How does your back feel? How's your energy? How's your mood?
There are plenty of people out there with chronic pain and low energy and who walk around feeling terrible all the time. But it never occurs to them that they might be depressed. And our healthcare system doesn't do a good job of connecting them with the screening or treatment that could help them feel better.
At any given moment, about 8% of adults in the US have symptoms of depression. That's far more common than cancer, heart disease, or other major illnesses. And it can lop years off of people's lives. But only about a quarter of those people ever get mental health treatment.
So where do the missing three quarters of depressed people end up?
"Typically where they are is primary care," Joseph Gallo, who researches depression in the elderly at the Johns Hopkins Bloomberg School of Public Health, told Business Insider.
Depressed people turn up in waiting rooms for doctors who've geared their careers toward diagnosing and treating physical symptoms. That's a recipe for misdiagnosis and mistreatment.
Lloyd Sederer, the chief medical officer at the New York state Office of Mental Health, told Business Insider that tha poses a challenge to these physicians.
"They go to their primary care doctor not saying, 'I'm depressed,' but saying, 'I don't have any energy,' or, 'My pain doesn't go away.' Or they have diabetes or heart disease and they don't take care of themselves [and the doctors can't figure out why]," he said.
They go to their primary care doctor not saying, 'I'm depressed,' but saying, 'I don't have any energy,' or, 'My pain doesn't go away.' Or they have diabetes or heart disease and they don't take care of themselves [and the doctors can't figure out why.]
Doctors might misunderstand the symptoms, or not take them seriously, which leads to worse outcomes for patients down the road.
"Depression is sort of like a hidden factor in heart disease, diabetes, and other medical conditions." Gallo said. "Because people don't take care of themselves. They don't adhere to the treatments the way they should. So they have more medical complications. That's a huge issue."
There are programs underway designed to get primary care doctors to screen for depression. Sederer pioneered one such screening program when he worked for the New York City government, which he has since taken statewide.
But both doctors agree that getting physicians to take the time to look for depression, and getting patients to report it, poses a significant challenge.
Primary care doctors are often overwhelmed by their patient loads, and don't feel they have enough time to sit down and ask about someone's feelings.
"Imagine a primary care doctor with 30 people in her waiting room," Sederer said. "She goes into a examining room, and starts to ask somebody questions about their mood, their concentration, whether they want to live. And somebody starts crying. And what does the doctor think? 'Oh my god! I'm not familiar with this. I don't know what to do with this. And my afternoon is ruined because I'm now stuck with this patient.'"
"There's a culture over time we've come to call 'Don't ask, don't tell' primary care," Sederer said.
Gallo adds that a big problem is that many patients with depression don't recognize their own symptoms.
"When you talk to older people and you ask them, 'What do you think the doctor means when they say depression?' they say different things than what the doctor means," Gallo said.
A doctor might think of a diagnosis in terms of a list of symptoms: aches and pains, mood, energy. But patients might not draw the same conclusions. And if they have a mental image of a depressed person, there's a good chance they don't think they match it.
"It doesn't describe how the person thinks of themselves. So to take [on a depression diagnosis] is to take on the identity of the depressed person," he said.
Both doctors believe that a major key to improving treatment access and outcomes for depressed people is to train primary care doctors to recognize it.
Sederer's screening system breaks mental health down to a numerical score, which physicians can measure over time and try to improve with treatment. He says about 80% of patients could be treated that way, without ever seeing a psychiatrist.
But both also agree that there's a long road ahead for changing the way the health care system deals with depression.
Have you struggled to get treatment for depression? Have you lived with depression without knowing you were sick or getting diagnosed? Are you a doctor who's met challenges treating depression in your patients? I want to hear about it. Shoot me an email at email@example.com or Tweet at me at @RafiLetzter. Thanks!
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