A Complex Problem
The treatment of mood disorders is not so simple as diagnosing depression and writing a prescription for Prozac. The individual causes of depression are diverse and poorly understood. The medications used to treat it are just as diverse and matching a drug with an individual is not a clear cut decision. Individual symptoms, co-existing illness, tolerance of side-effects, and medications previously tried are just a few factors that must be considered. Then there are the difficulties in making an exact diagnosis. Bipolar disorder in particular may be misdiagnosed, especially if patients "fall on the edge" of DSM-IV criteria.1 Symptoms of mania may be overlooked because depressive symptoms are the ones that feel so bad and first bring a patient in for help. Symptoms of bipolar disorder may also be confused with other disorders.2,3,4 Add the fact that there are no brain scans or blood tests one can take to make a definitive diagnosis.5 Doctors must rely on a set of signs and symptoms as well as the patient's history. Diagnosing and treating depression and manic depression is not a simple matter at all!
When one realizes the complexity of the matter, it becomes easy to see that treating mood disorders is not an exact science. Rather it is an artform requiring a combination of patience, knowledge, judgment, willingness to try new treatments, the ability to network with peers and a desire to keep up with current developments in the field. Compare that with the fact that most people first seek help through their family physician,6 a doctor who does not specialize in these conditions, but rather must be a "jack of all trades" treating and screening for a wide range of illnesses. Your family doctor simply does not have the time or energy needed to keep up with the specialized knowledge necessary to treat mood disorders.
What Your Doctor Doesn't Know Can Hurt
Studies show that 74% of people seeking help for depression will first go to their primary care physician. Of these cases, as many as 50% are misdiagnosed. Even of the cases that are correctly diagnosed, 80% are given too little medication for too short a time.7 Considering that depression can have a fatal outcome if not properly treated, these are some sobering statistics.
Of course, some people will do just fine with their primary care physician. They will get a proper diagnosis and may even be fortunate enough to respond to the first medication that their physician prescribes. This, however, may be more luck than skill since it is estimated that between 60%-80% of patients will respond to any particular medication.8
What if you are not one of the lucky? What if you are treatment resistant? What if you can't tolerate the side-effects? It won't take long to see that your doctor is floundering. Meanwhile, you have spent quite a bit of time and money seeing a doctor who is not adequately trained to treat you. Your doctor's inexperience at minimum may lead to frustration and added expense. At worst it can be a prescription for disaster.
Who's an Expert?
So, whom should you see to ensure that you are in the hands of an expert? Although there is some controversy over whether therapy, drugs or a combination of both are best for depression, there is really one type of doctor who is qualified to treat depression and other mood disorders using medications: a psychiatrist. A psychologist, also qualified to treat depression, is not a medical doctor and cannot prescribe drugs. A psychologist specializes in talk therapy. If you are uncertain whether you need medications, it is best to begin your treatment under the care of a psychiatrist. If you will also benefit from talk therapy, psychiatrists are generally able to handle this as well, although some may elect to refer you to another therapist.
Dr. Ivan Goldberg, a noted psychopharmacologist, provides an illustration of the differences in thinking between an inexperienced physician and an expert. While you probably wouldn't want to quiz your own physician with these questions, it does show that there is a wide gap in knowledge that can only be filled by experience. Choosing a psychiatrist over a primary care physician is no guarantee of experience, but it does improve your odds.
The Primary Care Physicians's Important Role
Keep in mind that you should not skip your primary care provider altogether. In fact, depending upon your insurance coverage, you may have to see him/her in order to get a referral. Your primary care provider does play a very important role, both in screening you for possible mood disorders and in screening for other illnesses that may mimic depression symptoms. Once it is determined that you are healthy and may possibly have a mood disorder, however, your doctor should make you a referral to a qualified specialist. If your doctor does not offer to make this referral, insist upon it. After all, you are paying your doctor for a service. You have the right to expect care from a qualified expert.