(Originally posted July 08, 2018)
An alarmingly common group of conditions are becoming the bread-and-butter of my practice as a Primary Care Doc.
Depression and anxiety along with their attendants (e.g., sleep disorders, irritable bowel syndrome), metabolic syndrome (consisting of obesity, diabetes, hypertension, lipid problems), and chronic inflammatory conditions (e.g., migraines, hypothyroidism, fibromyalgia, chronic fatigue syndrome, etc.) are gradually proving to be variations of a single but massive entity, not unlike the “autism spectrum” that has gained ground in the world of developmental neuroscience.
We don’t yet have a unifying name for this behemoth, but medical science is showing there are intertwined physiologic mechanisms that overlap, cross paths, both subtly and overtly influence each other, and so forth, manifesting in all these medical issues, in varied combinations depending on a patient’s individual genetics, culture and upbringing, habits, and circumstances.
As indicated above, just as certain conditions are beginning to get lumped together under the umbrellas of chronic inflammation and metabolic dysregulation, what we have historically referred to as “depression” is gradually acquiring a similar identity as a broader category of related conditions of the psyche – rather than merely referring to a single mood disorder. But even these “categories” are proving to not be discrete or separate, but in many ways interrelate on account of sharing hormonal and neurochemical mediators. Two main culprits are cortisol and insulin; others include serotonin and GABA (gamma-aminobutyric acid).
As doctors, we have seen these clinical entities rolling together again and again for decades but have failed to produce a management scheme that demonstrates any semblance of reliable efficacy. Or perhaps more accurately, we propose management plans that appropriately call upon participation from the patient… but without any specifics. Then when we find the patient’s condition declining rather than improving, we turn around and blame the unfavorable outcome on his or her failure to perfectly execute the plan, instead of acknowledging the pitfalls of the advice.
The plan? It generally goes something like this: “Eat right and exercise. Also, take this antidepressant and see a therapist.” And that’s about the size of it. We say this to patients without any further instruction and believe we have done our due diligence. We schedule a follow-up and walk away to document that the “patient was advised” so we can prove that our job was done. Then they come back, as scheduled, having made ZERO progress – or often having only gotten worse.
Doctors are trained to be problem-solvers. If a problem placed before us and addressed according to our training somehow winds up unsolved, we see only one of two explanations. Either there was an error in the execution of the solution on the patient’s part, or the problem doesn’t really exist to begin with – it’s just a figment of the patient’s imagination. Acknowledging that our methods are flawed and/or inadequate hadn’t really entered the realm of possibility. That is, until we have had to come face-to-face with these conditions in epidemic proportions.
It is critical to begin by understanding that we are simply at a particular point on the timeline of history in order to move forward with newfound understanding towards a higher plane: a point at which we have just barely begun to understand the pathophysiology behind “depression”, “metabolic syndrome” and “chronic inflammation”. Perhaps not that long ago (sadly, it is not uncommon in the third world to still find this belief) the notion of demon possession was considered an appropriate explanation for what we now understand to be epilepsy. It has only been upon understanding seizure disorder as a structural brain disease that treatments directed at the root cause of the problem could be developed then eventually improved upon with significant and progressive success. Continuing to treat it as a moral or spiritual failure can and does leave millions untreated and disenfranchised to suffer in solitude.
And here we are in the modern era still debating about whether conditions like fibromyalgia or chronic fatigue are true diagnoses, or simply moral failures on the part of the victim(s). Someday we are going to look back on this period in bewilderment at our primitive comprehension.
I personally have become convinced that it is critical for people suffering from depression and anxiety to understand themselves to have a biochemical imbalance, rather than a flawed character or a state of being at odds with God or the universe. Having these conditions certainly causes one to feel that way. And it is also what society tells us. But the simple fact is that there is an imbalance. Another tough fact is that our medical treatments are not yet far enough advanced to provide a cure.
The amazing truth, though, is that effective treatment IS AVAILABLE. But it comes primarily through education, rather than medication, (although medication certainly plays a role in certain cases), followed by practice and persistence. Yes, those latter two steps do require participation from the patient. But have we even taken note as to whether patients are being provided with instruction that can be followed before holding them accountable for following the instructions? If you were vaguely told that the solution to all your problems is to “eat right”, what would you do?
Please allow me to propose a slightly different tilt to the management of patients presenting to front-line providers (i.e., the primary care setting) with non-critical depression and/or anxiety (non-critical in the sense that they are not posing an immediate threat of harm to themselves or others – these individuals should be promptly referred for emergency care).
The initial step comes with determining the level of motivation held by a given individual struggling with one version or the next of Depression with or without the complications of Metabolic Syndrome or Chronic Systemic Inflammation. This alone is a complex endeavor because a hallmark feature of depression is a symptom called anhedonia which manifests as a lack of desire or interest in activities that were once considered desirable or pleasurable. Anhedonia is a well-known, long-described function of inadequate serotonin-mediated stimulation in centers of the brain involved with interest. As such, a depressed patient may appear superficially to be unmotivated to change. But in seeking medical help, by definition that “seeking” demonstrates some degree of motivation. The fact is, these patients are severely dissatisfied with their condition and want their lives back.
After this, the education needs to be specific to the patient’s needs. While both situations have a very high propensity to lead to depression for example, a patient struggling with obesity does not have the same set of needs as a patient struggling with chronic pain, therefore it is exquisitely short-sighted to manage depression with a cookie-cutter approach (“antidepressant and therapy”) when the root causes are so widely varied.
So yes: this takes time. In case anyone hasn’t noticed, primary care providers typically aren’t permitted much time with their patients. Maybe, just maybe, depression has accelerated into an epidemic at least in part due to the practices and policies that have depleted the value of the primary care doctor-patient relationship, forcing the front line into boiler-plate mode of “triage and refer” (ahem: “antidepressant and therapy”) instead of true diagnosis and treatment with the expertise of a professional.
Obviously, however, depression is a problem that is much larger and extends far further than a doctor can reach. In fact, I dare say that for all the depression diagnosed and managed in a clinical setting, at least the same quantity of disease burden if not more goes completely unevaluated and is self-managed by the victims, often with poor outcomes including addiction and suicide.
I have something to say about that, too. Stay tuned for Part II: The Non-Clinical Patient Perspective.
Thrive Adult Primary Care 
Great article, thank you.
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