"Prescribing" (suggesting?) marijuana...

[473912]

I passed a dispensary and it got me thinking. I'm told that marijuana will be legalized in the state soon. I do understand the federal illegal vs state illegal. For those working in states where it is legal as recreation, does that (or could it) change your practice? Maybe you can't prescribe cannabis technically, but could you suggest it as a relaxation/recreation for those with severe symptoms the same as you would.. yoga? Do you see that happening at all?

Just curious.

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[irish80122]

I enjoy having a license and reasonable insurance rates, so I think I will stay away from making that suggestion. Is there enough literature for treating any mental health diagnosis that it could really be called empirically supported? If not, it would seem that recommending it would be a significant risk.

 

[Therapist4Chnge]

Nope. It isn't in the bounds of my training. That said, I've seen some positive results with medicinal marijuana with a number of my SCI and chronic pain patients. The medical system's policy (when I worked there a few years back) was to not officially support use, but to still treat the patient. I saw multiple patients decrease opiate use and decrease dependence on other meds once they started medicinal marijuana, though it will be a tough thing to study formally.

 

[abhalla]

I can't speak to the idea of "prescribing," or suggesting marijuana use to patients, but as a graduate student living in Colorado, it has been interesting to see the salient public perception of marijuana as an "alternative medicine." A great deal of patients coming through our clinic and candidly discuss their marijuana usage, which from a biopsychosocial perspective is great for understanding patients, because I imagine some may not be as forthcoming in other states where marijuana is illegal and looked down upon. The small amount of high-quality research out there shows the benefit of marijuana for different issues, including neuropathic and noiceptive chronic pain (like Therapist4Change stated), nausea, and anxiety. Problem with these studies is that they are all conducted with cannabis provided by the gov't/DEA, so it is not certain whether marijuana purchased at dispensaries that differ in dosage, strain, and method of consumption are as efficacious.

 

[PsyDr]

The only state where psychologists can recommend medical marijuana is New Mexico. For ptsd. After 3 treatment failures. And you can't prescribe t. You can recommend them to the marijuana board and see if they approve it.

The literature is awful.

Imo: the vast majority of medical marijuana pts are seeking a medical excuse to use recreationally. The accompanying bs that goes along with that patient population is too much hassle and too much liability. I know colleagues who have own substance abuse treatment facilities and the amount of behavioral nonsense including major felomies is ridiculous. I can't tell you how many times I've heard "doc, alcohol/opiates/benzodiazepines/ marijuana/etc is the only thing that helps my mdd/gad/ptsd/adhd/bpd/etc.". I've very rarely heard "exercise/maintaining a healthy sleep schedule/etc helps diagnosis du jour.". When the latter's research is exceptional and the former is essentially nonexistent, well... There's a problem.


Don't even get me started on the self medication hypothesis.

 

[Ollie123]

I can't tell you how many times I've heard "doc, alcohol/opiates/benzodiazepines/ marijuana/etc is the only thing that helps my mdd/gad/ptsd/adhd/bpd/etc.". I've very rarely heard "exercise/maintaining a healthy sleep schedule/etc helps diagnosis du jour.".

This x10000. Doing forensics work right now and its pretty much what I hear on a daily basis. And you know what....it might well help them for a bit, but its usually not the only thing that will. If I'm in a state where it becomes fully legal (given where I'm moving, I don't think that's going to happen anytime soon), my approach will be similar to what I do for alcohol. Someone has a couple drinks with friends on the weekend? Not a problem. Someone drinks first thing upon waking up because its the only way they can deal with the challenges of the day? That we need to talk about....legal or not.

We do have medical marijuana in my current state. I'm actually astonished at the number of people who repeatedly get arrested for it when they probably could get a card and avoid all that trouble if they tried....

And yeah....terrible, terrible idea to be recommending it to patients. At most, one should be recommending they talk to a prescriber, just from a legal CYA perspective. Even that I think is a stretch given the state of the research.

All from the perspective of someone who actually does believe it should be legal for recreational use....

 

[xXIDaShizIXx]

Nope. It isn't in the bounds of my training. That said, I've seen some positive results with medicinal marijuana with a number of my SCI and chronic pain patients. The medical system's policy (when I worked there a few years back) was to not officially support use, but to still treat the patient. I saw multiple patients decrease opiate use and decrease dependence on other meds once they started medicinal marijuana, though it will be a tough thing to study formally.

