Depression Often Misdiagnosed, and Untreated

The New York Times had an interesting article about how depression is often misdiagnosed in the US, and how most people who actually have depression don’t get treatment.  They reference a research study just published in the JAMA Internal Medicine.Depression

This research study performed by Mark Olfson, Carlos Blanco, and Steven C. Marcus, looked at responses from 46,417 people on the Patient Health Questionnaire-2 (PHQ-2) which is a brief screening tool for depression. A score of over 3 indicates depression on this scale.

What did they find? They found that approximately 8.4% of all adults studied had depression, but only 28.7% had received any depression treatment in the previous year! That means 71.3% of the people who suffer depression got no treatment for this depression.

Of those who were being treated for depression, about 30% actually had depression based on the screening, and another 22% had serious psychological distress. That means that of the people in the study who were being treated for depression roughly 48% neither suffered depression nor did they suffer serious psychological distress, indicating inaccurate diagnoses by the treating professionals.

There were some interesting correlates of depression. About eighteen percent of those in the lowest income group suffered depression, while only 3.7% of those in the highest income group suffered depression. It pays to be rich!

Depression was more common in those who were separated, divorced, widowed, or who had less than a high school education. None of this is terribly surprising.

How did depression sort out by age?

In the 18 to 34-year-old group 6.6% suffered depression. In the 35 to 49-year-old group 8.8% suffered depression. Ten percent of the 50 to 64-year-old group suffered depression. Of those over 65, only 8.3% suffered depression. So at least in this sample the 50 to 64-year-old group was slightly more likely to suffer depression, and contrary to what many people think, the youngest adults were somewhat less likely to suffer depression.

Of those who were married only 6.3% suffered depression. Of those who were separated, divorced, or widowed, 13.3% suffered depression. Divorce is bad for mental health, with almost a doubling of rates of depression.

Most of the patients who were treated for depression were treated by general practitioners (73%), with roughly 24% receiving treatment by psychiatrists and 13% receiving treatment by other mental health specialists. (There was some overlap, that’s why the numbers add up to more than 100%.)  This may explain the rather poor diagnosis and treatment of depression because general practitioners although competent and intelligent, are very busy and typically only have a few minutes to spend with each patient, not enough to do a good job diagnosing and treating depression.

CONCLUSIONS ABOUT DEPRESSION FINDINGS

What can we conclude from this research?

  1. Almost 10% of the adult population suffers from depression. Of those people who have depression less than 30% of them will get any treatment for depression.
  1. You are more likely to suffer depression if you are in the lowest income group, divorced, separated or widowed, or have no high school education. If you are married you have half the probability of being depressed.
  1. Many adults receive depression treatment even though they don’t really meet the criteria for depression. In this study, almost half of the people receiving treatment for depression were neither depressed nor were they even particularly distressed.
  1. Rates of depression by age groups were relatively equal, with the youngest age group having the least depression and the middle-aged group (50 to 64) suffering somewhat more depression. Married people are suffer half as much depression as divorced, separated, or widowed people.
  1. Most people received depression treatment from their general practitioner or internal medicine doctor, with a smaller number receiving treatment from a psychiatrist, and even a smaller number receiving treatment from psychologists. This also meant that most people who receive depression treatment were treated using medication, and very few people received psychotherapy, even though most studies comparing medication to cognitive behavioral therapy for depression have shown that therapy performs at least as well as medication and probably better over the long term, with less relapse.

Reading between the lines of this study, it suggests that many people who feel depressed would benefit from receiving an accurate diagnosis from a clinical psychologist, and might very well also benefit from receiving cognitive behavioral therapy for depression rather than medication. Even if medication is indicated, a psychologist could recommend it to the patient’s general practitioner, and then monitor more closely the results.

The study also suggests that many people receive antidepressant medication who actually are not depressed, which needlessly exposes them to side effects and also fails to provide the correct treatment for what troubles them.

And finally, since only about 30% of those who suffer depression received any treatment for it, if you feel depressed, be sure to pursue treatment for depression. Get an accurate diagnosis and then get treatment, ideally with a psychologist or therapist who practices cognitive behavioral therapy. If you want more information about depression, I’ve written extensively about it with a complete list of depression articles.

