Skeletons in the closet?

In March of this year, I saw a new PCP for the first time in a while. I used the student health clinic while in grad school or have just continued seeing the same specialists (ie, psychiatrists). I told the doctor flat-out that I have epilepsy and osteopenia, that I struggled with anxiety and depression, and was in recovery from anorexia. We then did a standard family health history, in which I was asked about heart disease, cancer, and diabetes in my close relatives.

The PCP didn't ask about mental health issues in any family members, even though these were the main issues I was currently having (the epilepsy and osteopenia being, of course, secondary to anorexia). Even though, more importantly, that all three conditions (anxiety, mood, and eating disorders) have a substantial genetic component, and that a person is probably going to present to their PCP with one of these issues first, especially since I need a referral to see a specialist.

Recent research titled "Predictive Value of Family History on Severity of Illness" from the Archives of General Psychiatry examined how a family history of anxiety, depression, alcohol dependence, and drug dependence was related to age at onset, recurrence, impairment, and use of health services. The researchers found that family history was significantly associated with recurrence, impairment, and service use, though not age of onset, in each of these four disorders.

The authors conclude that "family history is useful for determining patients' clinical prognosis and for selecting cases for genetic studies."

So why have general clinicians shied away from asking directly about family history of brain diseases? They ask about Alzheimer's or brain cancer, but not depression and anxiety. Terrie Moffitt, one of the authors of the paper, gave two reasons in a recent press release. The first was the stigma attached to mental illness: even if doctors asked, would the patients respond honestly? Or would relatives even know about anxiety and depression in a close family member?

The second reason was related to the DSM itself, the Diagnostic and Statistical Manual of Mental Disorders, the so-called "Bible of Psychiatry," makes no mention of family history. At all. Whether this changes or not in the upcoming Fifth Edition has yet to be determined, but I think it's about time we simply started asking about mental health issues. Many risk factors are well-known, even if not well-understood. Even just by identifying those at highest risk, we can more quickly identify or even prevent some illnesses.


KristineM said...

I agree, Carrie, that doctors should ask for history of mental illness in the family in same way they ask about physical illness. Sure, some people may not be honest in their answers, but the more that this kind of thing is approached in a matter-of-fact way, the less the stigma.

I sure hope the DSM V recommends the mental health history.

Carrie Arnold said...

Absolutely right! The brain is part of the body- at least the last time I checked, it was. And I think we really need to stop thinking of mental health any differently than physical health. Mental health parity is good, but I think we need to do away with the distinctions altogether.

No, we don't fully understand depression or anxiety or anorexia or schizophrenia, but we don't fully understand diabetes or cancer, either. That doesn't stop us from asking about it.

Micco said...

I'm almost always asked about my family's mental health history in addition to their physical health history...

Miss Keira said...

I have noticed both my medical and psychiatric doctors ask about Family history of Mental Illness. My family doctor is aware of most of ours as she treats my mum also.

A lot of my abnormal/clinical psych textbooks list a family history as a risk factor so it seems highly relevant and no different to asking about history of diabetes (which I seem to get asked about a lot?)

jade1977 said...

Maybe it is just because I am in a big hospital town (Pittsburgh, PA) with a strong influence on mental health research, but I am always asked about family mental health. If it is happening here, I would assume (but you know what they say about that) that it would start rolling out to other doctors at some point.

Jessi said...

ohh i HATE first sessions with new shrinks and the like! just thinking about it gives me shivers!

Yeah I have been asked a range of questions re: family health too... some odd and some that should be deemed mandatory! ;)


take gentle care carrie

Just Eat It! said...

MDs never, ever ask me about mental health in the family. Therapists almost always do. I had one therapist draw out a family tree of mental illness in my family and all I could think was that someone pissed in my mental health gene pool.

I think it'd be important for doctors to ask simply because of the co-occurring side effects of mental health, specifically with eating disorders.

Amy said...

My one super vow for when I'm a parent is to be super forthcoming about our family's rampant history of mental illness. My mom's pretending that all was well didn't do any of us any favors.

Wrapped up in Life said...


Another one flies just beloew the radar.

Some things never change, and I doubt another 100 years will truly make a difference.

Carrie Arnold said...

I have been asked by psychiatrists and therapists about family mental health history--which is all well and good. My last psychiatrist even asked me what meds some of my family members had been on, because if your family member responds well to a particular med, then you're much more likely to respond well to it. But I've never been asked directly about my family or myself. I've always had to volunteer the information (which could mean that the doc didn't then have to ask but still...)

I think it's fantastic that some people have been asked about family mental health history, and I hope one day more people will be added to that list.

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I'm a science writer, a jewelry design artist, a bookworm, a complete geek, and mom to a wonderful kitty. I am also recovering from a decade-plus battle with anorexia nervosa. I believe that complete recovery is possible, and that the first step along that path is full nutrition.

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