Depression – Is it All in the Head?
Friday afternoon surgery; fed up, hungry and desperate to get home for the weekend, the patience of the primary care physician (General Practitioner, GP) is put to the test. This particular Friday afternoon, my supervisor’s patience appeared to be slowly failing.
“No you can’t have another sick note”, he boomed, “there is absolutely nothing wrong with you”. His eyes bulging, his face flushed, and doing all he can to avoid adding expletives to his sentence, he turns his back on what he hopes to be a finished consultation. Unfortunately, the patient, a middle aged female, fails to notice the smoke starting to billow from the GP’s ears.
“But I am depressed” she pleads, “I can’t sleep and my appetite has gone and I have no concentration and…and…”
“And yet you obviously have no problem looking up symptoms on the internet”, the GP retorts.
The patient stands up fuming. Assuming we are both about to be on the wrong end of the lady’s handbag, the GP and I cower. Thankfully, she suffices by glaring at us both (what have I done wrong?!) and then leaves the consultation room with the obligatory slamming of the door. The GP turns to me, and has a momentary chuckle at the medical student sat in the corner of the room, clearly stunned by the consultation he has just witnessed.
In the UK, there has been a massive shift of focus in the education of medical students. 50 years ago, you may have found students gathered in a cold lecture theatre learning how to draw the chemical structure of Rifampicin or pondering over Alice in Wonderland syndrome; nowadays you will find students being taught communication skills and patient-centred care. This shift has been met with skepticism from some of the older doctors who believe this to be trivial ‘airy-fairy’ medicine. Needless to say my supervisor was a no nonsense, old-school GP who prided himself on what he described as an increasingly rare ability of a doctor to say no to a patient.
On the subject of 21st century depression in Britain, my supervisor was eager to share his views. He believed that depression was an over diagnosed escape for people who did not want to work. Depression according to the ICD-10 criteria needs to have at least 1 out of the 3 core symptoms to make a diagnosis. It also needs to be present for 2 weeks and in my short time in primary care I have seen many cases where patients despite not qualifying for a diagnosis of depression, are given one nonetheless.
Why this is the case, is difficult to say. It is possible that clinicians find it easier to hand out a diagnosis that a patient for whatever reason wishes to have, than to put up resistance and hold firm to their medical principles. With undergraduate medical training the way it is, this attitude of prescribing to the whim of the patient would seem likely to increase.
So are medical practitioners in the western world at risk of creating a depression epidemic or are we at fault for being skeptical over its diagnosis? What are your own views on depression? Do you believe it warrants a primary care physician’s time, in the same way that a patient presenting with a peptic ulcer or back pain does? In addition, why are people in the west, with running water and a roof over their heads suffering from depression? Let us examine 2 cases below:
An African widow, supporting a family of five children has to walk miles to the river to fetch clean water and bathe her children. She has AIDS and she has probably passed it onto some, if not all, of her children. Life is as tough as it gets and she is far from happy.
Yet she is not depressed. She does not claim fatigue or loss of concentration, or low appetite. She has early morning wakening but this is to ensure she is the first to the best spot on the river bed.
Compare this to a middle aged lady, a mother of two living in Britain. She suffers from fatigue and spends most of the day lying wide awake in bed; too tired to move, too tired to talk, too tired to care. She often feels life is not worth living and will see a counselor, attend therapy sessions and be put on a selective serotonin re-uptake inhibitor (SSRI). She, in short, will be labelled with a diagnosis of depression, although no obvious trigger to the depression can be identified.
Looking at the two cases you would rightly argue that this is a facetious outlook on depression. The two ladies are obviously very different. They have a different genetic makeup, and therefore one maybe less inclined to depression. Alternatively, they may have different coping strategies.
Therefore we cannot confidently say that the two ladies are directly comparable. But I wonder if we were to take the African widow with her circumstances the way they are and put her into 21st century Britain, how long it would take before she came knocking on the GP’s door on a cold Friday afternoon.
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