinley screen new patients for mental illness. I think it might be pretty easy to pick out a problem in their regular patients. I think that Psychiatrist should have some guidlines they could distribute to GPs; when to treat, when to refer, when to call the ER.

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