I'd have to agree with T4C. I observed a psychologist recommending it, however it is not in our scope of training. We of course can always refer them out to physician that can (or the respective board depending on the state, etc), but we shouldn't be doing it, at least not for a while to come.

 

[PsyDr]

IMO: there is a huge difference between reducing anxiety and intoxication, although the two are often considered synonymous in the US population. Compare going on an 2 week well funded vacation with good food, sleep, social support, and exercise to getting intoxicated for 2 weeks under the same conditions. There's only one which we would expect to reasonably cause problems.

I do think that MJ should be legalized for recreational use, but I worry about what this will do for every neuropsych practice (e.g., "doc, my memory has gone to hell. I can't concentrate! Do I have ADHD/dementia?!".

 

[WisNeuro]

I do think that MJ should be legalized for recreational use, but I worry about what this will do for every neuropsych practice (e.g., "doc, my memory has gone to hell. I can't concentrate! Do I have ADHD/dementia?!".

What it will do? Those are like half of my referrals already. Although I have secondary gain to worry about as well, so that further muddies the water.

 

[PsyDr]

Goddamn.

 

[cara susanna]

I'm concerned about people using it for PTSD. There's some research indicating it isn't a great idea.

 

[WisNeuro]

I'm concerned about people using it for PTSD. There's some research indicating it isn't a great idea.

Yeah, I fear it's just being used as another avoidance strategy in the case of PTSD. I imagine it's quite good at tamping down anxiety sx in the short term, just like benzos, but I have yet to see any data about long-term efficacy. But, as a caveat, there is a dearth of long-term studies available. Also, it's going to be very politicized, on both sides, so get ready to see some very poorly designed studies to back pre-conceived notions.

 

[smalltownpsych]

I actually have more difficulties with my patients who are prescribed benzos and opiates than those who use marijuana recreationally. Would I recommend it to a patient? Not a chance. For the same reasons others stated. My own bias is that using psychotropic substances to adjust your mood is not the best strategy, but I still drink a lot of caffeine and am not quite ready to give that one up yet. So I aim for the optimal but also meet the patient where they are at. See Motivational Interviewing for a good rubric for that type of strategy.

 

[Nahsil]

I wouldn't recommend it, but if someone came to me already using it and didn't seem to have any real issues as a result, I doubt I'd care or try to get them to stop.

I smoked for a couple years (not anymore) and made 4.0s in undergrad, had a positive social and work life, blah blah...several of my friends in grad school smoke and do well. Seems relatively harmless compared to a lot of psychotropic coping mechanisms, dependent of course on frequency of use, the effects of not using, etc.

 

[erg923]

Yes, but your are, presumably, emotionally stable. The people who come to see you are not.

 

[Nahsil]

Right, which is why I'd never recommend it, because I couldn't predict its effects. If people are already presumably somewhat successfully using it as a coping mechanism, though, I'm not sure I'd try to convince them otherwise. The risks vs rewards aren't clear cut when it comes to marijuana. The "whys" of their use may be fertile ground for discussion, though, and who knows where that may lead.

 

[erg923]

Inhaling smoke into ones lungs is unhealthy. Period. If they decline an interest in quitting, fine. But as a licensed health professional, one is ethically obligated to address unhealthy behaviors.

 

[WisNeuro]

Inhaling smoke into ones lungs is unhealthy. Period. If they decline an interest in quitting, fine. But as a licensed health professional, one is ethically obligated to address unhealthy behaviors.

Meh, I'm obligated to address suicidality, homicidality, and abuse of vulnerable populations. Outside of that, it all depends on your role, and what changes the patient is willing to make.

 

[QAsPsych]

Inhaling smoke into ones lungs is unhealthy. Period. If they decline an interest in quitting, fine. But as a licensed health professional, one is ethically obligated to address unhealthy behaviors.

That is among the more ridiculously reductive statements I have read today.

 

[erg923]

Uh, ok. Is it safe to assume you guys don't inquire about smoking cessation with your patients then? If so, why not?

I thought my job was to offer a happier and healthier life/existence to those we serve. They are free to say no to any or all of it, of course.

 

[Therapist4Chnge]

He'll argue vape'ing, and erg923 would come back w. reinforcing unhealthy behavior.

 

[WisNeuro]

Depends on where we're at. Usually, smoking is the least of my worries, and one of the things my patients are the most unwilling to change. It's low yield in a lot of circumstances. I pick my battles. As for as MJ, I'm not a proponent, but it's less damaging than alcohol, and many other drugs, so it's not a huge target for me.

 

[QAsPsych]

It's complex. First off, using marijuana =/= smoking marijuana, esp. in states where marijuana use is legal at the state level and many people use edible marijuana products. Second, the number of behaviorally imperfect things people do precludes the possibility of addressing all of them. The idea that it is our ethical responsibility to address (even cursorily) every aspect of a person's life is ludicrous; I've never seen an ethical code that says anything like this, or known a medical doctor to do anything like this. It's effectively impossible, every person could be improved 0.0001% by improving their lifestyle in some way. You would want to triage an individual's problems; if marijuana usage is the greatest problem, OK, address it, I absolutely believe marijuana can be a problem for some people. But with most people in a treatment setting it is going to be so far down the list that we are going to deal with every problem that raises to a clinical level long before we get to it, and if they're using it recreationally and rarely I can't justify treating it that much differently from alcohol (which, used recreationally and rarely, shows better outcomes than non-usage, if I want to follow the science).

 

[erg923]

Correct. We address the most impactful and dangerous behavioral health habits. Addiction, whether its to nicotine, heroin, marijuana or alcohol is something I was always taught to assess and address. Not sure what the resistance is here? I work in primary care not in a psych clinic, so that may be factor here as well. Nevertheless, I am concerned when I hear psychologists assert that drug abuse (whatever the substance) is "far down the list" in treatment. Seems very strange to me.

And I would argue that the constant up and downs associated with daily nicotine withdrawal is relevant to, and directly impacts, psychiatric functioning.

 

[psych844]

. Not sure what the resistance is here?

Your avatar?

 

[erg923]

Your avatar?

The fact that Keith Moon make smoking "look cool" doesn't make it healthy.

 

[erg923]

.

 

[Therapist4Chnge]

Correct. We address the most impactful and dangerous behavioral health habits. Addiction, whether its to nicotine, heroin, marijuana or alcohol is something I was always taught to assess and address. Not sure what the resistance is here? I work in primary care not in a psych clinic, so that may be factor here as well. Nevertheless, I am concerned when I hear psychologists assert that drug abuse (whatever the substance) is "far down the list" in treatment. Seems very strange to me.

And I would argue that the constant up and downs associated with daily nicotine withdrawal is relevant to, and directly impacts, psychiatric functioning.

That's fair, though I generally favor a harm reduction model…as achieving some behavioral change is better than none at all.

 

[QAsPsych]

Correct. We address the most impactful and dangerous behavioral health habits. Addiction, whether its to nicotine, heroin, marijuana or alcohol is something I was always taught to assess and address. Not sure what the resistance is here? I work in primary care not in a psych clinic, so that may be factor here as well. Nevertheless, I am concerned when I hear psychologists assert that drug abuse (whatever the substance) is "far down the list" in treatment. Seems very strange to me.

Use of substances is not "drug abuse" for any reasonable definition. Addiction is a serious concern, but your statements seem to indicate that use is abuse and addiction, e.g.

Inhaling smoke into ones lungs is unhealthy. Period. If they decline an interest in quitting, fine. But as a licensed health professional, one is ethically obligated to address unhealthy behaviors.

Yes, if a person has an addiction we should address it; but it's unethical not to challenge normal use which is not presenting a serious risk to the client, because all use is somewhat unhealthy? I become concerned when I hear psychologists say things like that.

 

[erg923]

What is "normal use"of cigarettes? Seems like addiction.

 

[smalltownpsych]

If a patient wants to quit smoking, I will provide him with support and education about strategies, but usually my patients have more imminent concerns. My experience is that when their overall psychological functioning improves, they are more likely to be successful making other healthy life choices. Some of my patients should not even attempt to quit smoking until they are more stable, but some still try it anyway and next thing you know, they are taking 50 pills and headed to the ER.

 

[Peacemaker36]

Medicare's Physican Quality Reporting System (PQRS) now lists "counseled patient about smoking cessation" as one of the quality measures.

Not that it's generally a bad idea to counsel most patients to stop smoking. It's worrisome because it's a striking example of a third-party payer dictating what happens in the consulting room. In 10 years, few will even remember that the reason they always ask patients about smoking cessation is because third-party payers demanded it. Questions about smoking cessation will seem more and more like something that all psychologists obviously do all of the time.

Another reason for us not to take insurance, which is unfortunate for all of the patients who have to use it.

 

[Therapist4Chnge]

PQRS is a great example of gov't intrusion into the patient-clinician relationship.

 

[erg923]

Medicare's Physican Quality Reporting System (PQRS) now lists "counseled patient about smoking cessation" as one of the quality measures.

Not that it's generally a bad idea to counsel most patients to stop smoking. It's worrisome because it's a striking example of a third-party payer dictating what happens in the consulting room.

First, managed care has has its hands in how doctors and allied professionals practice for decades now, its not new. Second, if you are the one paying for the service (the managed care company) why is it so unacceptable that they should want some quality oversight. Makes perfect sense to me if you understand the business model of managed care.

 

[futureapppsy2]

Medicare's Physican Quality Reporting System (PQRS) now lists "counseled patient about smoking cessation" as one of the quality measures.

Not that it's generally a bad idea to counsel most patients to stop smoking. It's worrisome because it's a striking example of a third-party payer dictating what happens in the consulting room. In 10 years, few will even remember that the reason they always ask patients about smoking cessation is because third-party payers demanded it. Questions about smoking cessation will seem more and more like something that all psychologists obviously do all of the time.

Another reason for us not to take insurance, which is unfortunate for all of the patients who have to use it.

Why wouldn't you ask patients about smoking cessation, at least at intake? I mean, if a patient admitted to engaging in something like purging or non-suicidal self-injury you'd probably consider it odd or even negligent if a psychologist didn't at least discuss treating the behavior, right? Why should smoking, with its extremely well-documented health effects (much, much moreso than NSSI), not be at least brouched?

 

[erg923]

My experience is that when their overall psychological functioning improves, they are more likely to be successful making other healthy life choices..

I think it largely a myth.

 

[smalltownpsych]

Why wouldn't you ask patients about smoking cessation, at least at intake? I mean, if a patient admitted to engaging in something like purging or non-suicidal self-injury you'd probably consider it odd or even negligent if a psychologist didn't at least discuss treating the behavior, right? Why should smoking, with its extremely well-documented health effects (much, much moreso than NSSI), not be at least brouched?

I usually have to many other things to talk about and assess during the intake that have way more priority than smoking cessation. I also have some philosophical objections to telling people what choices they should or shouldn't be making in their lives. Nevertheless, if they pay me to ask the question, I probably will and check the little box in the EMR to show that I am a compliant pawn in the system.

 

[erg923]

I also have some philosophical objections to telling people what choices they should or shouldn't be making in their lives.

What?! You entire job is to help identify unhealthy behaviors (and thoughts) that effect mental or physical functioning and then to present alternatives.

 

[Peacemaker36]

It's interesting that there is debate about this. Personally I do check in with most patients now and then about smoking cessation, generally after they raise their smoking as a behavior they are ambivalent about. I might use MI strategies. But if the psychologist positions him/herself as clearly against the behavior, I think it alters the therapeutic relationship in an unproductive way.

I also think the clinical population one works with is a big factor. If you work with major mental illness, it's just not productive to take a hard stance against smoking.

From the Ethics Code:
Principle E: Respect for People’s Rights and Dignity
Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination. Psychologists are aware that special safeguards may be necessary to protect the rights and welfare of persons or communities whose vulnerabilities impair au- tonomous decision making. Psychologists are aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status, and consider these fac- tors when working with members of such groups. Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices.

 

[erg923]

It's interesting that there is debate about this. Personally I do check in with most patients now and then about smoking cessation, generally after they raise their smoking as a behavior they are ambivalent about. I might use MI strategies. But if the psychologist positions him/herself as clearly against the behavior, I think it alters the therapeutic relationship in an unproductive way.

From the Ethics Code:
Principle E: Respect for People’s Rights and Dignity
Psychologists respect the dignity and worth of all people, and the rights of individuals to privacy, confidentiality, and self-determination. Psychologists are aware that special safeguards may be necessary to protect the rights and welfare of persons or communities whose vulnerabilities impair au- tonomous decision making. Psychologists are aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status, and consider these fac- tors when working with members of such groups. Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices.

This is just complete silliness. None suggested we are/would be denigrating worth or rights.

And, how could I position myself for smoking?

 

[futureapppsy2]

It's interesting that there is debate about this. Personally I do check in with most patients now and then about smoking cessation, generally after they raise their smoking as a behavior they are ambivalent about. I might use MI strategies. But if the psychologist positions him/herself as clearly against the behavior, I think it alters the therapeutic relationship in an unproductive way.

Just out of curiosity, would you take the same stance with purging or non-suicidal self-injury?

 

[Peacemaker36]

That's a great question. I would say my stance on NSSI is that it's a behavior with many negative consequences, and I'm pretty clear about this with patients. I do label NSSI as a problematic behavior. If the patient isn't willing to try to give it up, it's definitely a topic every session (e.g., chain analysis, diary cards, etc.).

Smoking is more of a gray (smoky) area for patients with schizophrenia. I am aware of the research on mortality rates, etc., as well as ongoing debates about whether schizophrenic patients respond differentially to nicotine. It's possible that I should be targeting cessation more aggressively; I just don't think many patients would tolerate that approach. For example, paranoid patients with negative symptoms and very few coping skills. Maybe my approach needs adjusting, I don't know.

Some inpatient units still allow patients to smoke on grounds while they are admitted. I find that surprising.

 

[futureapppsy2]

That's a great question. I would say my stance on NSSI is that it's a behavior with many negative consequences, and I'm pretty clear about this with patients. I do label NSSI as a problematic behavior. If the patient isn't willing to try to give it up, it's definitely a topic every session (e.g., chain analysis, diary cards, etc.).

Smoking is more of a gray (smoky) area for patients with schizophrenia. I am aware of the research on mortality rates, etc., as well as ongoing debates about whether schizophrenic patients respond differentially to nicotine. It's possible that I should be targeting cessation more aggressively; I just don't think many patients would tolerate that approach. For example, paranoid patients with negative symptoms and very few coping skills. Maybe my approach needs adjusting, I don't know.

Some inpatient units still allow patients to smoke on grounds while they are admitted. I find that surprising.

NSSI can be an effective emotional regulation mechanism in people who lack other emotional regulation skills--it's just a (sometimes very, depending on the extent of the behavior) maladaptive behavior. Similarly, smoking can be effective at helping to manage symptoms in people with SPMI--but again, it's rather maladaptive and has major health consequences (moreso than most NSSI, actually).

People engage in maladaptive behaviors because, on some level, they actually work or are at least otherwise reinforced (see smoking being negatively reinforced by reducing withdrawal symptoms, for example). Our job as treatment providers should be to teach and reinforce more adaptive, more effective coping behavior.

 

[473912]

I love this back and forth. I'm glad I started this thread. (legs crossed, taps fingertips together).

 

[Nahsil]

The psychologist James Hillman talks about "root metaphors" in society. The medical field's root metaphor is that quantity of life = quality of life, the more life the better the life. That's a questionable absolute value in my opinion. I'm not a smoker, but I do things that are quite arguably "maladaptive" according to someone's rubric (perhaps not mine), because they bring me happiness, comfort, etc. That's certainly the way it is for many smokers, and I think it's a difficult thing, whether the value of life longevity should absolutely, in all circumstances take priority over engaging in "maladaptive" or "long-term destructive" behaviors which bring people satisfaction and help them cope in a more immediate sense.

I'm not necessarily pro-smoking, in fact I dislike it quite a bit, but the issue isn't clear-cut.

 

[Harmos]

Smoking has serious health consequences that affect the quality of one's life (and those around them). It's not as if smoking reduces the number of years the smoker is expected to live, say, by 5%, and has no mental or emotional or physical effects whatsoever on life before it ends.

I think the real question is more about how high smoking is on the list of problems that need to be addressed. It also depends on how the healthcare providers conceptualizes the case and believes what causes what. For instance someone in this thread had hypothesized that once general mental health improves, it would be easier for them to consider it and finally quit smoking. Another might see it differently. A physician probably approaches this differently than does a psychologist, because they have different backgrounds.