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Forgiveness and Happiness Researcher Fred Luskin Says Turn Off Your Smartphone If You Want to be Happy

Earlier this year I had the good fortune to spend several morning hours listening to Stanford professor and researcher Fred Luskin talk about happiness. Dr. Luskin is a psychologist who has done groundbreaking research on forgiveness over many years. He’s the author of many books, and frequently lectures about forgiveness. I often recommend his book Forgive for Good: A Proven Prescription for Health and Happiness to clients suffering from anger and hurt.

But this morning he was discussing happiness. He came into the room with no pretense. His hair was wild and curly, partly dark and partly gray. He was wearing a puffy black down jacket, a T-shirt, running tights, and sneakers. Clearly a man comfortable with himself, and not trying to impress.

He started off by doing something quite outrageous. He asked the audience of 30 people to turn off their cell phones. Not to lower the volume, or turn off the ringers, but to actually shut down their cell phones. This clearly caused some discomfort among the audience. He explained that the reason he wanted people to turn off their cell phones is so that they would truly focus on the present and to listening to him. He cited a statistic that people check email on average 79 times a day. Each time they check their email they get a burst of adrenaline and stress. Clearly this is not conducive to genuine happiness.

He pointed out that you can’t really be happy unless you can sit still and relax. “We are all descended from anxious monkeys,” he said, and clearly most of us do not know how to sit still and relax. “Happiness is the state of ‘enough’ “, he said, “and is not consistent with wanting more.”

He pointed out that wanting what you have equals being happy. And that wanting something else than what you have equals stress.

He talked about the beginnings of his career, when clinical psychology was focused on unhappiness and problems. There was no science of happiness. Now there is a huge area of research and writing on happiness called Positive Psychology.

He shared some simple techniques for enhancing happiness. One simple technique revolved around food. When you’re eating don’t multitask. Give thanks for the food, and really focus on tasting and savoring that food. One technique I have often used is to close my eyes while I savor food, which greatly intensifies the taste.

Another simple practice is whenever you are outside, take a few moments to feel the wind or sun on your skin.

He also talked about phones and how we use them. We are completely addicted to the little bursts of dopamine and adrenaline that we get each time we check our email or we get a text. And rather than be present in most situations, we simply look at our phones. Go to any outdoor cafe and look at people who are sitting alone. Most of them are looking at their phones rather than experiencing the surroundings or interacting with other people. Even sadder, look at people who are with others, either at a cafe, or a restaurant. Much of the time they too are lost in their smartphones.

He discussed how happiness is not correlated with achievement. Nor is it correlated with money once you have an adequate amount to cover basic needs. What happiness seems to be most correlated with is relationships. If you like yourself and connect with other people you will tend to be happy.

He reviewed  the relationship between impatience, anger, frustration, judgment and happiness. He pointed out that whenever we are impatient or in a hurry all of our worst emotions tend to come out. When someone drives slowly in front of us we get annoyed. When someone takes too much time in the checkout line ahead of us, we get angry.

I really liked his discussion of grocery stores. He pointed out what an incredible miracle a modern American grocery store really is. The variety of delicious foods that we can buy for a relatively small amount of money is truly staggering. But instead of appreciating this, we focus on the slow person in the line ahead of us, or the person who has 16 items in the 15 item express line. What a shame!

He pointed out we have a choice of what we focus on, and this choice greatly influences our happiness. We all have a choice to focus on what’s wrong with our lives, or what’s right with our lives. And we have a choice of whether to focus on how other people have treated us poorly, or how other people have treated us well. These choices of focus will determine how we feel.

We also have the choice of focusing on what we already have, or focusing on what we do not have and aspire to have. For instance, let’s imagine that you are currently living in a rental apartment. The apartment is quite nice, although there are things that could be better. The kitchen could be bigger, and the tile in the bathroom could be prettier.

Perhaps you imagine owning a house, and you feel badly about renting an apartment. Rarely do we appreciate what we have. Having a place to live is clearly infinitely better than being homeless. And even a flawed apartment is still home.

