The Role Of Depression In Primary Care

The monthly quality improvement report comes across the desk of the primary care providers, and eyes immediately shift to the numbers of the disease that is at the forefront today, hypertension and diabetes. Although it may be these disease states that catch the providers’ attention, depression scores are equally as important. Chronic medical conditions and depressive disorder frequently occur together, so, what if the key to successful management of all disease processes was ensuring depression was adequately treated? An individual who is depressed may be less likely to check their blood sugars, eat a healthy diet and get exercise, or be compliant with blood pressure medications. In order to manage depression, it needs to be followed closely,
which has been particularly challenging. The continuous struggle is twofold; getting the patients to follow up to monitor progress, and if they follow up, getting their PHQ-9 scores below a 10.
Of all of the mental and behavioral health disorders, depression carries the heaviest burden of disability and is responsible for 400 million disability days each year. It is currently the fourth leading cause of disability, and by the year 2020, will be the second leading cause (World Health Organization, 2014). One million people each year commit suicide and approximately 20 million more may attempt to end their lives because of depression (Marcus, Yasamy, Ommeren, Chisholm, Saxena, n.d.). As the span and prevalence of depression continues to surge, it becomes increasingly urgent to intervene with a diagnosis and treatment plan.
Although depression is not selective when it comes to culture, geography or even economic status, certain groups are at a higher risk than others. Research has shown that lifetime prevalence estimates are generally higher in high income vs low-middle income countries (Kessler & Bromet, 2013). A survey from seventeen different countries revealed that one in twenty adults experience a depressive episode, at least once annually, and in the United States alone, 15.4% of adults eighteen years of age and older, had at least one major depressive episode in 2014 (National Institute of Mental Health, n.d.). Unfortunately, the prevalence is on the rise; between the years of 2005 and 2010, the rates in the U.S. increased from 13.8 million to 15.4 million (Greenberg, Fournier, Sisitsky, Pike, & Kessler, 2015) with the incidence twice as likely in women than in men (Kessler et. al, 2013). There are no certainties with regards to whom depression will affect, but there certainly are commonalities surrounding the physical toll it can take.
In a depressed person, all body systems are affected; the central nervous system causes tiredness, lack of interest in activities, inability to concentrate, memory loss, irritability and anger; making everyday life difficult. The stress that occurs simultaneously with depression, causes frequent stimulation of the sympathetic nervous system, which can lead to heart disease over time. A depressed patient that is hospitalized for a heart condition, is two to five times more likely to have a heart attack or stroke in the following year. Furthermore, if the depression is untreated, there is an increased risk of mortality (Pietrangelo, 2014). Evidence suggests that those with depression pass away five to ten years earlier than those without the diagnosis; morality from COPD, cancer, diabetes and vascular disease (Katon, 2011). The direct impact of depression on the patient is inarguable, but perhaps the less known impact of depression is the effects it can have on the surrounding environment.
The effect of depression can permeate into surrounding family, friends and the community. Family members can feel the burden when their loved one suffers from depression as they often times experience physical morbidity (Sobieraj, Williams, Marley, & Ryan, 1998). Children are affected as well, especially in the presence of maternal depression, which has been shown to be a risk factor for poor growth in their children, putting a substantial influence on childhood growth, an effect that could potentially influence further generations (Marcus et. al, n.d.). This could explain why depression can cause a vicious cycle that is passed from generation to generation.
In addition to the physical and mental effects, depression also has drastic economic implications.
According to Greenberg et. al (2015), between the years 2005 and 2010, there was an increase of 21.5% (173.5 billion to 210.5 billion dollars) in direct care costs of depression. The direct cost of depression which is driving this, includes things like medication, hospital stays and the care of physicians. Of the 210 billion dollars, only forty percent was directly related to the treatment of depression alone. Moreover, for every one dollar spent on the treatment, an additional $4.70 is spent on the indirect costs, with an additional $1.90 spent on workplace related costs, and economic expenses linked with suicides. The indirect costs of depression are mostly associated with the persons affected by depression, and include things like a loss of productivity and missed work (Greenberg et. al, 2015). Depressive disorder also increases the cost of healthcare by carrying the largest medical plan costs of all behavioral health diagnoses (Conti & Burton, 1994). Essentially, the cost of depression extends far beyond the direct treatment as its implications can be seen in our economy as a
whole.
Edina is known as one of the most affluent cities in the metro area, and the socioeconomic status has a positive impact on care. According to the Bloomington Public Health (2015), Edina has a mean household income of $86,986, and 96.2% of the population with health insurance, allowing the residents to have access to healthcare and the financial security to pay for copays on visits and medications. With a racial make-up of predominately white (88%), Asian (6%), African American (3%), there may be a lower prevalence rate of depression as major depression occurs more frequently among minority groups rather than whites (Dunlop, Song, Lyons, Manheim, & Chang, 2003). There is an average life expectancy of eighty-three years and older, which also impacts depression as older patients are less likely to report depressive symptoms, or their symptoms may mimic those of a physical illness, making it a more difficult condition to diagnose (Ell, 2006). The socioeconomic status in Edina allows for great opportunity for healthcare, but there are still barriers that providers at the Crosstown Clinic contend with to treat depression.
