Measuring Success . . . "I think I'm a 5"

“So, Mrs. Kapsmanjacketter, on a scale of 1 to 10 with 10 being the most depressed you have ever been, how have you been feeling since our last visit . . . ”

And so, yet another rapid fire med check begins in the land of managed care.  How many times have you, my devoted psychiatric public, been in the position where YOU have been the recipient of that question.  I cannot count the number of times I have said it.  It is close to mandatory at this point.  There is the expectation that the experience of our lives be reduced to a numerical format that allows for evaluation and comparison to our past experience, our future expectations and the moods of all of the other millions of people showing up for their med checks.  Our treatment is supposed to be problem focused, solution oriented, and results are expected to be framed in a way that is measurable.  And so, we ask the question.  You assign the number.  And somewhere, someone is happy . . . a “3 out of 10” happy.  Or is that a “7 out of 10” happy?  See the depress-o-meter goes from 1 to 10 but so does the happy-sappy-meter.  So you have to be vvvveeeeerrrryyyy careful as a clinician which meter you are using and so does the patient, cause sometimes I am using the depress-o-meter and the patient thinks they are using the happy-sappy-meter and I get an answer of “8” and I think they are really depressed when they think they are really feeling very happy and then they get confused about why I am pushing their medication up when they are feeling very happy and I am writing about how their affect does not match their mood because no one who is an “8” on the depress-o-meter should be smiling like they are a “2” on the depress-o-meter and maybe they are hiding their true feelings and maybe they are actually psychotic or suicidal and are smiling because of other things going on in their head that they are not sharing with me and maybe they need to go to therapy TWICE a week even though their insurance company raised their co-pay to FIFTY DOLLARS and who can afford that sort of payment twice a week and getting that kind of advice is enough to sink your mood to a “4” on the happy-sappy meter (or is that a “4” on the depress-o-meter ) . . .

Whoever said it was easy being a shrink???

Point is . . . who the hell is ever a “10”??? 

I meant a happy “10” . . . like a “10” on the happy-sappy meter.

There is such a grand and varied range of human emotion.  The last several months have certainly reminded me of that.  But the experience of a happy “10” is far from the typical.  I can look back on some peak moments in my life when everything fell into place and,  for  brief periods, life was grand.  But then . . . life re-asserted itself.  The children, the parents, the siblings, the dog,  the boss, the situation . . . and I was again reminded about the wide and varied range of human emotional experience.  So how do we measure success when we are applying treatment?  Is the medication or the therapy really supposed to park our emotions in a state of static ecstasy?  Is anyone ever really a “10” on the happy-sappy-meter or would that, by itself, indicate that I have gone too far with the medication and need to consider a mood stabilizer?  And what about “happy as a clam?”  or “happy as a pig in shit?”  What about good old fashioned “happy enough”???

In my line of work, the end-point can be difficult to determine.  Blood pressure is easy.  Glucose levels are easy.  Blood flow is easy.  Either the numbers are in the “normal” range or they are not.  “Normal” is such a vague term for our experience as humans.  Some who come to me for treatment seem to want more from the medicine than I think the medicine can deliver.  They want a level of happy that is not appropriate for their circumstance in life or for how they manage their life and their relationships.  They want the medicine to deliver happy when a huge stumbling block to “happy” is that they are too sedentary, and don’t eat the right foods, and don’t read good books, and watch too much TV, and don’t pray or meditate, and don’t resolve long-standing conflicts with their spouses or children or parents or co-workers.  Anti-depressants are NOT supposed to make you happy.  They treat depression.  The endpoint of treatment with antidepressants cannot be expected to be a “10” on the happy-sappy-meter (a “1” on the depress-o-meter).  The endpoint is to take away the intense black-hole experience of depression that keeps one from living life.  Happy comes from how you live your life.  What you do when you don’t feel like doing (cause everyone doesn’t feel like doing at times).  What you eat when you feel like eating junk (cause everyone feels like eating junk at times).  What you think about when your brain keeps going to the negative (cause everyone’s brain goes to the negative sometimes).  There is a degree of choice with the management of one’s mood.  Certainly medicines play a role for many who are depressed.  The the role is not one of “miracle-pill”.  The medicine is one piece of a big puzzle of good mental health that must be joined by other good habits in order for it to be most effective.  

Life is an active process.  Good mental health takes time, effort and patience.  If you are sitting around waiting for the medicine to “kick in” so that you can go do those things that you know are good for you, you are putting the cart before the horse.  Feeling good comes from living a good life.  Take the medicine . . . but start living the good life now.  THEN watch as things fall into place.

–Dan Hartman, MD

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