Focus on Depression

A Look to the Future

The QIAs and case studies that were profiled in the preceding chapter illustrate the importance of a comprehensive approach to removing barriers to effective management of depression. Depression frequently co-occurs with physical disease and other behavioral disorders and can affect recovery and treatment response. For that reason, it is important for health plans to:

• Continue to emphasize depression awareness (symptomatology, prevalence, and impact) among members and providers through patient and practitioner education. Include not only primary care providers, but also specialists in chronic diabetes such as cardiovascular disease, diabetes, and arthritis.
• Assess patients for the presence of depression during treatment of chronic medical conditions and other behavioral disorders, such as anxiety or substance abuse, by using validated screenings tools as a standard clinical protocol.
• Commit to long-term management of depression and other behavioral disorders, and ensure that the commitment is widely understood among members and providers.
• Ensure that treatment adherence programs for depression extend their reach to treatment of comorbid conditions (and vice versa, if applicable), because depression can reduce treatment compliance in general.^[1]

Most chronic medical conditions, and some acute disorders, are potentially complicated by depression (for example, diabetes, cardiovascular disease, cancer, and arthritis). Comorbid depression can affect patient prognosis and treatment compliance and is associated with poor outcomes for a number of conditions. To optimize patient care for these conditions, the evaluation and treatment of depression must increasingly become a routine component of care. ^[2],[3]

Corporate Cooperation An employer-driven health care coalition, perhaps the first of its kind, initiated a unique program to identify leading health risks using the Behavioral Risk Factor Surveillance System (BRFSS) of the US Centers for Disease Control and Prevention (CDC). Following the BRFSS, depression and diabetes were identified as potential disease states for the study. Data were analyzed by an epidemiologist from the CDC who identified quality of life issues and suggested either diabetes or depression for the study. The coalition then worked together to further evaluate the health issues pertaining to both diabetes and depression. In an environment of growing recognition of depression by both the community and clinical practice, and the need for intervention, a consensus was reached by the coalition members to focus the initiative on the treatment of depression, which was identified as the most underdiagnosed disease state among employees. A significant benefit of the coalition was its public health approach to the recognition and treatment of depression. The coalition targeted not only the workplace, but also clinical practice and the broader community. The coalition includes a member of the pharmaceutical industry, which has supported and provided funding for a wide variety of programs. Funding was also provided through grants from the pharmaceutical industry and by the state health foundation in areas where interests overlapped. It has also received assistance from national leaders in depression such as the American Psychiatric Association, the CDC, and RAND, and has grown into a region-wide partnership of employers, providers, health plans, and community and government agencies. The coalition seeks to create a replicable model that will be applicable to other communities nationally. This initiative demonstrates the significant impact that collaboration within the corporate community can have in effecting change within the medical community and local health care systems. The goal of the initiative was to remove the stigma associated with depression, identify its direct and indirect costs, and create an infrastructure to support the appropriate diagnosis and treatment of depression. To accomplish this goal, the coalition called for a stakeholder-wide collaboration among employers, health plans, clinicians, school districts, universities, local health departments, local and national mental health associations, community and civic organizations, pharmaceutical companies, media, national academic researchers, and local, county, regional, state, and national governments. The coalition considered the participants’ health care and business models, and focused and prioritized programs on areas of common interest and concern. The initiative began with eight employers representing 45,000 covered lives and has since grown to 14 employers representing over 140,000 covered lives. The collation established task forces that led the development of the initiative while participating employers initiated and executed many of the programs. The collation initiative on depression was implemented in three phases. The first phase focused on educating employers, regional health plans, and primary care physicians on the human and financial costs of depression. A partnership was formed with local academia to obtain literature and educational materials on depression. These materials were used to educate all members of the coalition. A series of meetings were held to obtain physical leadership buy-in and to impact the development of the program. During this phase, programs were developed for data collection, education of employees on depression beginning with the least stigmatized forms of depression, including adolescent and postpartum depression, and consolidation of practice guidelines and drug formalities. A first-ever employee attitudinal survey was designed and conducted; and its results were used in the design of subsequent phases. Phase II of the initiative included expansion of educational programs, coordination of community interventions, and initiation of three pilot programs for the recognition and treatment of depression in cardiovascular disease, obstetrics, and oncology. Through partnership with local schools of pharmacy, medicine, and economics, and using data from employer surveys, practice guidelines were developed to assist the physician treating depression in these specialty settings. The initiative is currently in phase III, which centers on a public campaign to raise awareness of depression, through the local media as well as through prominent spokespersons. Phase III will conclude by seeking various ways to measure the impact of the project. Other efforts include the development of an employer Web site, which will give employees a resource for learning about depression as well as access to community resources and mental health benefits. The initiative also seeks to understand the inconsistent patterns of health plan reimbursement for depression, the system’s coding challenges, and the disparity of Medicare reimbursement for medical versus mental health diagnoses. This aspect of the program has the potential to significantly impact provider practice patterns, health plan claim payments, and government policy decisions both regionally and nationally See Appendices 1 and 2.

