Depressed? What Makes You Ask?
By Suz Redfearn Special to The Washington Post May 28, 2002
Last week, a top independent advisory panel recommended that primary care
doctors start screening patients for depression during routine visits. Why?
Because, according to the U.S. Preventive Services Task Force, providers such as
family doctors and nurse practitioners currently miss and mistreat more than
half of all cases of depression. In fact, of the estimated 19 million American
adults who suffer from depression, as many as two-thirds aren't being treated.
If primary care providers get involved, as many as 90 percent of those afflicted
can get treatment, the recommendation asserts.
All of which raises questions, of course.
So next time I go to the doctor, she's going to screen me for depression?
If she's decided to follow the task force's new recommendations -- which she is
not compelled to do -- yes.
If she's on board, she'll do one of two things during your visit: 1) Ask you
whether you have felt down, depressed or hopeless over the last two weeks, and
if you have felt little interest or pleasure in doing things during that time;
or 2) Use a questionnaire to ask you a series of similar questions.
But don't expect universal compliance, suggests Douglas Jacobs, a Boston-area
psychiatrist speaking on behalf of the American Psychiatric Association (APA).
"In an ideal world, everyone would be screened by their doctor, but that's just
not going to happen," he said. "Physicians are too busy."
What happens if I answer yes to the questions, or my answers to the
questionnaire deem me "depressed"?
If your doctor is following the guidelines, she'll follow up with further
diagnostic procedures. Most often this will consist of an interview drawing on
questions designed to identify depression as defined in the Diagnostic and
Statistical Manual of Mental Disorders - Fourth Edition (DSM-IV). Published by
the APA, this is the main reference used by those in the mental health field to
make diagnoses.
If your doctor makes a diagnosis of depression after that, she may prescribe
antidepressant medication or refer you to a psychologist or psychiatrist.
Does this mean that if I think I'm depressed, I should go to my primary care
doctor?
The task force says yes. According to Alfred O. Berg, a Seattle-based family
physician who chairs the body that made the recommendations, most depression and
anxiety disorders are now treated effectively by primary care clinicians. And
most doctors are plugged into a referral network, so if your doctor feels a
psychologist or a psychiatrist would better treat your condition, she can refer
you to one.
Will a diagnosis of depression go on my permanent medical record?
It depends on how your doctor keeps records. Some primary care doctors don't
keep records on their patients' mental health; others do. If this issue concerns
you, discuss disclosure procedures with your doctor, advises Berg. "Most do go
to great lengths to protect patient confidentiality," he said.
Don't insurers discriminate against people who have a history of depression?
Yes, insurers often consider depression history in their decisions. Some
disability insurance carriers, life insurance companies and long-term care
insurers ask for psychiatric records during the application process, and they
may deny coverage if they see something they don't like. Many health insurers
require people with a preexisting condition, such as depression, to wait for a
specified time before they're covered for that condition; alternatively, they
may exclude the condition from any coverage.
But the stigma that treatment for mental disorders once carried, even within the
system, is less prevalent, says Carol Kleinman, a psychiatrist in private
practice in Chevy Chase. "I do think this has improved a bit since so many
people take antidepressants now, and there's a higher level of sophistication
out there about depression."
How dependable are these depression tests, anyhow?
They are highly sensitive instruments, meaning they generate more false
positives than false negatives. That means that in preliminary screens for
depression, you may test positive if you are not depressed, but if you are
depressed you are unlikely to test negative. That's so everyone who may be
depressed will go to the next level and get more extensive questioning through
their doctor.
The DSM-IV criteria for depression, on the other hand, are the gold standard for
diagnosis, said Berg. That definition is somewhat mechanical, requiring a
certain number of symptoms in a set of categories before a person is pronounced
depressed. Screening inquiries deal with such details as the extent to which a
person is feeling lonely, crying easily, applying self-blame and feeling
hopeless about the future. Other parts of the test focus on physical
manifestations of depression such as headaches, lower back pain and disturbances
in sleeping, eating or sexual interest.
Depression screens may also help identify other conditions, such as anxiety
disorders, panic attacks and substance abuse.
If I'm diagnosed with depression, will my insurer cover treatment?
Many but not all insurers will cover depression treatment delivered in a primary
care setting, said Berg. Plans that offer coverage for prescription drugs
usually cover medications for depression, but some drugs may carry higher
co-pays than others. If you are referred to a psychologist or psychiatrist, your
plan may offer strict limitations on whom you may see and how much and what kind
of treatment will be covered. Call your insurance company for details.
Are there any online tests I can use to check myself out?
