IT’S NOT ALWAYS DEPRESSION!

Diminished activity, fatigue, weight gain and little interest in activities that once brought delight.

With normal laboratory findings, most doctors would diagnose depression.

It’s not always depression!

Other physical ailments presenting similarly make the history and physical pertinent, as well as understanding culture and the differences in the clinical narrative due to culture.

To simply say it is depression, without a thorough review of all symptoms, is to jeopardize the health of patients. Plus not appreciate the impact of culture on health outcomes.

Unfortunately, nowadays, that is the case. Most doctors don’t dig deeper and many have forgotten the relevance of a good history and physical. The latter now relegated to cursory scope on the chest and back.

Such is the state of medicine today in the United States! I know because I have been a physician for all my career.

The above symptoms are actually due to visual problems. Mine!

Diminished vision can affect ones ability to function. Presenting similar to depression as well as leading to secondary complications of depression.

[ Link to Visual problems http://www.health.harvard.edu/newsletter_article/the-quirky-brain-how-depression-may-alter-visual-perception ]

By not recognizing the primary problem as visual, misdiagnosis and unnecessary medications follow, as well as deterioration in vision and functional capacity.

Unfortunately, the medical textbooks do not tell doctors this. Many lazily believe those symptoms signal depression until stated otherwise, despite the fact that depression is a diagnosis made after other illnesses are excluded. This is not done, hence the massive over-prescribing of antidepressants.

[ Link with data http://www.drugwatch.com/2015/07/29/drug-abuse-in-america/ ]

Patients typically tell their stories to non-doctors at least 2 to 4 times before they see an actual physician. (And in many poor communities patients will not visit or see their doctor.) Still the narrative and details charted rarely reflect the patient’s complaints, leading to misdiagnosis. Here repetition of the patient’s history does not breed knowledge or accuracy.

Why does this happen?

In a nutshell, over reliance on technology to make the diagnosis compounded by a bureaucratic and arcane workflow. Also treating symptoms while ignoring the root cause.

Medical staff are often under-trained and over-worked. The importance of accurate charting (of the patient’s narrative) lost in time, ignorance and even arrogance.

The end result is this: many patients are over medicated and misdiagnosed.

The recent epidemic of opioid overdoses is an example where doctors treat symptoms without making diagnoses. Opioids were over prescribed, especially in Emergency Departments where toothaches were routinely treated with Penicillin and 15-30 pills of Percoset. Doctors became legalized drug dealers! One study showed in 2012, doctors prescribed enough narcotics for every person in the United States to have a 30 day supply.

Now the pendulum has swung in the opposite direction: pain is treated suspiciously. Everyone is an addict until proven otherwise.

What is the solution?

One solution is Community Medicine. Studies demonstrate that medical outcomes, or health outcomes, are determined in the community.

Over 50% of outcomes are determined in the community. That means lifestyle or culture is very important as well as the environment (which actually has a great impact on lifestyle) to managing diseases. Genetics accounted for 30% of health outcomes and a doctor’s office visit 15%.

Using technology to facilitate accurate diagnosis is good, but technology should not be the gold standard alone for diagnosing. The history and physical still remain pertinent and relevant. The absence of radiographic or laboratory findings does not exclude pathology.

Most importantly, doctors need to know the patient’s community, and be engaged with that circle, to understand and improve the health outcomes of their patients.

What do you think?

Do you have any other solutions?