Psychiatric Problems: Visiting a Family Medicine Doctor
Guest: Dr. John Freedy – Family Medicine
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I’m Dr. Linda Austin. I’m talking, today, with Dr. John Freedy, Assistant Professor of Family Medicine. John also has a Ph.D. in Psychology and was on our faculty, here, in Psychiatry for a number of years, and we worked together at that time. John, I want to talk to you today about a very interesting topic which is the presentation of psychiatric and emotional problems: depression, anxiety, post-traumatic stress, in a family medicine practice, as opposed to going to a psychiatrist or a psychologist. In our daily life, now, do you see a lot of psych problems?
Dr. John Freedy: Quite a bit. Actually, probably, somewhere between a quarter and a third of my patients have, either primarily or secondarily, one of those types of problems. I’ve talked with a number of my colleagues. They find it to be similar. And when you look at national data, most family doctors will say it’s at least that high. Some people will say it’s upwards of 40 to 50 percent of people coming in
have those sorts of issues.
Dr. Linda Austin: Now, are these patients saying, I’m here because I think I’m depressed, or are these patients coming in for headache or backache, or tummy ache and, along the way, saying that they recognize as a problem, or do you suspect that there may be a psychiatric issue?
Dr. John Freedy: It’s both. But, probably, it’s more often that people come in and they don’t recognize that this is depression, for example, or a form of anxiety. They come in with the physical complaint or, because something’s not going well in their life, their spouse or significant wanted them to come in. That sort of indirect presentation is actually more common, I think.
Dr. Linda Austin: So, what are some of the common physical symptoms that people who are depressed or anxious present with? Let’s start with depression.
Dr. John Freedy: Okay. Well, with depression, we call it the great pretender because it can look like just about anything, physically. But, the person may not sleep well. The person may lose appetite. The person may have somatic complaints: headaches, abdominal complaints. But they don’t seem to have an objective organic finding to back that up. So, the person comes in and you do the typical evaluation and the typical treatment, say, for reflux, and you’re really not finding something, and it’s, really, over a period of months, a year or more, and you don’t have anything to hang your hat on.
You start to look at mood symptoms, family history of depression, anxiety, substance abuse, the whole pattern. I talk with my residents about pattern recognition, this sort of somatic type of person without a clear physical finding,
and then there’s a family history that makes some sense. You’re probably dealing with something that’s either a depressive or an anxiety-type problem.
Dr. Linda Austin: I hear, also, people talking about worrying that Mom or Dad, who are now in their 70s or 80s, or 90s, even, are depressed and will start by taking that person to the family doctor, even if depression isn’t what the aging parent thinks they have. Is that something you see much of?
Dr. John Freedy: I see quite a bit. We, actually, had a lecture early this morning on altered mental status in the elderly. And there can be a lot of reasons for it. You know, one of the things I think about is, we don’t require insight if somebody comes in for another complaint. Say, somebody has some pain in the mid-region around their stomach, we don’t require them to know, well, is that an ulcer, or is that a gall bladder problem, or what have you. But, with depression, somehow we think the person can say, yes, I’m depressed or, no, I’m not depressed. Sometimes, you can. But, oftentimes, you’re really not aware. You don’t have the clinical skill to understand what it is.
So, I don’t think, as a family or as professionals, we should require that of people, or if they say, no, it’s not depression, well, that’s a point of view, and that may be. We’ve got to look at the whole situation and make a better clinical decision than that.
Dr. Linda Austin: How about anxiety, are there different body symptoms associated with anxiety than depression?
Dr. John Freedy: Anxious people are usually revved up. And it’s almost like riding a roller coaster or a wave, and there’s an energy that sort of tends to go up and down, up and down, with the individual. Sometimes it’s difficult to tease out what we would call an agitated depression from an anxiety. You have to look at the whole constellation of symptoms and what is, and what isn’t, present. But, in general, the anxious person is sort of running. It’s like the accelerator is stuck half the way down, and there’s a ruminative component that goes with it. And, I don’t know, it’s kind of difficult to separate the two. I have a hard time with that.
Dr. Linda Austin: It can be hard. Although, panic attacks, sometimes, can feel very dramatic, like heart attacks.
Dr. John Freedy: Absolutely. I think there are some studies that indicate that about one in five chest pains that come into ER settings are actually panic attacks. Of course, you have to rule out the organic; let’s make sure it isn’t a heart attack, let’s make sure it isn’t a dissecting aortic aneurysm. Once you rule that out, you’re left with, this seems a lot like an anxiety disorder and, by the way, you have a family history and, by the way, this is the fourth time you’ve been in the ER in a year and a half with similar symptoms, and we’ve ruled out everything else. Now, we think it could be anxiety and we need to help you to deal with that.
Dr. Linda Austin: If somebody listening to this is thinking, gee, I think I have depression or anxiety, is that a reasonable place to start, to go see their family medicine doctor?
Dr. John Freedy: Absolutely. Family doctors are, really, specialists in common conditions. So, if you think of it that way, if you go into the family doctor and say, I’m having a problem and I think it could be anxiety or it could be depression. The person’s really not going to bat an eye. They’re going to take that very seriously and assess it appropriately. The same way if you came in with something like a twisted ankle, they’re not going to think of it a whole lot differently. They’re just going to give it the care and attention that it deserves. Most of what you need can be taken care of there. But, part of what you’re trained in, in family medicine, is to coordinate care. And if it’s beyond the scope of what you do, you get the patient to a specialist that can help them with either medications or psychotherapy, or a combination of those.
Dr. Linda Austin: We’ve been focusing on depression and anxiety. Of course, substance abuse and alcoholism are other very common psychiatric disorders that
I’m sure you see plenty of in a family medicine clinic.
Dr. John Freedy: Absolutely, and the physical consequences of that over time, be it accidental injuries, or people start to get heart problems, liver problems, other sorts of difficulties as they go through that disease process.
Dr. Linda Austin: It’s hard, I know, very hard, for people to talk frankly with their doctor about alcohol problems. The other day, I did a podcast interview, actually, about the interesting topic of anesthesia awareness. One of the comments that the anesthesiologist made, which I think is so true, is that the danger that patients run when they’re not straight up with their doctor about high levels of drinking is that the liver can be compromised and can change the way other medicines are metabolized, so the doctor can really be kind of blindsided by a response that they don’t understand if they don’t know that there’s a heavy drinking issue going on.
Dr. John Freedy: I think that’s absolutely true. You’re trained as a doctor to assume all possibilities. So, for example, if you see that a person is depressed, you don’t assume that it’s simply depression. You think about other things it could be. And, coexisting substance abuse, particularly coexisting alcohol abuse, could be a possibility. A problem with the thyroid could be a possibility. So, you’re trained to look at all of those things. But, in the course of a busy day, you’re not always going to pick up on that with every person’s unique situation. So, it is important to feel like you can, and should be, honest with your doctor so that they can have the information at hand to best help you.
Dr. Linda Austin: Dr. Freedy, thanks so much for talking with us today.
Dr. John Freedy: Thank you.
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