Priority Topic: Depression, Priority Topic: Immigrants, & Priority Topic: Multiple Medical Problems

Depression

Key Feature 2: Screen for depression and diagnose it in high-risk groups (ex: certain socio-economic groups, those who suffer from substance abuse, postpartum women, people with chronic pain).
Skill: Clinical Reasoning
Phase: Hypothesis generation, Diagnosis

Key Feature 3: In a patient presenting with multiple somatic complaints for which no organic cause is found after appropriate investigations, consider the diagnosis of depression and explore this possibility with the patient.
Skill: Clinical Reasoning, Patient Centered
Phase: Hypothesis generation, Treatment

Immigrants

Key Feature 4a: As part of the ongoing care of all immigrants (particularly those who appear not to be coping): Screen for depression (i.e., because they are at higher risk and frequently isolated).
Skill: Clinical Reasoning
Phase: History

Multiple Medical Problems

Key Feature 3: In a patient with multiple medical complaints (and/or visits), consider underlying depression, anxiety, or abuse (ex: physical, medication, or drug abuse) as the cause of the symptoms, while continuing to search for other organic pathology.
Skill: Clinical Reasoning
Phase: Hypothesis generation

I was tempted to tack these learning objectives into a previous blog that fit, partly due to the urge to be lazy, but also because they really do mesh with so many patient situations I encounter. In previous blog posts, I have discussed the power of the social determinants of health to influence health status, which of course includes mental health. I have also talked about the bidirectional influence of mood and chronic pain, and I have talked about the importance of screening for postpartum depression. Without being too much of a bummer, depression is really everywhere. Or, without being too heavy, and recognising that I am skewed by seeing a greater proportion of the population who may be at increased risk for mental health concerns given their history medical issues, perhaps it is better to say that it can be anywhere. Certainly not everyone is depressed, but almost every single person in their lives has risk factors for depression or anxiety. On the flip side, some people are extremely resilient, and managing to deke out this omnipresent state despite a significant number of risk factors can be truly remarkable. Nevertheless, I think it is important to recognise, as a family physician, that any of my patients may be at increased risk for poor mental health if they present with ongoing health concerns. I may be the one person in the medical field who they are in contact with to do so.

I can't tell you the number of times patients have presented for bodily concerns and, once probed, reveal significant mood disturbance. After appropriate investigation for the other bodily concerns, depression, anxiety, or other psychiatric distress may in fact be the most likely etiology responsible for them. Alternatively, it could be a secondary to chronic physical discomfort, or it could be totally unrelated. In some patients, it may be all too intimately mumble-jumbled to really know. But does it matter? I would argue that it doesn't, and that whether it causes, contributes, results from, or is entirely separate from other somatic complaints, treating mental health concerns may have the possibility to alleviate or lessen the severity of other symptoms, or at the very least increase one's capacity to cope with them, and it deserves treatment as it's own disease process that decreases quality of life. It takes two seconds to ask, and patients are often so very honest. But yet clinicians often don't ask, at least when it is not their domain of care (ex: Emergency Room Physicians, Surgeons, Cardiologists, etc. etc. etc.). Partly, this makes sense. They are there to treat a specific issue and not the rest of the body. I can't imagine practicing medicine like that, although I appreciate specialists' commitment to ameliorating and improving the lives of the patients they serve in their way. As a Family Physician, screening and managing depression and anxiety, and other mental health concerns (ex: abuse, whether physical/emotional/sexual/financial etc. or self-inflicted such as via harmful use of prescribed or non-prescribed substances) is absolutely under my purview, and detecting and providing therapy for these issues could arguably be how I may have the greatest impact in my career given the prevalence of it. It is also intimately related to quality of life at least as much as any other disease process, and helping my patients achieve better quality of life is my purpose for doing what I do.