Doctors generally don't consider this a good idea. Their thinking is that you
could disregard the test if you don't like the results rather than getting the
treatment you might need. Also, docs feel that people who are depressed often
aren't thinking clearly, which could make self-assessment troublesome. That
said, the Zung Self-Assessment Depression Scale, which the task force
recommended that doctors use in initial depression screening, is available for
consumers by going to
www.prozac.com/SelfAssessmentTest.jsp. This is a
commercial site hosted by Eli Lilly, the maker of Prozac. Click on "Zung Scale
Self-Assessment Test" and then on "click here just to take the test," which
permits you to take the test anonymously.
Didn't The Post just run a big story that said placebos are just as effective as
antidepressant medications in treating depression? What's up with that?
Recent analyses have shown that in clinical tests, some patients getting sugar
pills reported better outcomes than patients getting the real antidepressants.
And one researcher has documented that people reporting benefits from a placebo
had measurable changes in brain activity of the sort often associated with
improvements from depression. This appears related to the fact that in most
studies, subjects getting the placebo were getting care and attention from
health professionals as part of the process. The result is controversial. In its
review of literature, the task force concluded that antidepressants are
"clearly" more effective than placebos for depression.
I don't like taking drugs. Doesn't therapy relieve depression, too?
Recent studies conducted at the University of Pennsylvania and Vanderbilt
University have shown that a form of treatment called cognitive therapy -- in
which a patient is helped to understand, recognize and reduce the effect of his
or her irrational thoughts and behaviors -- is at least as effective as
medication for long-term treatment of severe depression. The task force
concludes that therapy appears to be effective, but often takes longer than
treatment with medication. Other studies have shown that therapy and drugs
together work better for many patients than either one alone, but the task force
did not find this research conclusive.
The topic is also controversial. Geoffrey M. Reed, assistant executive director
for professional development at the American Psychological Association, which
represents psychologists, said that patients tend to prefer psychotherapy, but
managed care companies prefer that doctors treat the depressed with medicine.
Berg adds that in his experience, many times drugs work more quickly.
Suz Redfearn is a regular contributor to the Health section.
Source:
http://www.washingtonpost.com/ac2/wp-dyn/A7561-2002May24?language=printer
U Mass To Study How Primary Care Doctors Can Better Treat Depression
June 4, 2002
WORCESTER, Mass. (Worcester Telegram and Gazette) -- A woman comes in to her
primary care physician's office complaining of a headache that just won't go
away.
The doctor examines her, looking for neurological clues to match her symptoms.
Not immediately finding an explanation, he asks her what else is going on in her
life.
Well, she answers, her mother has just moved in with her because her father died
and nobody else could take her in, her husband drinks too much and her son just
got picked up by the police for doing drugs. On top of everything else, she
doesn't have enough money for the place where she lives, which has all kinds of
rodents and insects the landlord won't pay to remove.
"You hear this horrible story and think, all she's got is a headache?" said Dr.
Annette Hanson, medical director of the Massachusetts Division of Medical
Assistance. What the patient in Hanson's story has may be depression.
"It sounds like a horrible life, and depression may be the least of her
troubles," she said. "But that's what we can deal with, the illness. We can't do
much with all the rest of the stuff, but we can do something about her health."
Finding the best way to do that -- to identify and treat patients with
depression in primary care -- is the focus of a $100,000, one-year planning
grant won by the University of Massachusetts Medical School and the Division of
Medical Assistance. The Robert Wood Johnson Foundation is funding nine sites
across the country to link clinical and systems strategies for treating
depression in primary care. A two-year project to test improved screening,
assessment, treatment and management of chronic depression in primary care will
follow.
The UMass-DMA planning grant is different from the other eight project sites
because it focuses on people who are clients of MassHealth, the state's Medicaid
program providing health insurance to about 1 million people. MassHealth
coverage is available to people whose incomes are 150 percent or less of the
federal poverty level. For a family of four, the most recent federal poverty
level is $18,100.
"This is the first time this model has been tried in Medicaid populations," said
Carol Upshur, UMass Medical School professor in the department of family
medicine and a clinical psychologist. She represents the medical school in the
grant. "A big part is helping patients identify for themselves what's going to
be helpful. That's very different in a community where there aren't a lot of
resources."
Depression is an important illness to target. From 5 percent to 9 percent of all
adult patients seeing their primary care doctors suffer from depression, the
U.S. Preventive Services Task Force said in an article published last month in
the Annals of Internal Medicine. Half of those cases go undetected and
untreated, the authors found.
Depression costs $17 billion in lost workdays each year, second behind
cardiovascular disease, and can make other chronic conditions such as diabetes
worse, previous studies have shown.
If the widespread incidence of depression is well-known, so are some of the
difficulties in isolating it from a welter of other symptoms. There can be pain
moving from place to place, another chronic condition can mask or cause
depression, or sleep disorders can be brought about by both.
