Depression is an arch enemy if you suffer from one of many chronic, physical illnesses. It appears all the time, as an unwelcome intruder, in people with diabetes, heart and lung diseases, cancer, Parkinson’s disease and asthma. It impairs our ability to recover from these, and other, medical problems. Depression escalates health care spending for other medical disorders unless it is detected and treated.
Consider this: Depressed patients are at twice the risk of developing cardiac and artery disease (CAD) and stroke. They are four times more likely to die within 6 months after a myocardial infarction (MI or heart attack). They are three times more likely to be non-compliant with treatment – a reflection of how the illness diminishes our ability to or interest in taking care of ourselves as well as its harmful effects on the body’s stress response, immunity and hormones. As a result, those people, for example, with diabetes and depression average four times greater health expenditures. Individuals with major depression make an average of twice as many visits to their primary care physicians as do non-depressed patients – though not for their depression but for a myriad of other symptoms which are explainable when the depression is uncovered.
Goodness, these are troubling statistics. This state of affairs is not because there are bad doctors (though there are some of those just like in any profession). It is because depression has not yet gained a needed foothold in the standard operations of every primary care doctor’s office. We have not yet begun to screen for depression and set as a clinical standard the proven ways of effectively detecting and treating depression in general medical care settings.
Primary care practices have become the principal sites of medical care where adults with common mental health problems in this country (and throughout the world) go for care. These individuals seldom announce they are there for a mental condition. But good medical practice will readily reveal it. Moreover, most patients prefer to have their health and mental health care delivered in one place, by the same team of clinicians. This is called integrated health and mental health care.
Depression also will hurt you at work. It reduces the productivity of our businesses through absenteeism and presenteeism (showing up but not being able to do much). Data from the “National Expenditures for Mental Health and Substance Abuse (MHSA) Treatment” indicates that the U.S. spent $104 billion on mental health and substance abuse treatment in 2001. In 2005 total spending on mental health and substance abuse services was $135 billion. While depression clearly has a significant economic impact on society, the estimated total costs of depression in the US (in 2001) were $44 billion, in 1990 dollars. However, the majority (72%) of costs incurred by society are indirect costs in the form of reduced productivity, absenteeism, and mortality – not the direct costs of care. Medical care costs (inpatient emergency and outpatient medical and/or psychiatric care) comprised only 25% and medications were only approximately 3% of overall costs. In other words, it costs more to NOT treat depression than it does to treat it.
Depression is today the leading cause of disability (by Years of Life Lost, YLLs) and the 3rd leading contributor to the global burden of disease (DALYs 2008). Projections are that by 2030 neuropsychiatric disorders will be the leading contributor to the global burden of disease (these conditions include depression, bipolar disorder, schizophrenia, epilepsy, alcohol and drug use disorders, Alzheimer’s and other dementias, Parkinson’s, MS, PTSD, OCD, and panic disorder).
Moreover, depression is highly associated with suicide. Estimates are that as many as 90% of completed suicides occur in people with an active mental disorder, depression in particular. An estimated 60% of people over 55 years old who took their lives were in a primary care doctor’s office in the month before their death: otherwise known as a missed opportunity to detect and intervene.
What About Quality of Care for Depression in Primary Care Today?
The answer is short and troubling: The quality is poor. · Less than half the people with depression are properly diagnosed
- Less than half of those get any treatment.
- In total, one in eight (1/8) people with depression receive “minimally adequate care” (defined by minimal therapy visits and/or appropriate medications).
Yet treatment is effective: As many as 75% of individuals with depression will improve with appropriate diagnosis, treatment, and ongoing monitoring.
What Can Be Done?
A lot. In fact, a very specific approach to treating depression in primary care can achieve remarkably beneficial effects. This approach is well represented by the “Collaborative Care” model developed by the University of Washington. The success of Collaborative Care has been studied and now replicated in 40 (!) studies, including in rural areas as well as in ethnically diverse and impoverished populations.
The core elements of Collaborative Care are:
- Screening for depression (and in some instances other mental and alcohol and drug disorders): this involves the use of a screening tool that provides a depression score that improves when the condition improves. The PHQ-9 is an example of a depression measurement tool.
- Measurement-based, stepped care: The abnormal score, once the diagnosis is established (the doctor, not the test, makes the diagnosis), is followed over time. Evidence-based depression care paths direct the treatment. If a defined care path is not followed or does not result in improvement, then changes in treatment are made.
- An ‘activated’ patient: Patient education and engagement in their own wellbeing is an essential component.
- A care manager: The discipline of this person is far less important than their unrelenting attention to helping a patient engage and remain in treatment and self-care.
