Late last week, I learned what a bad job I'm doing taking care of people with depression -- assuming I've even made the correct diagnosis. I learned this grim news from a Minnesota report and from an article in the British medical journal, The Lancet.
First, the local bad news. For the first time, Minnesota clinics have received a report card showing how successfully we treat depression. On average, only 4 percent of our patients are in remission from their depression at six months; an important milestone in treatment. The best clinic, HealthPartners Regions-Maplewood, reported 11 percent "success." I haven't received the report card yet, so I don't know how my clinic did.
The bad news from The Lancet came in the form of a study. The authors reviewed 118 studies involving over 50,000 cases of depression diagnosed by general practice doctors. Just over half the cases were properly diagnosed. The most common problem was that these doctors diagnosed patients with depression when they didn't actually have the condition.
What's going on here? Are we really this bad at diagnosing such a common condition and treating it? How can this be so complicated?
Depression is very common. According to the National Institute of Mental Health (NIMH), at any given time there are over 20 million American adults, 9.5 percent of the U.S. adult population, suffering from a mood disorder. Also, depression, like all mental illness, is hard to diagnose.
Though it might seem obvious that someone is depressed, it's not. There's no blood test for it, no simple scan. Anxiety and substance use can complicate the clinical picture. The best thing we've got to make the diagnosis is a "tool" we call the PHQ-9, the patient health questionnaire with nine questions.
Based on the score of this test, we try to determine if someone's depressed or not. As simple as this is, the PHQ-9 isn't used by all clinicians; it hasn't been universally adopted.
But why in the age of "Prozac Nation," are we so unsuccessful at treating the condition? Why are only 4 percent of depression sufferers still suffering six months into treatment? The answers are complicated.
First, this success rate is likely artificially low due to the inability to collect accurate data. Clinics use everything from paper charts to sophisticated electronic medical record systems. There's no simple, easy way to collect information from hundreds of clinics.
Next, not everyone with clinical depression takes medication that's prescribed -- or gets therapy that's recommended. Though we have dozens of effective medications available, many have side effects, they often don't work, they can be expensive and some patients simply don't want to take a drug. People often don't show up for follow-up appointments. We're so busy in clinic that we rarely track people down; we're very passive in this regard.
Finally, many variables are at play: job loss or dissatisfaction, family stress, the economy, poor sleep, other health issues. A medication can help an underlying neurotransmitter imbalance, but it can't fix someone's life circumstances. The list goes on.
So what can be done?
First, clinicians need to do a better job of making an accurate diagnosis in the first place. We need to use the PHQ-9. It's not foolproof, but it's the best we've got.
Next, clinics need to do a better job of flowing up with our patients; if someone doesn't show up for an appointment, we need to be proactive.
We need to offer support, to check in on them, make medications changes when necessary, offer therapy when appropriate, refer to psychiatrists when things are complicated. Integrative mental health services, that is, offering mental health care with specialists in primary care clinics is a huge step in the right direction.
Finally, those doing the data collection need to do it accurately and consistently. I'm certain clinics in Minnesota are doing better than the 4 percent success rate indicates.
The bottom line: With our treatment of depression we have nowhere to go but up.