"There is a lot of stigma associated with mental illness, and components of
the illness itself often include fatigue or passivity, issues that make it
difficult for a patient even to raise it with a doctor," said Dr. Linda Weinreb,
vice chairman of the department of family medicine and community health at UMass
Medical School and principal investigator of the Robert Wood Johnson grant, with
DMA's Hanson. "You don't often have people walking through the door saying "I'm
really depressed.' "
If it isn't easy for patients to bring up their concerns, it's also not simple
for a primary care doctor to ferret it out, Weinreb said.
"The challenge is they have 15 things to do in 15 minutes. It's daunting to do
this as well as everything that's expected," she said. "But most people who are
depressed will get treated in primary care settings, so it's in our interest to
figure out how to do it better."
Several years ago, the Great Brook Valley Community Health Center in Worcester
was one of 20 sites measuring ways to improve care for people with depression,
based on chronic-care models for medical illnesses. Depression is an important
issue at the center, said Dr. Daniel E. O'Donnell, a family physician and the
center's medical director.
"In underserved settings like ours the proportion of depression may be
considerable," he said. "The challenge that one has with depression is
recognizing it and making sure that people receive adequate treatment for an
adequate period of time."
To recognize it, primary care providers can use a standard screening
questionnaire that can rule depression in or out. To treat it, a patient needs
more than just medication.
By its nature, depression waxes and wanes. The medications to treat it, while
they have improved in recent years, still have some side effects and may take
weeks before they become effective. That makes follow-up of patients critical.
"If we want to keep people in care and educate them in terms of how to manage
the stresses of life and adhere to treatment, we need some method of keeping
them in care," O'Donnell said.
At the GBV center, a nurse care manager meets with the patient to explain the
disease and the importance and duration of treatment. Some patients may choose
to pursue psychotherapy while others begin taking anti-depression medication
through their primary care doctor.
Screening and follow-up have made a big difference, O'Donnell said. Before the
program began, 20 percent of patients had at least 50 percent improvement in
their symptoms after 12 weeks of treatment. The most recent data, from March,
show that 54 percent of patients have demonstrated significant improvement over
the same period.
Significant improvement is defined as feeling 50 percent better, according to a
questionnaire answered by the patient.
Those figures are impressive, O'Donnell said, because they match what is
typically reported as success in clinical trials of anti-depression medications.
About 300 people have been through the GBV program.
"We have been able to actually mimic those results here through some of the
changes we made," he said. "People in clinical trials don't tend to be quite as
ethnically diverse. There has not been a lot published on ethnically diverse
populations."
The Fallon Community Health Plan, which is one of the grant's five project
partners, began a disease management program for depression in September, said
Dr. Michael H. Kelleher, medical director for quality and disease management
programs. Patients use a self-screening form if a primary care physician
suspects depression.
If the diagnosis is depression, patients are asked for their written permission
to be tracked by a case manager who checks to see whether they are taking their
medications and keeping appointments.
"So far, we have over 130 patients who are actively engaged with our care
manager," Kelleher said.
The screening tool used at the first visit begins the accurate assessment and
proper treatment, he said. "Getting the right diagnosis at the front end is the
critical piece."
Of Fallon's 190,000 members, about 11,000 are MassHealth clients, meaning
MassHealth pays Fallon a fixed monthly amount for members, who receive medical
and mental health care as well as medication.
For other MassHealth clients, who might go to group practices, coverage can be
more difficult to patch together. Sharing a case manager across group practices
might be a way to replicate the follow-up possible at a community health center
such as GBV's or an HMO such as Fallon. For MassHealth, the goal is to make sure
the quality of care is the same, regardless of where it's given or the payment
mechanism, said Hanson of DMA.
"There are lots of mismatches between the systems and practice that relate to
the insurance issues and different coverage," said Weinreb. "There's knowledge
about effective ways to care for people struggling with depression. What's less
clear is how to help change the system that insures people as well as allows
providers to do what looks like might help."
There's also -- and always -- the issue of cost. Information systems and support
services all have costs, Weinreb said, but on the other side of the ledger,
people who are depressed tend to use medical services a lot, either in doctor's
offices with aggravations of their medical conditions or in hospital visits with
unexplained symptoms.
Hanson, whose budget is set by lawmakers, has strong beliefs on the way to spend
health care dollars.
"If you give the right care at the right time and the diagnosis is correct and
the treatment is correct and people are compliant and helped to be compliant
with the treatment, they won't continue to be sick," she said. "It won't cost
you any more than it would have and it might cost you less."
Copyright 2002 The Worcester Telegram and Gazette. All rights
reserved.
Source:
http://www.intelihealth.com/IH/ihtIH/WSIHW000/8271/8014/350829.html
