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.

How Anger Works: The SAP Model ™ (Part 1)

In this article I will give you a simple cognitive behavioral explanation of how we get angry, and how you can use this knowledge to short-circuit and defuse your own anger. Anger is probably the most cognitive of all of the emotions. We can’t get angry without thinking. And most anger directly stems from our distorted thoughts.

There are three cognitive steps to getting angry. The first two are absolutely necessary for anger, and the third is like gasoline on fire, it intensifies anger. The acronym for remembering these three steps is SAP(tm), which is what anger will make you if you think these thoughts.

To help illustrate this lets consider a common situation where a person might get angry. You are driving on the freeway and a car cuts you off. You instantly react with anger. You steam all the way to work.

STEP ONE: VIOLATION OF SHOULDS or “SHOULDY THINKING”

The first step to getting angry is that you must have a set of shoulds or expectations that have been violated. Without this there is no anger. In the driving example what are your expectations? You tell yourself that the other driver shouldn’t have cut you off. He or she should have looked first and seen you. Obviously this should has been violated. This is what some cognitive therapists call “shouldy” thinking!

STEP TWO: AWFULIZING

But just having a set of shoulds or expectations is not enough to generate anger. The second step is necessary. In this step you exaggerate the negative consequences of the violation of the shoulds. You tell yourself it is awful and terrible that this event has happened. In our driving example your self talk is “Wow, the idiot could have killed me. It’s awful and terrible that they allow people like that to drive. Grrrrrr!” This step is called Awfulizing. Or Terribilizing, if you prefer. The key distortion is that you blow the event out of proportion. After all, if you are able to have these thoughts, then obviously no serious accident has ensued.

STEP THREE: PERSONALIZING

The first two steps will get you mad, but the third step of Personalizing or Blaming will make you crazy angry. If you tell yourself that the person didn’t see you, and it was an accident that they cut you off, you may still get angry. But if you tell yourself they did see you and purposely chose to cut you off anyway, then your anger spirals out of control. Blaming thoughts are like pouring gasoline on the fire of anger. They are responsible for such things as road rage.

So this how anger works. Let’s consider another example. This time we will use one closer to home. It’s early Saturday morning, and you are sleeping in after a long hard work week. Suddenly you are awoken by the loud noise of a lawn mower. It’s your neighbor George, who for some unknown reason, has decided that Saturday at 7:30am is a good time to mow his lawn. You are furious.

Let’s analyze this. What are the shoulds? Basically that your neighbor shouldn’t do noisy activities until 10 or 11 am on a weekend day. This should has been violated by George. What is the awfulizing? You are thinking that now you will be tired all day, and you’ll be cranky and irritable, and won’t have any fun. Is there a personalizing statement? Yes, you think, “George knows I work late, and knows I like to sleep in, so mowing his lawn so early is a direct insult to me!” And so you explode with anger.

So there you have it, a simple cognitive model of anger, the SAP model: Shoulds, Awfulizing, and Personalizing. Try an experiment. For a week, write down each anger incident you have by identifying the three Anger Thought Steps. This will help you to increase your awareness of how anger works, and prepare you for the next step, learning to defuse and eliminate your anger, which I will discuss in Part 2 of this article,  How to Stop Anger in its Tracks.

Copyright 2007 The Psychology Lounge/ TPL Productions All Rights Reserved

 

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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.

Why We Suck at Saving Money, and Suck Even Worse at Saving Time

Two recent articles in the New York Times got me thinking about why most of us really suck at saving money and more importantly why we suck at utilizing our time well. These are two separate but very connected issues. They are connected because after all we all know that time is money and money is time.

Both money and time seem like nonrenewable resources. Time actually is a nonrenewable resource. Although we don’t know exactly how much time we have, it’s a pretty good bet that most of us have between 70 and 90 years on this planet. And we each have 16 to 18 hours of conscious time each day. Just like oceanfront property, we can’t manufacture more time, we can only better utilize the time we have.

Money also seems like a nonrenewable resource for most of us. But it’s not really. In fact, thinking that money is a nonrenewable resource is probably one of the main reasons why people don’t use time better.

The first New York Times article, How to Pinch Pennies in the Right Places, gave a theoretical thought experiment. If you could save $10 on a $50 set of headphones, would you drive 30 minutes across town to get a better price at a different store? (Answer this before reading on.)

Or, if you could save $15 on a $400 television would you drive 30 minutes across town?

Research done by Daniel Kahneman and Amos Tversky in 1981 suggests that most people were more willing to drive across town to save money on the headphones than on the television. You save 20% on the headphones and only 3.75% on the television. But we don’t spend percentages, we spend dollars, and actually you’d be saving more money ($15) on the television than on the headphones ($10).

The same article discussed other research that suggested that consumers were willing to spend 20 minutes extra to save $3.75 on a $10 pen, but needed a savings of at least $278 on a $30,000 car to be willing to invest the same 20 minutes extra.

This of course is crazy! In the example of the pen people value their time at $11.25 per hour. But in the example of the car people are unwilling to make an investment of time that would pay them $834 per hour!

But we all fall prey to different versions of this. How much time do we waste surfing Amazon in order to save a few bucks on a product? Or to find a product that has 4 stars instead of 3 ½ stars?

This article also pointed out that people on the lower income level are less likely to fall prey to the percentage saved fallacy, because they care about each and every dollar. But I think the article misses a more important point – which is the real way to have more money!