All of us need to work on learning to emphasize generosity, awe, and gratitude in our lives if we want to be happy. Generosity means kindness and acceptance in contrast to anger and judgment. Awe is the ability to be astounded by the wonder and beauty in the world. Gratitude is appreciation for all the good things in your own life and in the world.

He cited one interesting study where researchers observed a traffic crosswalk. They found that the more expensive cars were less likely to stop for people in the crosswalks. Thus wealth often correlates with a lack of generosity and a higher level of hostility. Other data shows that there is very little correlation between wealth and charitable giving, with much of the charitable giving in the USA coming from those of modest means.

He also talked about secular changes in our society. He quoted a statistic that empathy is down 40% since the 1970’s. At the same time narcissism has increased by roughly 40%. This has a huge negative impact on relationships.

I was impressed by this simple but profound message of Dr. Luskin’s talk. Slow down, smell the roses, turn off your phone, focus on relationships, appreciate what you have, and become happier.

It’s a simple message, but hard to actually do.

I’m off to go for a hike in the hills, without my phone!

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Good News! You May Be Getting More Sleep Than You Think, Especially If You Suffer Insomnia!

The Wall Street Journal today had a very interesting article about how people with insomnia tend to greatly underestimate how much sleep they get and overestimate how long it takes them to fall asleep. They also overestimate how often they wake up at night.

Roughly 30% of adults have some insomnia each year. About 10% of people have chronic insomnia which means that you have trouble sleeping three times a week or more. According to the Journal article, 42% of insomniacs who actually slept the normal amount (6 hours or more) underestimated how much they slept by more than an hour. I looked up the research article which was published in Psychosomatic Medicine. According to this research, insomniacs who slept six hours or more typically showed a profile of high depression and anxiety and low coping skills according to psychological testing.

What’s also interesting is that even though insomniacs may be sleeping six or more hours a night, there does appear to be some real differences in their brainwave activity compared to good sleepers. Even though they are asleep, their brains are more active, which may account for why they perceive their sleep to be less than it really is.

Another interesting factoid was that normal people tend to overestimate how much sleep they get. Most people when asked how much sleep they get will answer between seven and eight hours, but they are actually getting six hours. That’s why people tend to be so sleep deprived. For most people six hours is not enough sleep to feel really good.

So what’s the answer to this sleep estimating dilemma? It turns out there is a very simple answer. The two gold standards for measuring sleep are brainwave measurements and activity measurements. While brainwave measurements are difficult to come by in the home, activity measurements are very easy and inexpensive to obtain. Many of the current fitness tracker’s have a sleep tracking function. For instance, according to my Xiaomi Mi Band, which cost me the grand sum of $15, last night I was in bed for seven hours and 58 minutes, and got three hours 20 minutes of deep sleep and four hours and 38 minutes of light sleep. I was awake for one minute. (Yes, I know, please don’t hate me all you insomniacs!)

For insomniacs who worry about how much sleep they are getting, I recommend buying a fitness tracker and wearing it every night. The best ones automatically track sleep without having the requirement that you push a button to activate sleep mode. This is pretty important as most people forget to press the button. I have been pretty happy with my Xiaomi Mi Band, which you can buy directly from the company  but I’m sure there are other brands of fitness trackers which offer similar features.

Also, as I’ve written about previously here and here, cognitive behavioral therapy for insomnia (CBT-I) may also improve the quality of sleep as well as the quantity. Some studies show that CBT-I improves people’s ability to accurately estimate their sleep time, and it also may calm  the over-activity of the brain that occurs when insomniacs sleep.

So here’s the executive summary for all of you sleep-deprived folks:

1. If you are an insomniac who is anxious and depressed, then you are probably getting more sleep than you think. Buy a fitness tracker with a good sleep tracking function, and you will see how much sleep you are actually getting.

2. If you want to improve the quality of your sleep, either practice meditation or see a CBT psychologist for CBT-I, as both of these interventions seem to lower the activity of the brain during sleep, which will improve your perception of your own sleep.

3. If you consistently feel anxious or depressed, consider getting some cognitive behavioral therapy for these problems, as they may contribute to sleep difficulties.

I’m off to bed now and hope I don’t have insomnia now that I’ve written about it!

 

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Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.