Depression, Suicide, and their Detection: Whose Responsibility?

Frank Jones, a 31-year-old military veteran comes into your office complaining about his knee. He tells you he felt pain while dong "squats” in the gym. You go through the typical "standard of care” routine practiced in almost every medical office. You go through the history and physical (H & P), which is generally referred to and routinely taught by just about every medical education program. You then decide which tests to order. Perhaps you order an MRI or some other imaging. You eventually make a diagnosis and then suggest a treatment strategy. If you are not an orthopedist, you may consider referring to one.

  • Sara Smith, a 60-year-old housewife enters your office presenting with "headaches.” You do the H & P and decide what other studies to order. Eventually you come up with a diagnosis and a treatment plan.
  • John Brown, a 19-year-old comes in complaining of discomfort while urinating. Again, the H & P is done; perhaps a urinalysis, IVP, and/or a blood workup is ordered.
  • Sam White is an 80-year-old retiree who describes shortness of breath, a "dull ache in my chest”, etc. Again, the H & P is done; then heart sounds are auscultated, an EKG is ordered, and a blood workup is ordered in addition to some imaging, and soon the diagnosis and the treatment plan are developed.

These all may be textbook scenarios, most likely taught in all medical education. All are appropriate, respective "standard of care” procedures of very different complaints / presentations /and diagnoses. Yet they all have one thing in common. What they have in common, according to the thinking of many respected clinicians, is "negligence” in a "standard of care” procedure. It might be seen as an omission during the H & P., and some might consider it a disregard for or a minimizing of a potential emotional disorder or a mood disorder resulting from the physical complaint. The practitioner may have tacitly assumed resolving the physical complaint will resolve the mood.

In these scenarios there are not any observable references addressing concern for the possibility of a patient’s emotional distress / disorder.

Granted, the average clinician may not have any training in diagnosing and / or treating behavioral disorders, and therefore may not be competent enough to definitively add a diagnosis of major depression to Mrs. Smith’s evaluation, for example. This clinician may not be concerned with recognizing any signs of emotional disorder, whether overtly by design ("it’s not my expertise, and she came to see me for my treating of her headaches”), or by instinct because this clinician has not had any (or adequate) training in detecting an emotional disorder. Some clinicians shy away from any involvement in emotional disorders out of fear of legal vulnerability, because they have not been trained for this "specialty” in medicine.

All the clinician has to do is indicate, in the patient’s file, that "there seems to be,” or "there might be,” or "I didn’t see overt indication of …. but there might be some indication of….,” or "I administered the MS exam and / or the MMSE and while there doesn’t appear to be an overt indication of …. this might be looked for in the future.” The idea being that someone picking up the file, sometime in the future, may think that "there might be similar indications during this present examination / visit,” and seeing a previous note of "suspicions” might trigger a closer evaluation at that point / time.

The overall concern or objective is that the general "standard of care” of any health condition should be to include / increase the awareness of potential conditions involving depression and / or anxiety disorders, especially since these are the disorders that statistically relate closely to suicidal ideation. An increasing number of studies are showing increased numbers of suicides and correlating increased suicides to increases in depression and / or anxiety disorders.

There was a time, not long ago, when no one would have wanted to be associated with an emotional disorder … or its stigma. Clinicians stayed clear of involvement (except for the specifically trained), and only the patients diagnosed and / or "treated” were those who voluntarily came forth or those who were mandated to come forth for one reason or another. It was accepted that being thought of as having any emotional disorder would be career ending. In addition, the typical clinician felt uneasy (or unqualified) in attempting to diagnose (and therefore "label”) someone with an emotional disorder, let alone try to treat him or her. Many probably would have just written a prescription for "relaxation,” "sleep,” or "pain.” Besides, in medicine, there often is an attitude of "my concern is with Mr. Jones‘ knee and not his personal life”! However, public attitudes have come a long way in being more constructively sensitive to emotional disorders and more willing to want to deal with these disorders.

Frequently, patients may not even sense / know that they are clinically depressed or anxious. How would a psychiatrist or psychologist even have the opportunity to detect the signs? But the same patient has no hesitation in getting his / her lungs checked out when he / she can’t stop coughing or getting the shoulder checked out when he/she cannot lift it. Enter the pulmonologist or orthopedist that the patient will go to.

It seems as if since society is expecting non-psychiatric medical practice to be more aggressive in recognizing emotional disorders. Shouldn’t medical education be more concerned with preparing non-psychiatric clinicians to be more alert to the signs of emotional disorders? Do we just depend upon those clinicians who elect to do psychiatric residences or train in the clinical psychotherapies? Or do we broaden medical education to give all clinicians more ample capability to detect "possible” emotional disorders?

Whose responsibility should it be to detect disorders such as depression and suicidal ideation?


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