Saving $10 or $15 on a purchase really doesn’t matter compared to lowering recurrent expenses. For instance, how much money do you spend each month on the following items: cell phone service, Internet service, cable or satellite TV, coffee drinks at your local café, restaurant meals, rent or mortgage, car payments? How much money did you spend on your last car? Spending $120 per month on cable TV comes out to $14,400 over 10 years. Nice late-model used cars can be had for $10,000-$15,000, yet many people drop $50,000 on a new car. Even just saving $30 on a less expensive cell phone plan means that you will save $3600 over 10 years.

(A number of years ago I looked at my recurrent expenses and realized that I was spending a lot of money on two business landlines, and on cable TV. I spent some time doing research and ended up purchasing a couple of Ooma telephone systems that when connected to the Internet provided completely free telephone service. I also put an antenna on my roof and switched to free over-the-air HDTV. The time invested was probably about 4 hours for all of the research and installation. But I saved almost $300 per month, without giving up anything I really cared about other than perhaps Monday night football (which is on cable TV only). My one-time four hour investment has paid me more than $10,000 in savings, which is roughly $2500 per hour! And I continue to save money each month.)

But the article also misses a more profound point, how to earn more money. People focus too much on saving money and not enough on earning more money, through work, entrepreneurship, education and training, and investment. In this era of the Internet there are 1 million ways to earn more money. And improving your education and training can help you earn more money in your current employment as well as well. Improving income opportunities lasts for life, while getting a good “deal” only lasts for a day! Or, if you can afford to invest money, then focusing your time on investing more successfully can yield huge benefits in total dollars. I know people that have spent the time to learn about investing in residential real estate, and who will retire with very nice incomes from the time they invested in acquiring and managing these properties.

Which brings me to the 2nd New York Times article, What Should You Choose: Time or Money? This is a fascinating and profound article. It summarizes research performed by Hal Hirschfield, Cassie Mogilner, and Uri Barnea which asked the question what do people choose, time or money? About 65% of their participants chose money over time, showing a small preference for money versus time. This in itself is not surprising or even particularly interesting. What’s more interesting is that those who chose time rather than money reported higher levels of happiness, even when the researchers controlled for participants’ amount of leisure time and income and money.

Realistically speaking, we are all in the business of balancing time against money. How we do this has significant implications in terms of our well-being and happiness. Research suggests that we should tilt in the direction of saving and valuing time rather than money if we want to maximize our happiness. There is ample research suggesting that experiences create more happiness than material possessions. And experiences take time (and sometimes money), while material purchases take money (and sometimes time.)

What can we learn from this research?

  1. When possible, tilt your decisions in favor of time rather than money. Don’t buy a cheaper house which requires you to spend many hours a week commuting. Don’t spend very much time in order to gain small savings in money.
  2. If you are going to invest time in order to save money, calculate your hourly “pay”, and only invest the time if the hourly salary is high. For instance, if it will take me 30 minutes to save 20 bucks, I’m earning $40 per hour. But if it takes me 30 minutes to save $5, then I’m earning $10 per hour. Try to be rational about these decisions and don’t pay any attention to the percentages saved, only to the dollar values and the time values.
  3. Time invested in saving money on recurrent expenses such as cable or satellite TV, car insurance, cell phone service, Internet service, etc. will always pay you a higher salary rate per hour. A few hours invested in researching less expensive alternatives and switching can save hundreds of dollars a month indefinitely which adds up to a very good return on your time invested.
  4. When you get excited about “getting a deal”, always calculate the true cost of the deal in time and in hassle. This will prevent you from driving across town to get a small savings or from spending too much time spent on the Internet looking for deals. (I am as guilty of this as most people, although I’m much more likely to spend time online rather than time in my car, even though both waste time.) Ask yourself whether on your deathbed you will be telling your grandchildren about this deal that you got. Remember that in the grand scheme of life, time is worth more than money. (See this classic parable about the poor fisherman and the entrepreneur.)
  5. Finally, remember that life is not just about time and money, it’s really about meaning and values. Spending money doesn’t really benefit you unless it ties into your core values and improves meaning in your life. That’s why even getting a multiplicity of small “deals” doesn’t really matter in the grand scheme of things. What matters more is whether you spend money to support your core values. That’s why grandparents sometimes pay for their grandchildren’s college, even though it’s an expensive proposition. And that’s why taking your family on a really fun vacation is a good investment as it leads to experiences and memories that potentially last a lifetime. (My siblings and I will always remember magical experiences from our family trips – playing telephone tag in the elevators of the Caesar’s Palace in Las Vegas, riding donkeys along a precipitous cliff in Grand Canyon, screaming “beep beep” on a narrow, twisting road in Spain when our rental car horn failed.)
  6. And even time should be evaluated in terms of meaning and values. Here in Silicon Valley a lot of people retire early. This isn’t always a good thing however. What I’ve seen is that they often end up spending time doing things that don’t really add to their happiness. For instance, they will design and build a custom house, usually quite large, which eats up several years of their life playing at general contractor and quality control inspector.
  7. Just as spending money intelligently is challenging, it’s even more challenging to spend time well. I struggle with this all the time. But I try to continually improve how I spend my time, for instance trying to focus more on writing these blog articles rather than watching television or reading a novel.

This article ended up being a lot longer than I expected, but I think these are profound and important issues for all of us to think about and to improve. Now it’s time for me to have some fun!

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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.