Depressing News: Mental Health Care Is Under-Treated in Primary Care Settings
In 1998, Susan Bumagin, an independent researcher and writer located in Gloucester, Mass., investigated the issues involved in optimizing treatment of depression in the primary care setting.
The goal of the project was to identify funding and organizational barriers to, and opportunities for, improved treatment. Bumagin:
- Conducted a literature review.
- Interviewed key researchers and practitioners, the staff of national policy and advocacy organizations, and major funding groups.
- Made site visits to established best-practices program/research sites.
- Despite proven guidelines designed to better recognize and treat depression, organizational and financial constraints in most health care practices make treatment difficult.
- As a result, many populations, including indigent ones, receive inadequate care for depression.
- The most promising approaches combine care for mental health with physical health care. Bumagin highlighted several best-practices programs, which take a more comprehensive and integrated approach.
The Robert Wood Johnson Foundation (RWJF) supported the investigation with a $49,158 pass-through grant to the Technical Assistance Collaborative in Boston.
This grant supported an investigation of the issues involved in optimizing the treatment of depression in the primary care setting. Depression is a chronic illness striking more than 17 million Americans every year. The costs of this illness including treatment, lost wages, and productivity exceed $43.7 billion per year.
This investigation stemmed from studies showing that depression is underrecognized and undertreated in primary care settings. Epidemiological studies from the federal Agency for Health Care Policy and Research (AHCPR) estimate that 50 to 70 percent of patients with criteria-based diagnoses are missed by primary care physicians and that even when initiated, treatment is often inadequate by psychiatric standards.
The project sought (1) to identify funding and organizational barriers to effective diagnosis and treatment of depression in the primary care setting and (2) to recommend changes that would improve current practices. To accomplish these goals, Bumagin:
- Conducted a literature review
- Interviewed key researchers and practitioners, the staff of national policy and advocacy organizations, and major funding groups
- Made site visits to established best-practices programs, research centers and funding organizations. These sites were:
- Health Partners in Minneapolis
- Group Health Cooperative in Seattle
- San Francisco General Hospital Division of Psychosocial Medicine
- The John D. and Katherine T. MacArthur Foundation in Chicago
- The Dartmouth College Depression Initiative in Hanover, N.H.
- Attended the 1998 meeting of the American College of Mental Health Administrators (ACMHA), which addressed issues of behavioral health and primary care.
- Compiled a summary of current practices and research initiatives.
Bumagin reported the following findings in a 1998 report to RWJF, Depression and Primary Care: Current Practice and Needs.
- Despite proven guidelines designed to better recognize and treat depression, organizational and financial constraints in most health care practices make treatment difficult. As a result, many populations, including indigent ones, receive inadequate care for this illness. Specific barriers to effective assessment and treatment include:
- Stigma. Some 20 to 50 percent of primary care patients who are referred to mental health specialists will not comply with the referral. Primary care providers also may hesitate to document depression for fear of blocking insurance coverage and/or facilitating financial discrimination.
- Access: Some 72 percent of primary care physicians say they cannot always or almost always obtain high-quality outpatient mental health services for their patients.
- Reimbursement. Reimbursement systems (fee for service, capitated, or salaried) do not usually provide incentives for primary care physicians to adequately address mental health issues.
- Organizational structure. Increased use of carve outs in managed care when mental health services are contracted out does not promote integration of mental health and primary care. Nor, in the public sector, do traditional divisions between community mental health and health centers foster effective integration. Public systems have focused limited resources on serious and persistent mental illness rather than chronic issues.
- Competing priorities of providers. The fast-moving pace of practice, especially in managed care systems, means that depressive symptoms receive less attention than physical or new complaints.
- Confidentiality. Mental health professionals often are reluctant to share patient information with primary care providers, which hinders continuity of care.
- Inadequate training of primary care physicians. Most education and training in the detection and treatment of depression fail to help physicians translate new knowledge into action. Care systems often do not promote or support changes in care behavior.
- The most promising approaches to treatment are integrative: they combine mental health with physical health care. Few existing programs provide such as comprehensive and integrated approach. The project describes one such best-practices model in some detail: The San Francisco General Hospital Division of Psychosocial Medicine teams primary care physicians with mental health clinicians to care for underserved populations, particularly ethnic minorities. Its case-management, group-therapy approach includes needed social services; simultaneous substance abuse and depression treatment; medication management; so-called physician extenders for telephone outreach and compliance; and short-term cognitive behavioral intervention. In its first year, the program saved the hospital $300,000; emergency room visits were reduced by 45 percent; and primary care visits were reduced by 30 percent.
Bumagin compiled several dozen ideas, presented as an appendix entitled "Recommendations from the Field" to the 1998 report to RWJF, Depression and Primary Care: Current Practice and Needs, cited earlier. While not intended as formal recommendations to RWJF, but rather as thought provokers for RWJF staff to consider, the recommendations constitute a critique of current diagnosis and treatment of depression in the United States, grouped in four areas: research, convening/dissemination, service demonstration, and medical education. See the Appendix for a summary of these recommendations.
Bumagin distributed the project findings and recommendations in Depression and Primary Care: Current Practice and Needs to RWJF staff in September 1998 and presented a Power Point show of the study's highlights.
AFTER THE GRANT
RWJF used the findings from this project in developing a $12-million national program, Clinical Care Management of Depression in Primary Care: Linking Clinical and Systems Strategies, which was authorized by the Board of Trustees in January 2000.
