Mental health questions from physical health providers
May 14, 2022 2:25 AM Subscribe
I’ve recently been to a variety of different health care providers for a specific physical complaint. As part of the intake at each visit, each of them has asked a version of the question “In the past two weeks have you felt depression/hopelessness/despair?” Why is this asked, and how is this information used?
Sometimes this is asked on an electronic or paper form I fill out, sometimes it’s part of the set of questions asked in person by a nurse or PA before I see the doctor. The physical therapy assessment that I take every every few weeks to track progress also asks this question. Is this new? Is it mandated by some standard of care or governing body? For me, the actual answer is usually yes but I sort of randomly answer yes or no depending on how forthright I’m feeling on a given day, and it doesn’t seem to matter one way or the other - if I say yes there is no follow up that I’m aware of. Does saying yes create a flag somewhere? Does it make it more likely that a doctor will dismiss physical symptoms as psychosomatic? Why two weeks in particular? What’s behind this question? Hoping especially to hear from folks who work in health care and have direct experience with this. I’m in the USA.
Sometimes this is asked on an electronic or paper form I fill out, sometimes it’s part of the set of questions asked in person by a nurse or PA before I see the doctor. The physical therapy assessment that I take every every few weeks to track progress also asks this question. Is this new? Is it mandated by some standard of care or governing body? For me, the actual answer is usually yes but I sort of randomly answer yes or no depending on how forthright I’m feeling on a given day, and it doesn’t seem to matter one way or the other - if I say yes there is no follow up that I’m aware of. Does saying yes create a flag somewhere? Does it make it more likely that a doctor will dismiss physical symptoms as psychosomatic? Why two weeks in particular? What’s behind this question? Hoping especially to hear from folks who work in health care and have direct experience with this. I’m in the USA.
I'm a neurologist in the US. We are required to screen for depression in all patients at least yearly. I'm actually part of a patient/physician study on improving depression screening. Our study uses the Geriatric Depression Scale, but on a clinical level my center uses the PHQ-2/9. Two weeks is the standard interval on these sorts of questionnaires.
Every visit seems like a lot, but it's easier to tell the MA or the electronic medical record to ask everyone instead of tracking only the people who were last asked this a year ago.
At least in my center, the info gets buried in Epic crap and is rarely used clinically. There is talk of creating a "mental health vital sign", like BP, to make it more apparent. I have mixed feelings on this; it reminds me of the efforts to make pain a vital sign about 10 years ago, and look at the mess that landed us in.
That said, I almost always ask my patients directly about their mood, because the conditions I see are strongly associated with depression, often unrecognized / untreated. When I was a fellow, a patient of mine died by suicide while I was out of town (I came back to the office to a voicemail from him... and then his brother) and it's haunted me ever since.
I'm sorry if your doctor is the sort who would dismiss your symptoms if they see depression in your chart. I have little tolerance for jerk behaviors from my colleagues, though of course not everyone has the privilege to be able to switch to a better provider.
posted by basalganglia at 3:10 AM on May 14, 2022 [30 favorites]
Every visit seems like a lot, but it's easier to tell the MA or the electronic medical record to ask everyone instead of tracking only the people who were last asked this a year ago.
At least in my center, the info gets buried in Epic crap and is rarely used clinically. There is talk of creating a "mental health vital sign", like BP, to make it more apparent. I have mixed feelings on this; it reminds me of the efforts to make pain a vital sign about 10 years ago, and look at the mess that landed us in.
That said, I almost always ask my patients directly about their mood, because the conditions I see are strongly associated with depression, often unrecognized / untreated. When I was a fellow, a patient of mine died by suicide while I was out of town (I came back to the office to a voicemail from him... and then his brother) and it's haunted me ever since.
I'm sorry if your doctor is the sort who would dismiss your symptoms if they see depression in your chart. I have little tolerance for jerk behaviors from my colleagues, though of course not everyone has the privilege to be able to switch to a better provider.
posted by basalganglia at 3:10 AM on May 14, 2022 [30 favorites]
panama joe, do you really mean that? In all circumstances?
