Doctor's Office Nurses Help People Manage Depression, But Who Pays?

Nurse care managers nearly double the likelihood of significant improvement among depressed patients, according to strong evidence in a new review of studies.
In this team approach, a doctor's office nurse monitors patients by phone and coordinates communication between medical and mental health providers.
"Care management models for depression help more people get better," said lead review author John Williams, M.D., of the Veterans Affairs Medical Center in Durham, N.C.
However, the approach may not be practical for many care settings. Most of the reviewed studies were conducted in large health care organizations and required additional resources or staff reassignment. "Practices in fee-for-service environments that do not reimburse for care management services have few incentives for implementing these interventions," the authors say.
Finding effective ways to treat depression is increasingly important because the mood disorder will be the second leading cause of disability in the developed world by 2020, according to the World Health Organization. Experts are trying the doctor's office-care manager approach because most Americans with mental illness are treated exclusively by primary care clinicians, not by a mental health specialist, studies show.
The review, which appears in the latest issue of General Hospital Psychiatry, includes 28 randomized controlled trials involving almost 11,000 patients, primarily in the United States and Western Europe. The majority of patients were white females, except for those in five studies based in Veterans Affairs medical centers and a study in Santiago, Chile.
Twenty studies resulted in patient improvements recorded for up to one year. Of these, three revealed that the benefits persisted for nearly five years. Patients reported better mental, social, physical and work functioning in the majority of studies that asked about these issues.
Most of the trials were of high quality, according to the reviewers. Yet the studies differed markedly in many aspects, making it impossible to pool the data in a meta-analysis. Instead, the reviewers describe the patterns of successful interventions.
Core elements of effective care management programs include a registry of patients diagnosed with depression and a health professional who:
educates patients about depression and encourages them to commit to specific treatment steps
monitors each patient's symptoms using a standard questionnaire
tracks each patient's treatment adherence
consults with a mental health professional if symptoms or compliance needs improvement
coordinates referrals to mental health specialists as needed
The studies also suggest that patients with different diagnoses may require different treatment approaches. Patients with major depression may benefit most from antidepressant drugs or psychotherapy and systematic follow-up by a care manager, the authors say. For minor depression, a period of "watchful waiting" before beginning treatment may be appropriate.
"Policy makers and health care organizations should promote [quality improvement] efforts that include well-trained care managers, patient support and education, longitudinal monitoring and decision support for medication management," conclude the review authors.
Some major health plans are developing versions of these models, Williams said. These organizations include Kaiser-Permanente, Aetna, the Veterans Health Administration and the U.S. Army.
However, substantial obstacles remain, because physicians sometimes object to the approach. "There are some who feel the doctor-patient relationship is very special and don't want it intruded upon by a third party like a care manager," Williams said. Others, he added, welcome the team treatment strategy.
Institutional barriers also abound. "Putting these approaches into place requires a combination of clinical and economic systems strategies at multiple levels, engaging patients/consumers, providers, practices, plans and purchasers," according to Jeanie Knox Houtsinger. She is deputy director of a $12-million national program  Depression in Primary Care: Linking Clinical and Systems Strategies  funded by The Robert Wood Johnson Foundation.
Developing mental health care standards and using pay-for-performance incentives for health care providers could play a great role in improving the quality of care for depression and other mental illnesses, Houtsinger added.
"Part of it is research," Williams agreed, "figuring out a way to modify these models so that they can work in various settings. Then, researchers bring evidence to policy makers who influence reimbursement practices to make it easier to implement these models."
The review was funded in part by the Centers for Medicare and Medicaid Services, the Department of Veterans Affairs and The John D. and Catherine T. MacArthur Foundation.

Clinical Depression Not A Normal Part Of Aging

As many as two million of the country's thirty-five million seniors, age sixty-five and above, suffer from major depression, and five million have depressive symptoms
Georgia, the elderly account for 20% of all suicides. Suicide among white males aged 85 and older is nearly six times the suicide rate in the U.S.
Studies show that that less than 3% of the elderly receive treatment from mental health professionals. Much like the general population, stigma is often a factor. The Georgia Crisis & Access Line, 1-800-715-4225, is one service that can make a difference.
"Many believe that depression is acceptable part of aging, but it isn't," said Gwen Skinner, Director for the Georgia Division of Mental Health, Developmental Disabilities and Addictive Diseases. "Signs of depression need to be understood, and families should support loved ones in getting help."
The Georgia Crisis & Access Line can offer both anonymity and confidentiality. In addition, callers can speak to a trained counselor about their symptoms, and receive various treatment options. Appointments with mental health professionals can be made on the spot. Depression that occurs in older adults is commonly known as "late-life" depression and can occur for many reasons. According to studies, many older adults and their caregivers believe that depression is a typical part of aging. Therefore, depression in older adults often goes overlooked and untreated. Symptoms of clinical depression can be triggered by other chronic illnesses common in later life, such as Alzheimer's disease, Parkinson's disease, heart disease, cancer and arthritis. Fortunately, clinical depression is a very treatable illness. More than 80% of all people with depression can be successfully treated with medication, psychotherapy or a combination of both.
Symptoms of late life depression include a persistent sad, anxious or empty mood, loss of interest or pleasure in activities once enjoyed, sleeping too little or too much, persistent physical symptoms that don't respond to treatment in addition to difficulty concentrating, remembering or making decisions, feelings of guilt and thoughts of death.

