Warning - Family Physician

Do you rely on a family physician to diagnose and treat your depression? Perhaps you should reconsider. In January 2001, three studies came to light that strongly suggest primary care physicians are better off poking and prodding our bodies than getting inside our heads.

The first, an Indiana Community Cancer Care-Aetna US Healthcare-Pfizer study of the records of 100 patients who were prescribed antidepressants in primary care, found that 90 charts contained documentation of just three or fewer symptoms of major depression, sixty revealed one or more criteria, and 40 contained no documentation of any criteria. The required five or more symptoms were to be found in only seven charts. Use of screening tools was documented in only four charts. Only 57 of the charts revealed a depression-focused follow-up visit, while just five charts indicated an educational intervention.

In other words, these doctors were indiscriminately handing out meds.

Not surprisingly, only 37 percent of the patients improved. Sixteen percent were referred to specialists. There were two suicide attempts. The article cited other studies suggesting that primary care physicians misdiagnose depression in as many as two out of three cases, and when the correct diagnoses is made, patients are often treated with subtherapeutic doses prescribed over periods of time too short to produce a benefit. The article also noted that 50 percent of patients quit their antidepressants after less than 30 days, but if a follow-up visit was scheduled, 86 percent of patients complied.

According to the authors of the study: "These survey results may add credibility to concerns ... that antidepressants are being used too frequently and without proper consideration and justification."

This is not a minor problem. In 1998, more than 130 million prescriptions for antidepressants were written in the US, the vast majority by primary care physicians, very few who refer their patients to more specialized treatment or counseling.

In the second study, UCLA-Rand researchers found that only 19 percent of a sample of depressed or anxious people they surveyed received appropriate treatment from their primary care physician.

By contrast, 90 percent of those who saw a psychiatrist got proper care.

The study surveyed 1,635 people, more than 80 percent who had seen a health care provider in the past year. On average, only 30 percent received proper treatment.

Those least likely to have benefited were African Americans, men, people with less than a high school education, and those younger than 30 or older than 59.

According to James Underberg MD, who operates a general internal practice in New York City, in an article in WebMD: "In a busy general internal medicine office, physicians often don't have the time to fully explore those kinds of problems. Most of the time, we're limited to ten or 15 minutes."

Enough time to spot a tumor or a heart beat irregularity, perhaps, but nowhere near enough to unearth the silent enemy that is depression and intelligently work with the patient in finding the right treatment. The final study bears this out, a survey of 1,001 patients and 900 primary care physicians commissioned by the National Depressive and Manic-Depressive Association which found that more than than three-quarters of those being treated for major depression felt their illness is not under complete control.

Other key findings include:

While 69 percent of physicians said they usually mention sexual problems as a possible side effect of medications and 47 percent usually mentioned weight gain, only 16 percent of patients reported either problem was ever brought up.

Forty percent of patients believe they have to tolerate avoidable medications side effects compared to just nine percent of physicians who believe side effects can't be avoided. While 90 percent of the patients who had side effects said they told their primary care doctor about them, close to 20 percent also reported that their doctor did not do anything in response.

Almost half of all patients surveyed reported having had side effects, which caused 55 percent to stop taking their antidepressant and 17 percent to skip doses

Seventy-one percent of the physicians said treatment decisions were made jointly with the patients, but only 54 percent of patients concurred. Only 36 percent of patients reported that their doctor asked about their preferences or willingness to tolerate certain side effects before making a decision about which antidepressant to prescribe.

"This data reveals a serious disconnect in the patient/physician relationship," commented Drew Pinsky MD, a participant in the survey. "The most important tool we have to monitor progress during the treatment process is open and effective communication."

Ultimately, responsibility for proper care is in your hands. Try to think of your brain as being every bit as important as your heart and act accordingly.

For three free online issues of McMan's Depression and Bipolar Weekly, email me and put "Sample" in the heading and your email address in the body.

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Discussions

Pat (Dec 25, 2001): I just found your site this morning and am very impressed with the depth and clarity of your articles. I work on a very personal basis with people and am often privy to all their problems. I have been alarmed for years regarding the indiscriminate use of antidepressants without follow-up and without referral to someone with specific mental health training. However, even feeling this way, earlier this year when my 38 year old son became so depressed he could not function I suggested he go to the doctor, tell him all that had happened and how he was feeling to see if there wasn't something that could be done. Though he told my son he suspected Bipolar, this doctor prescribed Paxil instead of referring him to mental health for evaluation. I'm sure you know what happened. My son soon felt better, then was euphoric, but by July was full blown manic with delusions and had to be involuntarily committed to the state hospital. Don't these doctors know what antidepressants alone can do to someone with Bipolar Disorder? I have to wonder how many times this same thing has happened to others with undiagnosed Bipolar Disorder and how many lives have been destroyed or lost in the process. Thanks for letting me vent.

McMan (Dec 25): Hi, Pat. One of the cruelest things about having bipolar is the very medication that promises to be our salvation can turn out to be the most damaging. I have my own minor horror story, which pales in comparison to many of the others I have heard. This is an illness that demands treatment by the best minds in medicine, but the sad reality falls far short.

Eric (Sept 20, 2002): While I agree with most of the articles on this website this is one I must disagree with. I personally believe after my experiences with severe depression that any family doctor or internal medicine doctor should be able to diagnose and treat straightforward depression or anxiety disorders. Any family doc should be able to pinpoint panic attacks, OCD, Generalized Anxiety or depression. And they should be able to treat most cases of unipolar depression and most anxiety cases.