What about post-partum people who have post-partum depression? Should they not disclose this to their OB doc? How about people who are considering suicide? I have had professional interactions with people I barely knew who disclosed that they "have a plan and are ready" to commit suicide. We obtained emergency psychiatric care in these cases. Would you have them not disclose this because it might be held against them by the insurer?
posted by citygirl at 6:22 AM on May 14, 2022 [8 favorites]
What about post-partum people who have post-partum depression? Should they not disclose this to their OB doc? How about people who are considering suicide? I have had professional interactions with people I barely knew who disclosed that they "have a plan and are ready" to commit suicide. We obtained emergency psychiatric care in these cases. Would you have them not disclose this because it might be held against them by the insurer?
posted by citygirl at 6:22 AM on May 14, 2022 [8 favorites]
Depression runs in my family. My experience - I had had something pretty awful happen to me not long before my visit.
I answered yes, then came more questions, which I answered yes to. I explained the circumstance, and that I knew it would get better. At which point my GP cut off my anti-depressants and told me I needed to see a psychiatrist.
Bad, it's now more of a hassle to obtain my meds.
Good, the psychiatrist started me on a new regimen (my GP was afraid to change what I had been doing for 30 years) and the cloud has lifted a bit.
posted by rudd135 at 6:48 AM on May 14, 2022 [3 favorites]
I answered yes, then came more questions, which I answered yes to. I explained the circumstance, and that I knew it would get better. At which point my GP cut off my anti-depressants and told me I needed to see a psychiatrist.
Bad, it's now more of a hassle to obtain my meds.
Good, the psychiatrist started me on a new regimen (my GP was afraid to change what I had been doing for 30 years) and the cloud has lifted a bit.
posted by rudd135 at 6:48 AM on May 14, 2022 [3 favorites]
Hey anonymous. It might be worth you checking in with a mental health professional, because feeling depression, hopelessness, or despair as consistently as you describe is something to worry about and get checked out.
Sending you a big hug through the internet.
posted by EllaEm at 6:52 AM on May 14, 2022 [9 favorites]
Sending you a big hug through the internet.
posted by EllaEm at 6:52 AM on May 14, 2022 [9 favorites]
To add to what citygirl points out (I've had those emergency psych calls, too -- it's traumatic for everyone involved, but far less traumatic than a suicide), I've also seen people have devastating outcomes (stroke, seizure, coma) when a non-disclosed drug -- recreational or prescribed -- interacted with something else they were given. This is what happened to Libby Zion, for instance, and lots of other people whose parents didn't have the clout to launch a full-scale investigation into the death of their child.
Of course, disclosure requires trust, and people esp from marginalized communities have very good reasons not to trust the system!
posted by basalganglia at 6:57 AM on May 14, 2022 [3 favorites]
Of course, disclosure requires trust, and people esp from marginalized communities have very good reasons not to trust the system!
posted by basalganglia at 6:57 AM on May 14, 2022 [3 favorites]
Can confirm that every initial intake exam at various medical offices have included a question or two re:mental health.
I recently made the mistake and answered the questions brutally honestly (it was with a physical therapist) and all that did was trigger a “if you would like, we can give you information on available mental health and suicide prevention resources” response.
posted by Thorzdad at 7:57 AM on May 14, 2022 [3 favorites]
I recently made the mistake and answered the questions brutally honestly (it was with a physical therapist) and all that did was trigger a “if you would like, we can give you information on available mental health and suicide prevention resources” response.
posted by Thorzdad at 7:57 AM on May 14, 2022 [3 favorites]
In the past, many doctors did not fully assess or pay attention to depression and suicidal feelings. The depression screening is to assess the patient. It's standard protocol at most health care providers. It also exists to make sure health care providers follow up on and treat depression and suicidal feelings. Depression is a genuine physical illness with significant effects, up to and including death by suicide.