GRANT DETAILS & CONTACT INFORMATION
Research on Activities Needed to Optimize the Treatment of Depression in Primary Care Settings
Technical Assistance Collaborative, Inc. (Boston, MA)
Dates: April 1998 to September 1998
Summary of Recommendations from the Field
"Recommendations from the Field" was first published as an appendix to Depression and Primary Care: Understanding Current Practice and Needs. Boston: Technical Assistance Collaborative 1998. The following contents may be of use to institutions, organizations, and individuals concerned with optimizing treatment for depression. Ideas are presented in four broad areas: research, convening/dissemination, service demonstration, and medical education.
- Research is needed to identify the prevalence of depression in public health settings and the treatment protocols that address the many challenges faced by low-income people.
- Research is needed to identify the best assessment instruments, particularly those instruments that connect research to practice.
Utilization of Services
- A controlled study is needed showing which effective interventions lead to decreased utilization.
- Better research is needed about high users of primary care services, particularly those with clinical depression presenting as somatic complaints, chronic pain with co-existing depressive symptoms, and depression and anxiety co-existing.
- Research is needed to show the range of depressed patients seen in primary care as opposed to mental health settings. This would include patients who may not meet formal depression criteria but who are at risk for developing full-blown depression.
- Research should focus on specific populations for example, minorities, the elderly, adolescents, low-income and underserved people, and the disabled.
- Current tools measure outcomes for depression, but more work needs to be done to improve outcomes.
- Meaningful outcome measures need to be developed for the primary care setting for both practitioners and patients.
- Longitudinal studies are needed to discover which actions lead to better outcomes and at what cost.
- Randomized controlled studies are needed to determine whether better services do, in fact, become cost-efficient.
- Research is needed to find out what role financing structures play in fostering better incentives for care.
- Research is needed on reimbursement structures as obstacles to care.
- Study depressive symptoms, not the diagnoses. Look at how symptoms emerge as diagnoses, how they cluster, and their persistence and severity over time.
- Determine how to stratify risk for depressed patients into low, medium, and high to help practitioners target treatment.
- Focus research on what works for practitioners, rather than on the current screening and guidelines.
- Create a better picture of the real world of the practitioner with its competing demands through more practice-based research.
- Foster the development of systems of care that focus on the needs of the patient rather than the needs of the discipline/clinician. Current research has focused too much on clinician actions, beliefs, and skills while largely ignoring patient factors or the effects of the practice environment.
- Identify a broader range of interventions (beyond medication.
- Do research on minor depression, who has it, and what to do about it.
- Research the impact of competing demands on primary care physicians, especially in relation to how such physicians manage patient symptoms.
- Do research on how best to follow up with depressed patients.
- Develop tracking systems to alert practitioners to those with depressive histories.
- Improve the quality of existing studies with key add-on studies.
- Develop workplace studies that are generalizable.
- Address the question, Is quality improvement better done through a carve-out or carve-in partnership?
- Explore other treatment modalities that include stress management.
Cross-Fertilization Between Researchers
- Develop an active working exchange that stimulates new thinking and experimentation about researchers.
- Study the few HMOs doing research in this area.
Build Research Infrastructure
- Bring investigators together with expertise in content, methods, and dissemination to define a research and practice agenda.
- Sponsor a research conference focusing on these questions:
- What models are available to improve the care of depression?
- What have we learned about research methods on depression interventions?
- What does it take to implement such quality-of-care interventions in real-world settings?
- Partner with the National Institute of Mental Health and others to bring together mental health and primary care practitioners.
- Develop a service demonstration project to demonstrate that case management works with high-risk populations.
- In capitated systems, study how isolation and lack of social support may accompany recurrent illness and how to address this.
- Conduct pilot demonstrations and accompanying research that shows how mental health providers can best be used in the public sector, especially with co-morbid mental health and substance abuse issues.
Relationships Between Health and Mental Health Practitioners
- Study HMO integrated systems.
- Support collaboration between primary care physicians and mental health professionals by using a tiered approach.
- Explore ways primary care physicians can prepare patients for mental health visits, make information available by phone, and so on.
- Develop strategies that encourage patients to discuss their condition.
- Create posters and other public education that involve primary care physicians and mental health providers.
Health Services and Consultant Liaisons Within Community Mental Health Settings
- Develop systems that help those with persistent mental health conditions to access health services. In such systems, primary care physicians would be mental health professionals.
Promote Use of Phone Follow-Up by Clinical Providers
Find Ways to Create Successful Patient Adherence to Medication
Create Demonstration Projects as Research Laboratories
- Support the development of networks so that primary care settings can incorporate episode-based data collection.
- Study the recognition by practitioners of obstetrics-gynecology (OB-GYN) of mental disorders and barriers to treatment.
Study a Nurse Consumer Peer Model
- This model brings together nurses and the consumer advocacy movement , for example mental health associations. These two forces can be marshaled to work to help patients and to keep health costs down.
- Create programs that adapt communication skills training for the screening, identification, and treatment of patients with clinically significant depression.
- Develop culturally responsive services. Providers from other cultures are needed. Explore the use of training for ethnically diverse peers to provide services.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Bumagin S. Depression and Primary Care: Current Practice and Needs. Boston, Mass.: Technical Assistance Collaborative, Inc., September 1998. 30 copies distributed to RWJF Chronic Care Goal Group. Martin D. Cohen, M.S.W. of Technical Assistance Collaborative created "Appendix II, Depression in Primary Care Settings: Summary of Key Informant Interviews (National Policy and Advocacy Organizations)."
Presentations and Testimony
Susan Bumagin and Martin Cohen, "Depression and Primary Care: Understanding Current Practice and Needs," for the Chronic Care Goal Group, The Robert Wood Johnson Foundation, September 14, 1998, Princeton, N.J.
Report prepared by: Kelsey Menehan
Reviewed by: James Wood
Reviewed by: Robert Narus
Program Officer: Doriane Miller