Are too many people diagnosed as having depression?

Are too many people now diagnosed as having depression? Two experts give their views in this week's BMJ.
Professor Gordon Parker, a psychiatrist from Australia says the current threshold for what is considered to be 'clinical depression' is too low. He fears it could lead to a diagnosis of depression becoming less credible.
It is, he says, normal to be depressed and points to his own cohort study which followed 242 teachers. Fifteen years into the study, 79% of respondents had already met the symptom and duration criteria for major, minor or sub-syndromal depression.
He blames the over-diagnosis of clinical depression on a change in its categorisation, introduced in 1980. This saw the condition split into 'major' and 'minor' disorders. He says the simplicity and gravitas of 'major depression' gave it cachet with clinicians while its descriptive profile set a low threshold.
Criterion A required a person to be in a 'dysphoric mood' for two weeks which included feeling "down in the dumps". Criterion B involved some level of appetite change, sleep disturbance, drop in libido and fatigue. This model was then extended to include what he describes as a seeming subliminal condition "sub-syndromal depression".
He argues this categorisation means we have been reduced to the absurd. He says we risk medicalising normal human distress and viewing any expression of depression as necessary of treatment. He says:
"Depression will remain a non-specific 'catch all' diagnosis until common sense prevails."
On the other side of the debate Professor Ian Hickie argues that if increased diagnosis and treatment has actually led to demonstrable benefits and is cost effective, then it is not yet being over diagnosed.
He says increased diagnosis and treatment has led to a reduction in suicides and increased productivity in the population. Furthermore the stigma of being 'depressed' has been reduced and the old demeaning labels of 'stress' and 'nervous breakdown' have been abandoned.
He says concerns about the number of new drug treatments on the market are unhelpful, arguing that new drugs to treat depression have reduced the prescribing of older, more dangerous sedatives and says that the consequences, such as suicide, of not being diagnosed or receiving treatment are rarely emphasised.
Audits carried out in the UK, Australia and New Zealand do not support the notion that the condition is over diagnosed, far from it, he says. Instead he points to the diagnosis rate of people with major depression and says this needs to be improved in which case rates of diagnosis must continue to rise.

Post Combat Stress Prevalent In More US Troops

Soldiers and Stress
There are an estimated 150,000 U.S. troops in Iraq, and approximately 25,000 in Afghanistan. Like soldiers in other wars before them, a significant number of those returning home are bringing back emotional scars from combat. VOA’s Melinda Smith has more on what is being done to identify soldiers who suffer from depression, anxiety and post-traumatic stress.
The welcome home for many U.S. troops could be any warmer. They are back in the arms of their loved ones, and the fear and anxiety experienced during combat seems distant — at least temporarily.
But a study published in the Journal of the American Medical Association shows that problems are showing up three to six months after coming home. Dr. Charles Milliken and his colleagues at the Walter Reed Army Institute of Research in Washington, D.C. conducted the study.
Dr. Milliken explains, "Things happen fast over in the combat theater. It’s only after a soldier’s been home for some time and has time to think about what he’s been through, that some of those problems start to become something that weighs on his mind."
Tom Williams is retired from the U.S. military. He was in the medical corps in Iraq and Afghanistan. He says, "I spent the first six months I was back, looking at the ground to make sure I didn’t get my legs blown off."
U.S. troops returning from deployment in Iraq and Afghanistan routinely undergo a health checkup that includes a look at possible emotional and psychological issues.
Army researchers have studied the effectiveness of the initial assessment, as well as the additional screening and mental health training done a few months later. Dr. Milliken says this study helps identify a larger population of soldiers. "For the next 30 days following the screen a number of soldiers enter the mental health system. So something about the screening and training is actually encouraging soldiers to go get care."
The screening involves answering a series of standard questions relating to mental health stress and meeting with medical personnel. Then, soldiers participate in something called Battlemind training.
"Battlemind training helps soldiers understand what are some common problems that lots of folks experience after being in combat for a year. It helps give them ideas about what they can do about these problems," Dr. Milliken said.
Dr. Milliken and veteran Tom Williams both say the second screening is a valuable incentive for soldiers to seek help. "We know soldiers tend to have stigma about going in to get mental health care, so something about the screening-training process is countering that stigma and making it more okay for them to get care," Dr. Milliken said.
Williams adds, "It takes time for reactions to start and it takes time for you to recognize that there’s something wrong — that your behaviors are not just affecting you, they’re affecting someone you probably love or care for."
When Army researchers looked at results of the second screening, they decided to focus only on soldiers returning from Iraq because they had had consistently higher rates of combat exposure. At least 88,000 soldiers from that group had completed both screenings. – Courtesy – Journal of the American Medical Association