Real understanding of mental health is rudimentary in my opinion and experience, but the screening is a big step forward. If you are depressed, it can be really hard to have the energy to reach out. You may need to work with more than 1 provider and try different meds, but I hope you will get any help you need; it can dramatically upgrade your daily life.
posted by theora55 at 8:03 AM on May 14, 2022
Real understanding of mental health is rudimentary in my opinion and experience, but the screening is a big step forward. If you are depressed, it can be really hard to have the energy to reach out. You may need to work with more than 1 provider and try different meds, but I hope you will get any help you need; it can dramatically upgrade your daily life.
posted by theora55 at 8:03 AM on May 14, 2022
Since Covid started, it's become a "thing" in the area where I live that pretty much all medical professionals are doing some version of this. One provider explained, when I expressed surprise at how common it had become, that the increase was intentional and directly related to the new mental health issues many were experiencing due to the pandemic. It's an active movement to connect with those who might not reach otherwise reach out.
posted by stormyteal at 9:04 AM on May 14, 2022 [3 favorites]
posted by stormyteal at 9:04 AM on May 14, 2022 [3 favorites]
This is so tricky. When I had bad postpartum depression, those questions were useful. But also the depression was not...subtle. Like, it would have surfaced without a screening question. On the other hand, it took years for a severe immune disorder to be diagnosed because fatigue, difficulty with daily tasks, etc. kept getting flagged as a mental health issue. (I am a woman and I think sexism probably played a significant role in this as well.) So, 1) Yes. I always get asked this at doctor's appointments and medical intake forms and 2) while I think the intention is good the outcomes are mixed. Such is life, I guess.
posted by jeszac at 9:35 AM on May 14, 2022 [1 favorite]
posted by jeszac at 9:35 AM on May 14, 2022 [1 favorite]
Depression screenings are becoming far more routine than historically have occurred. This is on par with why your blood pressure is taken even if you come in to a clinic, regardless of if that’s even tangentially associated with your current problem.
This has been made fairly standard for all children seeking medical care, much to the chagrin of mental health professionals who have long since reached carrying capacity.
posted by furnace.heart at 10:02 AM on May 14, 2022 [1 favorite]
This has been made fairly standard for all children seeking medical care, much to the chagrin of mental health professionals who have long since reached carrying capacity.
posted by furnace.heart at 10:02 AM on May 14, 2022 [1 favorite]
A lot of folks have covered the clinical side here, but to offer a brief perspective from someone in (academic) medical research that uses these metrics in pretty much every analysis we run:
In a very general sense, a lot of the research we do involves the relationship between chronic pain and depression. The correlation is well established and we know that treating both together consistently leads to better results for both than treating either in isolation will do. But, chronic pain and depression are both extremely tricky to study. Unlike, say, blood pressure or A1C values or "current smoker; Y/N?", there are no purely objective ways to diagnose them or measure severity. Having these as a discrete value in a cross-sectional analysis can be useful, but for the kind of research we do having a series of values is where they really become important. Your personal value on Tuesday, the 10th doesn't matter much to me in a vacuum. But having a series of values allows us to run different kinds of analyses. I might want to see if people with chronic pain that see a physical therapist have trends in one direction or the other in their PHQ scores. To do this I'll need to account for a variety of other variables (demographics/SES, duration of treatment, other treatments tried, other diagnoses like hypertension or COPD etc. etc.) to get as close as I can to seeing the direct effect PT has on the depression values of patients with a Chronic Pain diagnosis. If I also have pain metrics that most PT patients use (generally there's a "severity" and an "interference" metric) I can then see if depression changes in chronic pain patients that use PT independently of pain severity (and again, these are objective measures, so they're really most useful when you have a series of them and can check for variance in scores).
Anyways, I don't want to get too into the weeds here, but there's an example of a non (directly) clinical way that this info is useful.
