Posted by katekite on May 28, 2002, at 6:38:09
In reply to Re: Lots of testing first, diagnosis first, then meds » katekite, posted by BarbaraCat on May 26, 2002, at 21:22:08
There are psychological tests such as those described here: http://www.deltabravo.net/custody/psychtests.htm
The most common is the mmpi which is supposedly very good at picking up subclinical obsessiveness or depression etc as well as personality type.
For possible ADD a "continuous performance test" is useful. Those who take and 'fail' the test are something like 90% likely to have ADD.
Then there is brain imaging such as PET scans, horribly expensive but can show which parts of the brain are more or less active than normal, helping target drug therapy. Something to do probably only if many drugs have failed and the diagnosis is becoming murkier and murkier.
An EEG is cheaper. May pick up on seizure activity for people who have 'episodes' of anything. Also some disorders show other EEG changes, particular waves are slower, etc.
A routine blood panel will show things as weird as hypophosphatemia which can present as only panic attacks. No one should start drug therapy without a routine blood panel and thyroid check.
Then there is ruling out all hormonal problems. This isn't usually done because they are uncommon (except thyroid which usually is done) and its not cost effective to check everyone for everything.
Here's an excerpt from a text on pharmacology:
"Patients with depression exhibit increased hypothalamic–pituitary–adrenocortical (HPA) activity, as evidenced by an increase in the number of adrenocorticotropic hormone (ACTH) secretory episodes and an increase in the magnitude of cortisol secretory episodes. This HPA overactivity is further reflected in elevated urinary "free" cortisol (UFC) levels, which appear to be about twice as high in depressed patients as in normal controls, but lower than in patients with Cushing's syndrome."
So suppose you feel depressed, you're gaining weight, freaking out all the time. Option one is telling your family doctor you feel depressed and they prescribe an ssri. Option two is asking for hormonal testing and then a referral to a psychiatrist and getting them to do an MMPI. Suppose the hormonal testing picks up early Cushings because cortisol is higher than even depression should be? Well then the ssri would have been the wrong approach. A percentage of people with cushings commit suicide before their disorder is even discovered.
Suppose you were depressed before but this year you've gotten really even more depressed. Is that just worse depression that needs a higher dose, or did something else start?
This is not to say that most people who have treatment responsive depression or anxiety etc don't have that only.
Sometimes people's presenting complaints are just the new symptom that they aren't used to. Someone who's always been slightly depressed but now also has panic attacks isn't going to come in and say, hi I don't know what its like to be happy.... they will say, I've been having anxiety attacks. They most likely would be treated for panic and not for their less severe but more chronic problem. An mmpi might well pick that up.
To me it seems more like an issue of getting the class of medication right the first time. The varieties of problems we have just can't be diagnosed in the time a typical practitioner has, plus we generally come in in some sort of crisis which makes it hard. Many docs have favorite drugs they always start with no matter what the presenting complaint.
I'm just bitter because I started pulling my hair out at 12. An impulse control problem. I got depressed at 20, was on and off depression meds for 10 years. I got an anxiety disorder at 25, added in benzodiazepines. I got misdiagnosed as bipolar last year. I really have ADD. Had that been found by an easy 20 minute test back at age 12 I wouldn't have pulled my hair out for so long. Had it been found at age 20 I would have been treated for the primary problems and not the secondary symptoms.
So maybe I'm the only one that needed more testing and objective assessment back when I first presented. But I doubt it.
Its all a matter of cost effectiveness to insurance companies and payback on effort and liability avoidance for doctors. Its acceptable to them if they miss 1% of medical diagnoses or misdiagnose 5% of psychiatric problems -- but it isn't fine for us.
If anyone replies to this harangue we should probably move to psychosocial babble.