Sunday, May 07, 2006

Mental Health and Primary Care

There is a commentary in the 5/2/2006 Philadelphia Inquirer about the re-definition of normal modes of being, as disorders. Dr. Dworkin clearly states the current problem:

Doctors now view everyday unhappiness and clinical depression as lying on a continuum, with biochemistry accounting for the whole range of human moods, from pathological to normal variants. Whether a patient suffers from clinical depression or just everyday unhappiness is immaterial because neurotransmitter imbalance is thought to be the cause of both. In both conditions, antidepressants are the treatment of choice.

Statistics affirm the new attitudes. In the United States, doctors treat both major and minor depression with medication at roughly the same rate, even as the symptoms of minor depression merge into everyday unhappiness. In one study, for example, doctors medicated 77 percent of their patients with major depression, yet practically the same proportion (68 percent) of patients suffering from minor depression received the same treatment.

And he notes one surprising cause of the medicalization of different degrees of normal experience:

Perhaps the most curious thing about the new physician attitudes is the branch of medicine that has embraced them. For the last 40 years, critics of the medical approach to unhappiness have focused their attacks on psychiatry. Yet the movement to treat unhappiness with drugs originated in primary care, which remains the force behind the movement to this day. It was primary-care doctors who overprescribed Valium in the late 1960s; it is primary-care doctors who overprescribe drugs like Prozac and Zoloft today.

From 1988 to 1998, the prescription rate for psychotropic drugs tripled in the United States, with antidepressants accounting for most of the increase. Primary-care doctors wrote 75 percent of the new antidepressant prescriptions during this period. According to IMS Health, a health-care consulting firm, from 1998 to the present, the prescription rate for antidepressants doubled again - with primary-care doctors writing the majority of these prescriptions.

Primary care doctors are the gatekeepers of modern medicine. As such, there are great demands placed upon them to optimize the use of medical resources. Throughout medical school, end even into residency, I watched, appalled, as primary care doctors usually tried to move patients with psychosocial problems right out of their offices. Psyhological concerns take time to address. And in a busy primary care office, time is tremendously valuable and the demands placed upon outpatient physicians to see as many patients as possible effectively forces well-meaning physicians to skim-over these patients and leave their concerns unaddressed. Maybe it is a misuse of resources for patients with sub/non-clinical sadness to visit a primary care doctor to have their concerns addressed, but how would they know where else to go? Primary care physicians may be exacerbating patients' problems by "treating" normality and introducing people to potentially very problematic side effects.

Really, this is pitiful and tragic: imagine a patient who comes to his doctor's office complaining of "stress" or "sadness" about a current relationship, who leaves with a prescription for an SSRI. That SSRI then causes sexual dysfunction and the patient's problems multiply.

What to do? Refer. Primary care physicians maybe should not be the gatekeepers when it comes to deciding who should get mental health care. Maybe primary care doctors should refer directly to a psychologist or a psychiatrist. This proposition really is not that outlandish. Physicians are held to the practice standards of specialists, when those specialists are available. For instance, a primary care doc who wants to set a broken leg would be held to the standard of care that is provided by the local orthopedist. If the primary care doc can't provide that level of care, he should refer, or be held liable for malpractice.

If a primary care doctor cannot handle mental illness, or even rule it out effectively (which is the problem posed by the Inquirer article), at the same standards to which psychiatrists are held, then that doctor should refer that patient to a psychiatrist, not just send the patient home with a prescription for sertraline, paroxetine, or, heaven forbid, that fluoextine/olanzapine combo for bipolar depression.