More Than Half the Days

Posted on by

It was a regular primary care visit and my patient felt well. I clarified several of their questions about how to take their medications properly and why some of the medical treatments we’d prescribed them were important for their overall health and life expectancy. The conversation flowed. They were engaging and exuded positivity.

It came to the part of the visit when I went through my system-generated reminders based on the patient’s medical record (topics and screenings I was supposed to review at certain intervals with my patients as their primary care doctor). Among the reminders was a depression screening questionnaire which was due.

“How many times in the past two weeks have you felt like you would be better off dead? Options are ‘not at all,’ ‘several days,’ ‘more than half the days,’ and ‘every day,’” I said.

“More than half the days,” the patient said. The questionnaire was 9 questions long. By the end, it was clear that the patient had untreated depression. Interesting how the first part of our appointment didn’t suggest depression. To uncover the patient’s depression required additional, and specific, evaluation.

“Tell me more about what you mean by these feelings,” I said walking through their answers to each of the questions on the depression screening questionnaire.

The patient would go on to describe living alone with no friends or family nearby. No activities outside the home. A lifetime of being socially awkward – preferring to be alone because of the awkwardness. Feeling as though they had a hard time connecting with people. “I thought it was just normal for someone my age,” they said, referring to their feelings of sadness and thoughts of death.

How common is depression? Is it normal to be depressed? What exactly is the difference between the medical definition of depression and a transient dark mood?

A lot about being a primary care doctor is brainstorming solutions to life’s persistent problems. Sometimes there are medications that can help, but usually the non-medication interventions and lifestyle changes are just as (or more) important than the medications.

The patient and I discussed how to take their antidepressant correctly (they were already on a medication for depression, but they were not taking it daily as intended due to confusion on how it was designed to be taken).We discussed exercise classes to strengthen the mind and body and to create an avenue to be around other people sometimes. We discussed hobbies and activities that brought them joy. We discussed what might be normal for their age.

This patient was motivated. Perhaps they could find a path to better mental health. It would take time. The brain is the hardest organ to heal. To help ease the journey, my clinic had all kinds of mental health resources (including exercise classes) patients could use for free. When we finished our visit, I walked the patient over to the mental health team’s office attached to my clinic. The mental health team would share with the patient additional resources beyond those offered by primary care such as individual and group therapy sessions.  

The statement, “more than half the days” would resurface in my thoughts for weeks to come. Not because it was unusual, but because depression is so common. I’ve known how common depression is since I entered healthcare. But, for the first time, I have the chance to help some patients find a path to healing now that I’m a primary care physician. Of course, the clinic where I work is special and has more mental health resources than most primary care clinics in the US.

What would I have done for this patient and others like them if my clinic was not set up to help people with mental health challenges? What if there were no therapists, wellness classes, or psychiatrists on staff to help any patient who came through my door? What if this patient had to wait for months before they could be seen for their mental health concerns?

When the phrase “more than half the days,” crossed my mind I thought about the 1000s of people walking around feeling they’d be better off dead more than half the days of their lives. I thought of the probability of there being time during their regular primary care visit to be properly diagnosed with depression. I thought about the probability of their primary care clinic having the resources needed to help them if their depression was diagnosed. The math suggested that many people’s depression would go undiagnosed or, if diagnosed, untreated because many people couldn’t access the treatments they needed. To be profitable primary care appointments get shorter and shorter, with many clinics scheduling appointments that are 20 minutes or less. The length of the appointment doesn’t factor in the complexity of the patient even though as patients become more medically complex, a 20-minute appointment becomes more absurd. Between health insurance access issues, healthcare costs, and healthcare professional shortages many patients don’t have access to medications, therapy, and other mental health treatments that have been proven to work.

Healthcare in the US has so much opportunity for improvement it’s maddening. No setting reminds me of this more than primary care. No disease category reminds me of this more than mental health. The better I know the US healthcare system, the less hopeful I become that it will ever serve all people. But sometimes there are little micro settings where all the resources a patient needs are there if they choose to use them. This patient was in that situation and, so, I was hopeful that they’d find a future in which they felt better off alive than dead more than half the days. I was hopeful that they wouldn’t die by suicide.

Depression can be sticky and hard to overcome in the best circumstances. But depression, like all diseases, is more likely to be cured when the patient can access the best treatments. The more I learn about healthcare, the more I believe everyone should have access to the best treatment for the most common conditions. And, currently, that is not the reality in America.

References: