Improving Care For Depression

content provided by the Faculty of the Harvard Medical School

Improving care for depression

New approaches to managing a chronic illness

Patients with depression are much more likely to receive effective treatment today than in the 1990s, but the results often fall short of what most patients want and deserve - full relief. The length of depressive episodes and the risk of recurrence have changed too little. Most people who seek help for depression rely exclusively on primary care medicine - family doctors, who are generalists. They are usually the gatekeepers even for patients who eventually use specialized mental health services for psychotherapy or antidepressant prescriptions. So non-psychiatric physicians, mental health professionals, insurers, and HMOs have been looking for ways to improve the detection, diagnosis, and treatment of depression in primary care.

Surveys suggest that there is plenty of room for improvement. A third to a half of depressed patients who see a primary care physician are not accurately diagnosed, and even when depression is identified, it is often inadequately treated. Patients do not get a sufficient dose of antidepressants for a sufficient time, do not return for follow-up visits often enough, and usually receive no psychotherapy at all.

Physicians often lack the time, training, and experience needed to persuade patients to keep appointments and continue taking antidepressant drugs. Nearly 50% of depressed patients in primary care stop taking their medication within three months, and 60%-70% stop within six months, the usual recommended minimum time. They quit because of side effects, or because they feel a little better and think they no longer need the drug. And since they are not seeing a doctor regularly, there is no one with whom to discuss their options for controlling the side effects or choosing alternative treatments. In one review of employer data, only 20% of depressed patients had as many as three contacts with a clinician in the first three months after the diagnosis. A survey found that only about 20% of people who report depression have had any counseling or psychotherapy in the past year. Blacks, Hispanics, and the poor - who on average have less access to health care than whites and the well-heeled - are especially likely to miss out on treatment or quit at an early stage.

A failure to communicate

Doctors and their depressed patients often seem to be talking past one another. A few years ago the nation's chief advocacy and support organization for mood disorders, the National Depressive and Manic-Depressive Association (now the Depression and Bipolar Support Alliance), conducted a survey of doctor and patient attitudes. About 50% of primary physicians said they always inquired about depression when a patient saw them for another medical problem, and the rest said they sometimes asked, but nearly a third of patients said their doctors never asked. Doctors usually said they had given patients detailed instructions about medication, emphasizing the need to continue taking the drug even after symptoms improved. But many patients denied that they had been told anything. Either physicians were not doing all that they thought they were, or patients were not listening and remembering.

Whether patients in the survey were listening to doctors or not, they complained that doctors were not listening to them. They said physicians usually did not encourage them to ask questions or tell their story. Most doctors said they discussed options and made decisions about treatment jointly with the patient. But only about a third of patients said that doctors asked about their preferences and willingness to tolerate side effects before deciding which drug to prescribe, and many said the doctor did not pay attention when they complained of side effects.

Depressed patients often sense a loss of control over their lives, so it is especially important to encourage them to make their own decisions and give them a stake in their treatment. A study published in 2006 found that patients who felt more involved in decisions were more likely to get the treatment recommended by experts, more likely to recover fully from depression, and less likely to relapse.

Screening

Because of embarrassment or a belief that nothing will help, depressed patients are often reluctant to bring up the subject with their doctors. So there is increasing interest in screening, on the model of blood pressure or blood sugar tests. The President's New Freedom Commission on Mental Health has recommended screening for depression, and some foundations, HMOs, and insurers are promoting it.

The time pressure in medical offices is so great that a short, but valid screening test is most likely to be used. An acceptable two-question test goes as follows: Over the past two weeks, have you felt down, depressed, or hopeless? Over the past two weeks, have you felt little interest or pleasure in doing what you usually do? Some studies suggest that almost every patient who needs treatment for depression will answer yes to at least one of these questions, and about two-thirds of patients who answer yes will have treatable depression. The Patient Health Questionnaire-9 (PHQ-9) is a longer (nine-question) screening test based on the symptoms of depression described in the American Psychiatric Association's diagnostic manual.

Despite the growing enthusiasm for screening, some still question its value. They suspect that it picks up too many people who are undergoing a temporary adjustment reaction and require little or no treatment. They believe it can divert resources from chronically ill patients who are in greater need. At least one review, by the Cochrane Collaboration, did not show that screening improves outcome in depression.

Under new management

The failure to show improved outcomes suggests that early detection of depression in primary care may make a difference only if there is effective follow-up treatment. Many experts are recommending that primary care physicians reorganize their practices to collaborate with mental health professionals in creating a management program that resembles the methods used in treating diabetes and other chronic illnesses. Systematic management can be especially useful for depressed patients because depression makes it difficult for them to take initiative, care for themselves, and pursue treatment.

Depression management can take various forms. A nurse or other professional can serve as a case manager who advises the physician about the progress of treatment. The case manager periodically checks with patients to monitor compliance with treatment, drug side effects, and signs of relapse and to make sure appointments are kept and referrals to mental health services are followed up. Patients and physicians may be provided with educational materials, including pamphlets and videotapes. Arrangements can be made for "stepped care," in which patients who do not respond to treatment by the primary care physician move on to a mental health professional. In areas where mental health services may be less available, physicians can be acquainted with guidelines that tell them how to evaluate progress and choose reasonable second- and third-line treatments. They can use a questionnaire like the PHQ-9 to track depressive symptoms in the same way they use tests that track blood sugar levels in diabetic patients. All these methods help primary care physicians to communicate, for example, with psychotherapists and with patients.

Results

Evidence from demonstration programs suggests that depression management systems are effective. One example is the Improving Mood: Promoting Access to Collaborative Care Treatment (IMPACT) program for people over 60 treated for depression in primary care. In this program, the depression care manager, usually a nurse, provided telephone checkups and a relapse prevention plan, and patients were referred to a psychiatrist if they did not improve. Comparing IMPACT with usual care, researchers found that patients were free of depression for nearly four months longer over a two-year period. Nearly half of patients in the program showed a 50% or greater reduction in depressive symptoms, compared to 19% in usual care, and differences persisted even a year after the program ended. An HMO that adopted a version of this program found advantages over usual care continuing for as long as three years.

A similar program for younger patients not only improved depressive symptoms and quality of life but also reduced racial disparities in the outcome of treatment. Patients in the STAR*D (Sequenced Treatment Alternatives to Relieve Depression) collaborative study responded equally well to treatment by a primary care physician or a psychiatrist when they adopted a management program that included self-monitoring of symptoms and drug side effects.

Two general reviews covering dozens of studies have found that depressed patients in disease management programs are more likely to comply with treatment recommendations and more satisfied with the results, especially when the program includes case management, telephone checkups, and collaboration between primary physicians and mental health specialists.

In 2006 the Depression and Bipolar Support Alliance published a report titled The State of Depression in America. It recommends that insurers and HMOs reimburse primary physicians for screening, diagnosing, and treating depression according to expert guidelines. The report also recommends on-call access to case managers and behavioral health specialists in physicians' offices; referral of depressed patients to mental health services before leaving the generalist's office; and mood charts in which depressive symptoms are monitored like blood pressure.

Public and professional attitudes toward depression have improved since the 1980s. The public understands the condition better, stigma interferes less with recognizing it, diagnosis has been standardized, and primary care physicians are more familiar with antidepressant drugs and more willing to prescribe them. These changes may have opened up possibilities for wider use of care management systems. Because of the resulting demands on professional time and resources, instituting those systems will not be easy. But it might be a major step toward fulfilling the unrealized potential of recent developments in the treatment of depression.

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Last updated:	August 22, 2006