Therapy Can Improve Postpartum Depression Without Drugs

Postpartum Depression
For the estimated 13 percent of new mothers who experience postpartum depression, counseling and peer support groups appear to offer symptom relief without medication, a new review of research suggests. However, at least one expert cautions against ruling out drug therapy altogether.
Postpartum depression -- unlike the much more common "baby blues," which affect 70 percent to 85 percent of new mothers -- typically occurs from three days to six weeks after the baby's birth, but can develop any time during the first year after delivery. A woman with postpartum depression often struggles with feelings of sadness, anxiety, fatigue and restlessness.
Left untreated, postpartum depression poses serious health consequences for mothers, children and families. Not only are these mothers at a higher risk of developing future episodes of depression, but the condition can negatively affect interactions between babies and mothers. Children of depressed moms are at greater risk of language deficits, social difficulties and attention problems.
Although it can be treated with antidepressant medications, "research suggests that 50 percent of mothers will not take a pharmacological treatment for postpartum depression," often due to concerns about medication side effects or passing the medicine to infants in breast milk, said Cindy-Lee Dennis, Ph.D., the review's lead author.
"We need an alternative to pharmacological interventions," said Dennis, a perinatal researcher and associate professor at the University of Toronto, Ontario. Her review evaluated nine randomized controlled trials conducted in the United States, the United Kingdom, Canada and Australia.
The review appears in the latest issue of The Cochrane Library, a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.
It turns out that providing a supportive environment could be a medication-free way to alleviate depression symptoms in new mothers, the results suggest.
The review included 956 women with symptoms of postpartum depression and found that, compared to usual postpartum care, mothers who received any type of psychosocial or psychological intervention had a 30-percent lower risk of still having depressive symptoms at the final study assessment, which occurred within the first year postpartum.
"Women prefer to talk to someone to help them work through their depression ... Mother-to-mother or peer support is extremely important in the postpartum period. It provides realistic social norms of what it is like to be a mother," Dennis said.
Previous studies have shown that there is a clear connection between postpartum depression and a lack of social support, but despite this relationship, few well-designed studies have evaluated the effect of support groups and counseling in alleviating new moms' depressive symptoms, according to Dennis.
Health care professionals facilitated all of the social and psychological interventions in this review, which were face-to-face except for one that involved telephone-based peer support.
Both social interventions (such as counseling and peer support) and psychological interventions (such as cognitive behavioral therapy) appeared to be similarly effective in reducing symptoms, based on results from the two trials that compared them.
"The review is helpful in some ways, but really points out the deficiency in research in this area in general," said Jennifer Payne, M.D., co-director of the Women's Mood Disorders Center at Johns Hopkins School of Medicine.
Although the review results suggest that new moms with depression benefit from social and psychological interventions, the review authors said that the included trials could not offer data on whether these interventions reduced depression symptoms long-term.
As a result, drawing conclusions about how to treat depressed women is risky because we do not have all of the necessary data, Payne said.
Payne agreed with the authors' conclusions that psychosocial and psychological interventions are a viable treatment option for patients; however, what is not clear is which women need medications in addition to these therapies, she said.
"When you have someone with a first onset of depression and it's mild to moderate, those are usually the patients that I think about offering psychological intervention, but anytime someone is mildly to moderately depressed, you have to think about medication, usually in conjunction with a psychological intervention," she said.
However, Payne added that even in cases of mild to moderate depression, health care providers might advise treatment with medication, often in conjunction with psychological intervention. Furthermore, in women who have severe symptoms or have a history of depression, treatment with medication is usually necessary to relieve depressive symptoms.
What is the take-home message here? Not only do additional support and psychological interventions work, but also, they are what new moms want, Dennis said.
"These psychosocial and psychological interventions are consistent with mother's treatment preferences . . . If treatment is linked to women's perceptions as to why they are depressed and they are interested in the type of treatment offered, they are more likely to be compliant," Dennis said.
Overall, new mothers should remember that postpartum depression is a treatable condition. Simply choosing to live with depression symptoms is not in anyone's best interests, Payne said. Even if a depressed mother avoids exposing her baby to antidepressants, "the baby is still being exposed to a depressed mom and that's not good for the baby."