I don't think that MJ has to be addressed only because it is (or was) illegal. Sugar and carbs are legal but obesity has serious consequences, more so than MJ. And alcohol, which is legal for adults, is implicated in so many illnesses and societal problems, the numbers are truly frightening.

But sometimes MJ really is number one on the list. And I don't mean just for someone who has high likelihood of developing schizophrenia. It's about how it affects the person's brain, but also smoking itself, the people the person associates with, financial concerns, STDs, family relations and lots of other issues that can have at their core this person smoking MJ with "friends" every night.

 

[Nahsil]

But sometimes MJ really is number one on the list. And I don't mean just for someone who has high likelihood of developing schizophrenia. It's about how it affects the person's brain, but also smoking itself, the people the person associates with, financial concerns, STDs, family relations and lots of other issues that can have at their core this person smoking MJ with "friends" every night.

you could say that for just about anything, though. Gambling, illicit activities, cultural and personal beliefs, etc...I don't see any reason for marijuana to be more likely to cause reckless behavior or emotional/interpersonal instability, etc, than a lot of things.

 

[erg923]

you could say that for just about anything, though. Gambling, illicit activities, cultural and personal beliefs, .

If these were affecting your patients' physical or mental health functioning, why wouldn't you address these?

 

[erg923]

The psychologist James Hillman talks about "root metaphors" in society. The medical field's root metaphor is that quantity of life = quality of life, the more life the better the life. That's a questionable absolute value in my opinion. I'm not a smoker, but I do things that are quite arguably "maladaptive" according to someone's rubric (perhaps not mine), because they bring me happiness, comfort, etc. That's certainly the way it is for many smokers, and I think it's a difficult thing, whether the value of life longevity should absolutely, in all circumstances take priority over engaging in "maladaptive" or "long-term destructive" behaviors which bring people satisfaction and help them cope in a more immediate sense.

I'm not necessarily pro-smoking, in fact I dislike it quite a bit, but the issue isn't clear-cut.

These philosophical musings may be good masturbation material for you, but its really irrelevant to clinical practice.

You are a behavioral health provider. Smoking is a health behavior. From every objective metric we have, smoking in unhealthy (i.e., contributes to thew development of disease). You should present alternatives. The person may decline. If so, you move on. If they don't, you may have helped saved their life, not too mention free them from an addiction that affects psychiatric functioning (a recognized mental disorder, btw.) This can take, literally, 30 seconds. This is not a "complex issue." This is your job.

 

[Ollie123]

As someone who studies smoking, this thread has generated some important research questions. The presumption within the literature is always that smoking is merely "overlooked" by folks in this field (and medicine too for that matter). The fact that there might be some providers who object on philosophical grounds is interesting and not something I've seen mentioned outside nuanced contexts (i.e. concerns about hypocrisy by providers who smoke themselves, etc.).

Not surprisingly though, I tend to side with erg. Its an easy question to ask and should be a part of any thorough intake - particularly given it has an impact on many other areas that impact psychological functioning (sleep, exercise) and is a marked risk factor for other problems (heavy alcohol use). The way I usually frame it to docs is that it seems silly to treat someone's high cholesterol and even run blood tests, follow up regularly, etc. when smoking is incredibly more likely to be the thing that kills them. We see it with inpatient alcohol treatment (more likely to die of smoking-related disease than alcohol-related disease). I haven't seen these numbers, but I wouldn't be surprised if smoking was also the leading cause of death among people presenting to the psych ER with threats to harm themselves (vs. actual self-harm). With regards to it being something that gives them pleasure...the same could be said for drinking heavily!

That said, I think its important to ask and attend to it. That doesn't mean it becomes the emphasis of treatment and we ignore the fact that they are actively hallucinating. There is definitely a "triage process" that has to occur for problems with some populations that, quite simply, have an overwhelming number of them and we can't do it all at once. I still think its important to get it on the record, even if all that means is that it is 1% more likely the next time they come in another provider sees that and addresses it (at the population-level, that would make an enormous difference in public health). It may not be their priority, but I think its important to remember that mental health in general is often not a priority for people. I'm not sure I'd advocate completely ignoring depression/anxiety in someone with cancer, nor alcohol abuse in someone who recently became homeless. We might triage, but we'd want to know so we or someone else can circle back to it later.