In the clinic, generally, people come in for their annual physical, and if depression is diagnosed, they are open to the idea of treatment. Some patients agree to psychotherapy, then decline the following day when the office calls to schedule an appointment. If medications are initiated, or PHQ-9 scores need to be rechecked, patients agree to follow up at the recommended time, but fail to either schedule an appointment or are a “no show” at their scheduled time. A key issue, is that antidepressant medications cannot be refilled without proper follow up; if patients are not following up, medications are not being refilled, questioning if patients are adhering to treatment regimens. The barriers that Edina Crosstown Clinic face may be different than those that are faced globally, but non the less, challenging.
Globally, barriers to effective care include the lack of resources, lack of trained providers and the social stigma associated with depression.
One primary resource expected to worsen in the coming years are the shortage of mental health care providers. Today, fifty-nine percent of psychiatrists are fifty-five years of age or older, and in the past nineteen years, there has been only a twelve percent increase of psychiatrists entering the workforce (Sederer, 2015), ensuring a shortage of providers. Another significant barrier to diagnosing and treating depression is the stigma associated with the condition. Social stigma can often deter those battling with depression from accessing the help they need for fear of judgment or discrimination. In some countries, social stigma of depression may be worse, in part due to religious and traditional beliefs (Goldsmith, Pellmar, Kleinman, & Bunney, 2002). Developing countries experience the same barriers the U.S. faces, but can be worse, as access to even a primary care provider is limited, and finding a psychiatrist is near impossible. Care is often provided in community centers and providers may have minimal education (Goldsmith et. al, 2002). All of these constraints make it more difficult for a patient to get the initial and ongoing treatment necessary for
depression.
There are also barriers to treating depression within the health care systems that is meant to treat depression. Medicare and private health care policies occasionally have restrictions on specialists, drugs, and psychotherapeutic care, which do not allow for proper management of the depression (Goldman, Neilson & Champion, 1999). Internal care processes, such as, the lack of communication with a mental health specialist, or practicing within different network systems so care visits cannot be viewed by other providers (Whitebird, Solberg, Margolis, Asche, Trangle, & Wineman, 2013), pose further barriers. As providers and patients struggle to overcome these obstacles to get treatment regimens in place, it is no wonder that the grasp of depression continues to grow.
After review of many randomized control trials, it is clear that it’s not the type of treatment that matters as much as ensuring treatment is done correctly and followed up upon. There have been four components identified and deemed necessary to successfully manage the care of a depressed patient. The process is triggered when a patient has a diagnosis of depression, identified by a PHQ-9 score. The first, and most important intervention identified is the introduction of a care management role. Ideally, a mental health professional would be in this role, but nurses are thought of as being more feasible and accepted by primary care. The purpose and most significant aspect of the care manager is to ensure there is follow up with patients. Follow up includes monitoring the depression status, and when an adequate response is not being achieved, reporting to the physician so actions can be put into place. Other tasks completed by the case manager are: ensuring the proper referrals, follow up contacts and the use of support resources are going as planned. All of these tasks are completed via telephone calls. Patients having received phone calls from the case manager, had more improvement in their depression regardless of adherence to their antidepressant medications. After twenty-four months, the patients have better mental and physical function, with a possibility of remission (Solberg, Trangle, Wineman, 2005). The second component is ensuring that a mental health physician is involved in the care. This is particularly helpful if the patient prefers a psychiatrist, or if treatment modalities fail with a primary care provider. The case manager will organize a consultation, and ensure a shared care connection between the primary care provider and a psychiatrist (Solberg et. al, 2005).
Education and support for patient self-management is another element for success. Strategies that involve patients in self-management of preventive care is a small intervention that makes a big difference. The principle was first introduced in the Institute of Medicines “Crossing the Quality Chiasm” report with the idea that a more patient centered approach would engage the patient in their health, improving outcomes. Steps to education and support, are providing the patient with a collective definition of the problem, assist with goal setting and planning, self-management training and support services, and again, most importantly, active and continual follow-up. Finally, patient preference is of utmost importance. Studies have shown that depressed patients in the primary care setting often want treatment, but more so with counseling rather than medications (Solberg et. al, 2005), so it is imperative that care is patient centered, always keeping their best interest at heart.
Ideally, it would be optimal for every primary care clinic to have the ability to put together a care team with the members as listed above. Realistically, primary care clinics may not have the budget to staff a mental health professional required to make the collaborative care team. Fortunately, there are interventions that can take place to improve the quality scores, and improve the health of patients. It would be beneficial for each provider to team up with a nurse, so when a PHQ-9 test reveals depression in a patient, a care plan is initiated. The provider and patient would discuss goals and treatment options, and make a plan that is best for the patient. Before the visit ends, the patient and nurse should formally meet, as the nurse will be the point of contact, making the follow up calls, essentially taking the role of the care manager, as described above.
Although a mental health professional cannot be on site, one should be available to a provider, as needed. Should a patient choose to have psychotherapy, the plan of care should be shared with the mental health professional, and continuous communication of the patient’s progress should be exchanged after each appointment, to ensure proper management of the depression.