The problem with psychiatrists is they tend to overanalyze constantly and many tend to overmedicate. Most depressives and anxiety patients do not need to be overanalyzed and overmedicated. Most need a straightforward diagnosis and at most, two psychiatry drugs, usually an antidepressant and maybe a benzo short term. Many will do best with just one drug, at the sufficient dosage. Family doctors tend to not do the psychological overanalyzing and do not tend to overmedicate with psychiatric polypharmacy. Many patients do best when not subjected to the strange overanalyzing practice of many psychiatrists.

Where a psychiatrist is needed is for situations where hospitalization is needed, mania or psychosis is present, or the depressed person is not getting sufficient relief from antidepressant drugs ie; "treatment resistant depression." Anytime ECT is deemed necessary, a psychiatrist is obviously needed.

What I'm saying is it just depends on your diagnosis. Most unipolar depressives and anxiety disorders will do just fine with their family doctor. However the more severe psychiatric disorders like bipolar, schizophrenia and psychotic depression usually require a psychiatrist.

McMan (Sept 20): High, Eric. Since writing this article, I ran across an article in Biological Psychiatry that noted that ironically it is easier for most physicians to order expensive and often unnecessary tests for a patient with a vague physical complaint than to spend the extra time necessary to make a more accurate diagnosis or provide education and counseling. You may think pdocs overanalyze, but I submit it is virtually impossible to diagnose and educate a patient in the two minutes PCPs have between tapping the chest and snapping on that latex glove. I wouldn't have my PCP doing bypass surgery on me, and I feel the same way about my brain.

Melissa (Nov 21, 2002): At our last local NAMI meeting, someone pointed out that many area people use their primary care physician for depression under the guise of some physical problem because their insurance will cover it. If they want to use a psychiatrist, they have limited coverage and no choice under contract requirements. Neither one a good idea, really.

I don't think my pdoc overanalyzes anything. He doesn't have the time to. But my primary care physician didn't even know why a bipolar would take Lamictal, much less the side effects associated with it. I'll stick with my pdoc.

Sally (Dec 12, 2002): I have been fortunate in having a family physician that has known us a long time. When my daughter was diagnosed with bipolar disorder during a psychiatric hospitalization, one of the problems I ran into was getting aftercare for her. Adolescent psychiatrists are rare and very busy, even in a city the size of Los Angeles. It would be 2 months before she could even be seen by an adolescent psychiatrist who had familiarity with bipolar disorder in our area. The medications she had been prescribed in the hospital (Neurontin) turned out to be, as the literature has indicated, a dud. I was not about to allow her to suffer for 2 months, so we turned to our family doctor.

He said, first of all, you need to be seen by a psychiatrist. I am really out of my league here. But he was aware of Zyprexa for the treatment of mania and Lexapro as an antidepressant with a calming effect. He placed her on the lowest clinical doses and she had good results. Her psychiatrist, whom she has since seen and will be following up with for regular med checks, felt that it was an appropriate regime.

I might add that my family doctor is married to a psychotherapist, so perhaps he's a bit more aware than some. In addition to prescribing some meds that were helpful, he indicated the need for regular therapy. My daughter sees a psychologist weekly and she feels that that does her as much good as her medications do. She wouldn't relinquish either one.

Squiggles (May 1, 2003): We have a sensitive and conscientious GP
looking after our health in both physical and psychiatric conditions.

Insofar as a question about psychiatric drugs comes up and is referred to resident psychiatrists at the hospital, i think a GP is quite good; but if decisions are made without thorough knowledge of psychiatric drugs, then obviously it is not as good.

I think we are fortunate that our doctor is very flexible to listen to our suggestions and to go to the top psych. dogs when trouble appears.

I cannot tell from experience if just a psychiatrist would be better - there is
always the danger of him or she being an Adlerian or Gestaltist or something - in which case I would rather go to an orthodontist.

p.s. it is always a pleasure to receive your Newsletter Mr. McManamy - thanks for putting in all the work.

Kelley (Feb 13, 2004): My family physician is just out of med school and has had his practice for 3 years. After reading the thoughts on whether or not to use a family physician, I am concerned that I might want to see a psychiatrist instead, though the thought scares me because a psychiatrist may put me on too much medication. I have taken 150 mg of Wellbutrin 2x a day for a year. Due to feelings of worthlessness, agitation, anxiety, mood swings and a sudden sever lack of concentration/memory, and not being able to think as quickly as usual, he prescribed Zyprexa (5mg). Everytime I take a pill it knocks me out for a good 12-14 hours, it puts me right to sleep and if I don't get enough rest, wow, am I agitated and tired and do not want to be bothered. Being a mother of 3 children (3, 6, and 9) I find it hard to find 12-14 hours of time where I am practically a vegetable. It has been 4 months since Zyprexa was prescribed and I still have 3 pills left. Sometimes I find myself cutting them in half. My diagnosis is depression. He has not diagnosed me as bipolar or schizo though from what I have read I would lean toward bipolar. After reading that Zyprexa was for schizophrenia, I freaked out and told him I was uncomfortable taking the drug. He told me that there were other reasons dr's can prescribe zyprexa that were not yet fully documented. I often wonder if I should be taking Wellbutrin and Zyprexa together.

McMan (Feb 13): Hi, Kelley. Zyprexa is FDA-approved to treat mania. However, if it is knocking you out, you should let your doctor know so he can either adjust the dose or try a different med. The onus is on you to inform your doctor.

Silverfox 7/12: My daughter was prescribed an antidepressant at 11 years of age. It sent her into a psychotic episode. The physician was just not versed in early onset bipolar. A general MD does not know that interactions of psychotropic drugs or combinations that can effectively treat the symptoms. They don't keep up with the newer drugs that are much better for individuals with bipolar disorder.

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John McManamy

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These things aren't equipped to pick up depression, nor - in too many cases - are the primary care physicians attached to them.