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I was recently asked to write a paper for a peer-reviewed journal read by primary care physicians, rheumatologists, and orthopedists on the diagnosis and treatment of depression in patients with rheumatoid arthritis. I decided a sensible approach would be to elucidate the symptoms for which to be alert in diagnosing depression in patients with medical illness, and, in particular, patients with a chronic, debilitating illness. I also thought it important in this forum to include a discussion of the effects depression might have on the course of the patients’ rheumatoid arthritis and on the tendency of such patients to present frequently for doctor appointments.
I became perplexed, however, in pondering how to discuss treatment options. Was I expected to present a cookbook approach to the treatment of an illness for which the cookbook has become - by virtue of the permutations and combinations of the ingredients - a gourmet text?
My recipe for the treatment of depression in one easy lesson could then proceed to a distillation of psychotherapy for the general practitioner - a glib paragraph going from Freud to Klein to Winnicott.
My dilemma deepened as further questions kept presenting themselves. Does a rheumatologist write articles for psychiatric journals elaborating the algorithms for the treatment of rheumatoid arthritis? Would I feel comfortable treating rheumatoid arthritis, and would it even be appropriate? When would I refer a patient to a rheumatologist - only when a joint needed to be tapped or a knee injected with cortisone? Or would I do so each time the patient needed a nonsteroidal anti--inflammatory?
I quickly realized as I began writing the article and was citing the "CPC Guideline for Treating Depression in Primary Care" that I did not agree with the notion that a simple how-to manual - even one prepared by an experienced psychiatrist - could qualify nonpsychiatric physicians to treat an illness as serious and complex in its etiology and treatment as depression.
An article that reduces depression treatment to a simple formula such as prescribing paroxetine hydrochloride 10 mg at suppertime is downright dangerous. It perpetuates the idea that popping a pill is a panacea and strikes an unnecessary blow to the biopsychosocial model, which is already fighting for the acceptance it deserves. Coming from a psychiatrist, this would be a most egregious error. Surely we owe more to George Engel.
There are so many situations in which a seemingly straightforward treatment goes awry. Treatment resistance leads to a series of decisions based on clinical acumen. The solution might be to increase the dose of the patient’s current medication, or, possibly, to switch within or between drug classes. Alternatively, augmentation with a second drug might be appropriate, or perhaps the patient is a candidate for electroconvulsive therapy.
As we psychiatrists know, careful attention must be paid to treatment compliance, because some of the unique aspects of depression may affect this. All physicians treating depression must also be aware of drug-drug interactions and have a knowledge of risk factors for suicide - and an ability to elicit this information from a depressed patient. It is necessary as well to appreciate the fundamental contribution that corroborative history from family and friends makes to a thorough psychiatric evaluation. It is essential to take the time to collect these data, but the primary care physicians or rheumatologists for whom I was supposed to write are probably less likely to set aside an adequate block of time to gather this crucial information than is a psychiatrist.
I could no more remain current with the antibiotic du jour or the latest antihyper-tensive on the market than could a nonpsychiatrist keep up with the details of our ever-expanding psychopharmacologic armamen-tarium.
While it is true that articles such as the one I sat down to write might heighten awareness of depression and increase the number of patients receiving treatment, the question remains, Who should be providing this treatment?
Among the least compelling - and most objectionable - arguments in favor of general practitioners treating depression is that patients may have a negative bias about seeking help from a "mental health professional." Complicity by much of the medical community in this attitude - that their psychiatric colleagues are best avoided - betrays their patients and serves to perpetuate a negative stereotype of psychiatry.
The solution is for psychiatrists to stake out their role by more clearly establishing boundaries between what we do for patients and what our nonpsychiatrist colleagues do.
Dr. Baum is a clinical senior instructor in psychiatry at the University of Rochester School of Medicine and Strong Memorial Hospital.