- Psychiatric consultation to the primary care physician: This means an active, weekly review of cases that do not improve, not waiting for the PCP to call.
- Training of clinical and administrative staff.
- Ongoing performance measurement and quality improvement of the delivery of integrated care.
In December 2010, a game changing article was published in the New England Journal of Medicine by Dr. Wayne Katon and colleagues. This article showed that the collaborative care approach not only improved depression, it significantly improved blood pressure, diabetes control and lipid levels. For patients and doctors, this is the Holy Grail: an approach that benefits health and mental health!
Doctors are good learners. If they need to do something, they will learn to do it. If you measure their performance, they learn how to do it even better. We see that with rates of immunization, mammography, reducing surgical complications, and evidence-based treatment of a host of common and serious diseases like diabetes, asthma, and heart disease. But general medical physicians have yet to tackle depression (even though it is ubiquitous in their practice) because it has not been systematically measured and monitored.
Collaborative Care can be done. It will take clear standards of care, training, and ongoing quality improvement. Not doing it carries a price we cannot afford: human suffering, morbidity and mortality, as well as great family and economic burden. At first, leadership medical groups will need to show it can be done. Then others will find the determination and the ways to follow-suit.
Work Underway in New York State
A collaboration between the NYS Department of Health and the NYS Office of Mental Health is underway to progressively implement Collaborative Care in primary care settings. ‘Early adopters’ will identify how to succeed and demonstrate that patients and providers can take pride in their achievements. These state agencies will seek the aid of the University of Washington and the Institute for Healthcare Improvement to provide training in Collaborative Care and to scale it up across NYS.
Stand by for more information that will emerge in the months ahead on this initiative to integrate health and mental (behavioral) health.
Conclusion
There was a time when you or a loved one would have gone to a family doctor and you would not have had your blood pressure measured. A time when we did not measure blood sugar (much less the ongoing measure of glucose control, the hemoglobin A1c), or cholesterol. A time when care paths were places to walk in shaded glens, not treatment protocols. Not so today.
Some day we will look back and wonder how we did not measure and treat depression, and other behavioral health disorders, in primary care? We are starting on the transformation road now. It will be uphill and bumpy. So is all change.
A legendary, if notorious, character said: “There is nothing more difficult to take in hand, more perilous to conduct, or more uncertain in its success, than to take the lead in the introduction of a new order of things. Because the innovator has for enemies all those who have done well under the old conditions, and lukewarm defenders in those who may do well under the new. This coolness arises partly from fear of the opponents, who have the laws on their side, and partly from the incredulity of men, who do not readily believe in new things until they have had a long experience of them.” He was Niccolo Machiavelli; he lived in the 1500s. Times may have changed, but not what it takes to get something done.
But it was Mahatma Gandhi who said in a more recent century, “…first they ignore you, then they laugh at you. then they fight you, then you win.”
Dr. Sederer is Medical Director of the New York State Office of Mental Health, Adjunct Professor at the Columbia/Mailman School of Public Health and Acting Director of the Nathan Kline Institute for Psychiatric Research. His website is www.askdrlloyd.com.
References
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Moussavi S, Chatterji S, Verdes E, Tandon A, Patel V, Ustun B. Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet. Sep 8 2007;370(9590):851-858.
Charles Roehrig, George Miller, Craig Lake, and Jenny Bryant, Health Affairs 28, no. 2 (2009): w358–w367 (published online 24 February 2009; 10.1377/hlthaff.28.2.358)
Sederer LI, Petit, JR, Paone, D, Ramos, S, Rubin, J, Christman, M. Changing the Landscape: Depression Screening and Management in Primary Care, Health Policy Institute, Washington DC, 2007
Louoma, J. et al. “Contact with Mental Health and Primary Care Providers Before Suicide: A Review of the Literature” in American Journal of Psychiatry, June 2002. http://ajp.psychiatryonline.org/article.aspx?Volume=159&page=909&journalID=13
Unutzer J, Schoenbaum M, Druss BG, Katon WJ. Transforming Mental Health Care at the Interface with General Medicine: Report for the Presidents Commission. Psychiatr Serv. January 1, 2006
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine. Sep 2001;16(9):606-613.
Katon WJ, Lin EH, Von Korff M, Ciechanowski P, Ludman EJ, Young B, Peterson D, Rutter CM, McGregor M, McCulloch D. Collaborative care for patients with depression and chronic illnesses. NEJM 2010; 363(27): 2611-20.
Sederer, LI. Let’s Not Get Too Depressed About Depression, The Huffington Post, February 8, 2010, www.huffingtonpost.com/lloyd-i-sederer-md/lets-not-get-too-depresse_b_452599.html
