With Michael Clark, MD, Associate Professor of Psychiatry and Behavioral Sciences at Johns Hopkins University School of Medicine
For some patients suffering from the chronic disease fibromyalgia, their disability is worse than their fibromyalgia would suggest it should be. In such cases, Michael Clark suspects a link to depression. "If you take two identical patients with fibromyalgia and you overlay a major depression on one of those patients and not the other, and then compare them, all of their symptoms of fibromyalgia will be worse, all of their functional capacities will be worse, other treatments for fibromyalgia will not work as well, and that will be a person whose illness experience is much more severe than the person without a co-morbid major depression."
The challenge for physicians is to sort out whether or not the patient has developed a true co-morbid major depression "The hallmarks of a major depressive disorder boil down to a change in a person's self-attitude or sense of themselves as a good person," Clark said. "When you hear someone describing themselves as a person who deserves to be punished or a person who has no worth or use, that's a danger sign. When you hear people describing the inability to experience pleasure in any of their usual activities, even despite their illness, that's a red flag. And, finally, when you hear people talking about being hopeless about the future and, in particular, thinking about death or even suicide, those are signs to take very seriously. That's a person who likely has a major depression and who is certainly at risk for suicide, and they need specialized care for that condition."
Should the average practitioner go ahead and prescribe antidepressants?
"They almost have to," said Clark, "because there are not enough psychiatrists to see all of these patients, and primary care doctors have a wide-ranging skill set; they must do this." Clark said that referral to a psychiatrist should happen when the primary care physician has tried a number of things and the patient is not getting better, or when there are clues that this is a more serious illness than they are used to managing. Psychiatrists can also provide more ideas and a chance to collaborate with someone who has seen more difficult cases or refractory cases and come up with novel therapies.
Do you think primary care providers should treat depression in chronically ill patients or refer them to a psychiatrist for treatment? Why?