This may just be everyone’s favourite, and not something we do everyday. Introducing a new intervention into practice. It’s wonderful to come to work with a new skill set, a new way to measure, or a completely new perspective on a common clinical problem.
In retrospect, I’ve done it a few times in my practice, but only a few. I remember, in ~ 1984, understanding that I would never be able to do a Hamilton score on my patients in a family medicine setting. Learn about the score, they said, it’s important, but you’ll never be able to do it in a clinical interview. Just takes too long. “Leave the formal measurement of depression severity to psychologists”. Words from my professor’s lips…
Then the HAMD7 came out in about 2005. Five minutes, and you’ve got a score. I remember laughing about it. I mean, after being in practice for (then!) almost 20 years, you think you know what you’re doing. I went to a lecture about this score, and couldn’t believe it. Sitting down and formally scoring someone. A stiff, formal approach I thought, an unfeeling, metric, right angle approach to a fuzzy problem. Isn’t your feeling better? You know, don’t you just know in your gut, doesn’t your patient know if they’re getting better? You do the SIGECAPS, look at your last note, see how they described things last time, make a fuzzy judgement on a fuzzy problem, and then decide what to do with the dose. That’s how it was done. Really.
I tried it out with a patient, someone I felt was in the stable phase of their treatment, in the six months coast out after recovery. We both felt the depression was gone. Tried the HAMD7, why not? And got a 4.
0-3 is recovery. Not 4. I think I said something like, “see how stupid this score is? We both know you’re better, right? Aren’t you?” The patient laughed, and said, well, let’s really test it. What would you do now, if it was reliable, a good test?
I bumped her meds up, got her back, got a score of 3 the next month, and she reported she felt it. Felt better. Definitely. So I was sold, and have been doing the HAMD7 since.
Is that an appropriate way to make a decision about how to introduce a new maneuver into your clinic day? It’s the way it’s usually done, and I confess, I’m still doing it. We get clinical impressions, and make gut decisions. Not completely bad, but not completely good, either.
It’s better to introduce a maneuver, and do some measurements, and look at some outcomes. Yes, the HAMD7 is in itself a measurement. How do you look at that? In a quantitative type trial, I suppose you’d split your patients in two, do HAMD7s on half, and gut measurements and decisions on the other. Bring the groups through to treatment conclusion, and do some other kind of score like the PHQ9, or Zung, on both groups to see the outcomes. This is the sort of thing that turned me off doing any kind of analysis in clinic. My training from 30 years ago led me to believe that I’d never get enough numbers to get any kind of meaningful result. Quantitatively.
Not qualitatively. This kind of analysis, as stated above in this little epistle, is real, tangible, fibrous, and can be done in your clinic. And give you answers, and guidance.
Do you have a problem in clinical practice? One of mine was, and is, insomnia. You can learn and practise CBT, or DBT, be practising for years, and still not have a solid approach to this basic problem. Well, you can start from scratch and try to develop a program, or try to find one.
I suggest trying the latter. You can develop something de novo, but it will take a great deal of time, and still needs validation. I’ve myself written a little ebook on CBT/ DBT for patients, with an insomnia wrinkle. But what I do in clinic is use a well investigated, proven approach for patients. A step by step, almost spoon fed approach that’s been studied in over 25000 patients, at a respected site (Harvard, Dr Gregg Jacobs). I discovered this after I had done substantial research, and written my ebook.
So what do you do? Do you go with the approach you cooked up on your back burner, or use a defined strategy that has been well tested? Clearly the latter. I have to admit to feeling a little crushed, but managed to salve my emotions realizing that my ebook was really intended to teach CBT/ DBT, hoping that patients would find sleep along the way. Sort of like the YMCA approach to teaching water safety, advertised as swimming lessons, but really intended to plant some seeds to make a good person, a good human being.
If you’re interested, please see www.cbtforinsomnia.com, Dr Gregg Jacobs’ site. Here, you’ll find an online course you can take re insomnia. I wish I’d found this before doing all my research: it would have saved a year of my life. This site simply needs better advertising…
At any rate, take the course, and receive a spoon fed approach to helping your insomniacs. Learn a way of tapering off meds that is so slow it sounds ridiculous: and works, in my as yet limited experience.
So what is my approach to starting CBT-I in my family practice? I want to know if it works. Further, I want to know if my Canadianized version is effective. Canadianization? A new word perhaps. Two hour counselling sessions don’t fly in family practice. At least north of the border. You need a bare-bones, more punchy but still supportive approach.
How do I set up my qualitative study, realizing that I’ll only have 10-20 patients a year, not 25000? How do I manipulate the described course for my own patients? How do I make it work in my practice? How much material do I need to include, and what can I cut out?