The inherent difficulties involved in coordinating patient care for medical conditions are redoubled with regard to depression management. The specialty mental health and general medical/primary care sectors must develop more effective means of communication to ensure patient-centered treatment continuity and effectiveness.

In addition, therapeutic approaches that promote functional, as well as symptomatic, recovery will most likely involve significant contributions from practitioners traditionally considered peripheral to the health care system, including those in the human services and voluntary support sectors of the de facto mental health system. Incorporation of these sectors into a patient-centered approach to depression management will involve new information-sharing pathways, which must continue to protect patient privacy and confidentiality even as they promise to make care more seamless.

As discussed in the chapter of Barriers of Effective Management, the lack of parity with regard to financing treatment for behavioral and medical disorders is a reflection of the stigma historically attached to behavioral disorders. This area represents a major challenge in the ongoing effort to improve depression care. Progress on this front will necessitate changing long-held, firmly entrenched views about the nature of behavioral disorders and about the efficacy and cost-effectiveness of treatment. These changes should include:

• Recognition of the organic basis and chronic nature of depression and of the impact of untreated depression on functioning and ability to comply with treatment regimens
• Reassessment of the true cost of depression with regard to reduced productivity, social consequences, and effects on comorbid medical conditions
• Improved algorithms that are accepted by practitioners and health plans for assessing and determining the effectiveness of both medication and cognitive treatment strategies, both as general components of care and on a case-by-case basis
• Acceptance of a revised value proposition for depression care for all stakeholders that reflects reassessment of both costs and treatment benefits

The management of depression and other behavioral disorders has been affected by historical attitudes and factors and by the continuing flux in overall patterns of health care. The health care system in the United States must continue to evolve to provide more effective treatment of chronic conditions. Providing better care for patients with depression and other behavioral disorders will improve the system and will shape its evolution.

Many groups are in a position to effect profound changes in the delivery of care for behavioral disorders. Although the need for change has been recognized for many years, an evolving awareness of depression’s toll has resulted from the accumulation of evidence from clinical, social, and economic studies. This awareness should be viewed as a mandate to facilitate improvement now and over the long term.

For far too long, those affected by behavioral disorders have labored under outdated views of the nature of such disorders and the remnants of stigma. Health plans, employers, and providers, as well as patients and their advocates, must now provide the leadership needed to overcome the societal and organizational barriers that have impeded progress in the management of depression and related disorders. This leadership will be most compelling if it is based on a high level of collaboration and cooperation between the various stakeholder groups. By “speaking with one voice,” these groups will be far more able to influence key decision-makers and to affect needed reforms.

[1] -Ciechanowski PS, Katon WJ, Russo JE. Depression and diabetes: impact of depressive symptoms on adherence, function, and costs. Arch Intern Med. 2000;160:3278-3285.

[2] - Frasure-Smith N, Lesperance F, Talajic M. Depression and 18-month prognosis after myocardial infarction. Circulation. 1995;91:999-1005.

[3] - Agency for Health Care Policy and Research (AHCPR). Depression in Primary Care: Volume 1. Detection and Diagnosis. Clinical Practice Guideline. 1993. Available at:http://www.mentalhealth.com/bookah/p44-d1a.html#Head0. Accessed March 3, 2004.

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