The health insurance companies know exactly how you should practice. These days, despite the admonitions of Nancy Reagen, they are pointedly telling you to use drugs – and quite peeved when you don’t.
A recent postal arrival from a major insurer arrived on properly forbidding stationery. The declaration – it was incumbent that I put patient M on antidepressants. How could I be so inconsiderate and foolish not to do so? It was at least a variation on their usual missives, which demand I fill out voluminous preauthorization papers. Not uncommonly, these “polite requests” ask me to justify providing generics like fluoxetine to people who have done well with them – and poorly off. Tell me, do the same companies demand preauthorizations from internists for giving people with high blood pressure anithypertensives?
M has been my patient for many years. She recently reached Medicare status. Long ago she took antidepressants. Overall, they did not make her feel much better. They also caused weight gain. Messed up her sex life. Made her feel flat. Instead she received through cooperative consultation a host of different treatments, from cognitive-behavioral treatments to light therapy, that involved no drugs and made her feel far more comfortable and functional.
Yet her health insurer knows more.
Who Gets Treated – And Who Needs It
Recently a report came out from Columbia University studying who gets treated for depression. Using a national health survey with a simple, self-reported measure, they found about 29% of people with depression got some from of treatment. It might be some acknowledgement of interest from a GP, a session with a psychiatrist, or more commonly an antidepressant drug, but over 70% of those surveyed. received no kind of treatment. Nada.
As for those who were treated for depression, only 29% were self-classified as depressed. In other words, over 70% of people treated for depression did not classify themselves as depressed.
Here’s an interesting symmetry. The large majority of people self-classified as sufferering depressive symptoms don’t get formal, clinical treatment. A similar percentage of people receiving depressive treatment are not self-classified as depressed.
There are lots of potential reasons for this seeming conundrum: 1.The self classification is a crude guide. 2. Lots of people who clinicians think are depressed don’t see themselves that way. 3. Some of the people who are treated for depression no longer feel depressed. 4. Lots of patients with vague malaise are put on antidepressants, thanks to very active pharmaceutical marketing over the past thirty years.
There are plenty of other reasons. But some speak directly to patient M.
How You Get By with Depression
I see M about twice a year. She was eventually impressed with evidence that light is as effective a treatment of depression as drugs. Even though she hates to walk, she grudgingly does so in the mornings. Walking in light improved her mood. It also helped control her weight.
Though she dislikes doing cognitive behavioral homework, she will do some of it. She admits she finds CBT helpful. Which brings up the question of why the health insurer is mandating drugs, but not CBT?
We often we talk about the relationships in her life that, as far as she’s concerned, give her the most grief. She’s real worried about her partner’s health, and what happens if he can’t work. She wants to retire, but does not know where she can afford to live on her probable retirement income.
She has taken my admonitions about depression and socialization to heart. She gets out with more people than she used to, especially folks from work. She spends more time in nature. Among many other suggestions, I’ve proposed that she might try dancing, but that’s not her thing.
M still has residual symptoms. She’s tired more than she likes, and rarely gets up from her chair at the office to get out and talk to people, or at least peek outside. She’s happy with many aspects of her life, though not others. She still wishes she weighed less. Content to write plans for the business where she works, she is less interested in writing out plans and solutions for herself and her own life.
But she gets on. She feels much, much better than she did years ago. She thinks the future will be brighter, which she never did before.
And she really does not want to be on drugs.
In a clinical world discovering a new mania for guidelines, it’s important to ask about the “standard of care.” Are the new CDC guidelines for opiate use going to save millions, or send thousands to early deaths from heroin? Does it make sense to privilege drugs as the main treatment for depression, when the arguments for different therapies are so strong? Is it right to completely neglect public health and the many causes of depression that could be addressed by national policies, like encouraging walking?
Often guidelines will be life saving. Sometimes they will be the playthings of corporations that will use their profits to help buy pliant politicians. How else does Congress refuse Medicare the right to bargain for medications, which has cost the public hundreds of billions?
Is that in the public interest? Sometimes no more than the guidelines used to tell people how they should be treated – whether they like it or not.