Depression (and Anxiety, measured by the PHQs good friend the GAD) hit the sweet spot trifecta of being quick/easy to record, clinically relevant/commonly diagnosed, and can be variable over the course of a patient's lifetime. From a researcher's perspective, we would *love* to have a ton more information collected at each point of contact, but that's not a reasonable ask of our clinical providers, their staff, or their patients.
As to who all is using your personal medical record: that likely depends on who your provider is affiliated with. Primary data collection is ideal, but is also expensive and time-consuming (and frankly a pain in the ass) so EMRs are very useful. We get access to those in a variety of ways, but most often via the major regional healthcare network our academic institution is affiliated with. There are also health record data brokers that work out legal agreements with providers (either independent or a network) to purchase records, clean them up, and lease access to them for research purposes. These are great (they're usually massive data sets, minimum 500,000 patients, often much more, with a series of visits within a network of providers) but are also pretty damn expensive, at least for us in the non-profit world, although we have successfully built the cost into the expenses of grant applications. The VA uses a similar Virtual Data Warehouse for their records, which is about the most secure, large EMR you're likely to find in the States.
posted by Ufez Jones at 1:42 PM on May 14, 2022 [5 favorites]
In a very general sense, a lot of the research we do involves the relationship between chronic pain and depression. The correlation is well established and we know that treating both together consistently leads to better results for both than treating either in isolation will do. But, chronic pain and depression are both extremely tricky to study. Unlike, say, blood pressure or A1C values or "current smoker; Y/N?", there are no purely objective ways to diagnose them or measure severity. Having these as a discrete value in a cross-sectional analysis can be useful, but for the kind of research we do having a series of values is where they really become important. Your personal value on Tuesday, the 10th doesn't matter much to me in a vacuum. But having a series of values allows us to run different kinds of analyses. I might want to see if people with chronic pain that see a physical therapist have trends in one direction or the other in their PHQ scores. To do this I'll need to account for a variety of other variables (demographics/SES, duration of treatment, other treatments tried, other diagnoses like hypertension or COPD etc. etc.) to get as close as I can to seeing the direct effect PT has on the depression values of patients with a Chronic Pain diagnosis. If I also have pain metrics that most PT patients use (generally there's a "severity" and an "interference" metric) I can then see if depression changes in chronic pain patients that use PT independently of pain severity (and again, these are objective measures, so they're really most useful when you have a series of them and can check for variance in scores).
Anyways, I don't want to get too into the weeds here, but there's an example of a non (directly) clinical way that this info is useful.
Depression (and Anxiety, measured by the PHQs good friend the GAD) hit the sweet spot trifecta of being quick/easy to record, clinically relevant/commonly diagnosed, and can be variable over the course of a patient's lifetime. From a researcher's perspective, we would *love* to have a ton more information collected at each point of contact, but that's not a reasonable ask of our clinical providers, their staff, or their patients.
As to who all is using your personal medical record: that likely depends on who your provider is affiliated with. Primary data collection is ideal, but is also expensive and time-consuming (and frankly a pain in the ass) so EMRs are very useful. We get access to those in a variety of ways, but most often via the major regional healthcare network our academic institution is affiliated with. There are also health record data brokers that work out legal agreements with providers (either independent or a network) to purchase records, clean them up, and lease access to them for research purposes. These are great (they're usually massive data sets, minimum 500,000 patients, often much more, with a series of visits within a network of providers) but are also pretty damn expensive, at least for us in the non-profit world, although we have successfully built the cost into the expenses of grant applications. The VA uses a similar Virtual Data Warehouse for their records, which is about the most secure, large EMR you're likely to find in the States.
posted by Ufez Jones at 1:42 PM on May 14, 2022 [5 favorites]
Oh - and this is not why you're answering these questions at your PT's office - from an epidemiological perspective, having all of these values in the before-and-after times is going to be invaluable when it comes to attempting to assess the impact something massive like COVID (or a natural disaster, or anything else that collectively traumatizes at a societal level) has in both the short and long terms on a population. Eventually, and I'm sure there are several teams already hard at work on this, public health research is going to have to reach some sort of collective agreement as to how to account for a global pandemic for the foreseeable future.
posted by Ufez Jones at 2:47 PM on May 14, 2022 [2 favorites]
posted by Ufez Jones at 2:47 PM on May 14, 2022 [2 favorites]
the screening is a big step forward
but it doesn't do anything.
I mean: it doesn't do anything good. there is some possibility that it will someday contribute to doing something very bad, insofar as official on-the-record depression is not something you want every non-psychiatric medical person to know about you if you have any plans to one day get in a painful car accident or similar. since it is one of many data points that factor into an arcane formula sometimes used, by some people and in some places, to determine your abuse risk profile re: prescription meds. so are some other psychiatric conditions. so is a history of sexual assault.
in terms of it being a step forward re: simply recognizing depression as a physical illness, I would say that recognition without treatment or assistance is sometimes worse than no recognition at all. my emotions are my own business but I have consistently answered Yes to the only two questions about physical symptoms that I remember being on there, which are Do I have sleep troubles bad enough to destroy my life? & Have I had unexplained weight loss recently? yes I do and yes I have, and I have said so consistently for a couple of years now.
these answers have never been addressed or acknowledged in any way whatsoever, by anyone, ever.
of course, as physical symptoms, they don't necessarily indicate depression (in my particular case I have a pretty good idea of their respective causes, but I have learned not to offer my opinion to doctors unless they ask for it.) they can also indicate things that are a lot worse. so this does not improve my opinion of the questionnaire's usefulness.
If you are depressed, you should tell the truth about it when asked if and only if you are interested in accessing medical treatment for depression. however, doing so will not actually be sufficient to start the process of accessing treatment, and this is very important to know. a depressed person might reasonably believe that answering truthfully constitutes asking for help. and going through what you believe to be the correct avenue to seek help and finding that nothing at all happens can, if you are depressed, be demoralizing or worse.
posted by queenofbithynia at 7:43 PM on May 14, 2022 [6 favorites]
but it doesn't do anything.
I mean: it doesn't do anything good. there is some possibility that it will someday contribute to doing something very bad, insofar as official on-the-record depression is not something you want every non-psychiatric medical person to know about you if you have any plans to one day get in a painful car accident or similar. since it is one of many data points that factor into an arcane formula sometimes used, by some people and in some places, to determine your abuse risk profile re: prescription meds. so are some other psychiatric conditions. so is a history of sexual assault.
in terms of it being a step forward re: simply recognizing depression as a physical illness, I would say that recognition without treatment or assistance is sometimes worse than no recognition at all. my emotions are my own business but I have consistently answered Yes to the only two questions about physical symptoms that I remember being on there, which are Do I have sleep troubles bad enough to destroy my life? & Have I had unexplained weight loss recently? yes I do and yes I have, and I have said so consistently for a couple of years now.
these answers have never been addressed or acknowledged in any way whatsoever, by anyone, ever.
of course, as physical symptoms, they don't necessarily indicate depression (in my particular case I have a pretty good idea of their respective causes, but I have learned not to offer my opinion to doctors unless they ask for it.) they can also indicate things that are a lot worse. so this does not improve my opinion of the questionnaire's usefulness.
If you are depressed, you should tell the truth about it when asked if and only if you are interested in accessing medical treatment for depression. however, doing so will not actually be sufficient to start the process of accessing treatment, and this is very important to know. a depressed person might reasonably believe that answering truthfully constitutes asking for help. and going through what you believe to be the correct avenue to seek help and finding that nothing at all happens can, if you are depressed, be demoralizing or worse.
posted by queenofbithynia at 7:43 PM on May 14, 2022 [6 favorites]
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