Clinical Economics: Managing patients with depression

Depression is one of the most common mental health conditions in the United States, according to the National Institutes of Mental Health. It has been estimated that this disorder will affect approximately 18% of adults at some point in their lives.

Patients with depression incur heavy physical, financial, and emotional burdens. Depression is linked to higher rates of obesity, heart disease, stroke, sleep disorders, and other conditions, and it often co-occurs with other illnesses. Symptoms negatively affect energy, concentration, memory, and decision-making.

Depression accounts for more than $210 billion in annual medical expenditures in the United States. About 40% of this total is directly attributable to depression. The remainder is associated with treatment of related physical and mental illnesses, reduced productivity, and costs associated with suicide, with workplace costs accounting for about 50% of expenditures.

Despite significant improvements attainable through depression management, an estimated 75% to 80% of patients either do not seek or are not receiving proper treatment. Primary care physicians can address this gap by identifying patients at risk for depression and implementing a multidisciplinary plan of care for those patients requiring treatment and support.

“The earliest and best opportunities to identify depression are in the clinics of primary care providers,” noted the Prevention Practice Committee of the American College of Preventive Medicine.

NEXT: Patient management tips for depression

Patient Management Tips

Screen patients for symptoms. While many patients are diagnosed with depression as adults, symptoms of depression can develop at any age. Up to 1 in 33 children and 1 in 8 adolescents have clinical depression.

Depression often co-occurs with other conditions, especially cancer, strokes, heart attacks, diabetes, HIV, Parkinson’s disease, eating disorders, and substance abuse. Extensive patient screening tools or questionnaires are not always necessary; focused patient communication can efficiently open the door to further discussion and confirmation of a diagnosis.

The use of the following screening questions showed a sensitivity and specificity of 97% and 67%, respectively, when used in a primary care setting with patients not receiving psychotropic drugs:

• During the past month, have you often been bothered by feeling down, depressed, or hopeless?

• During the past month, have you often been bothered by little interest or pleasure in doing things?

If either of these questions is answered in the affirmative, further investigation should be conducted using a validated screening tool.

Address treatment non-adherence. Up to 80% of patients with depression who receive treatment-including medication, referral to psychotherapy and support groups, or a combination of these methods-show improvement in their symptoms in four to six weeks.

Related:Integrating primary care and mental health key to improving patient care, lowering costs

However, medical non-compliance is the cause of approximately half of cases of unsuccessful depression treatment. About 25% of patients given an initial prescription for an antidepressant either do not get it filled or never take the first dose.

Patients often stop taking their medications too early due to adverse effects, financial concerns, fear of addiction, or short-term symptom improvement that leads them to believe it is unnecessary to continue treatment.

A phone call from a practice assistant to a patient can increase the initial uptake of treatment significantly by asking three questions:

• Did you get the prescription filled?

• Did you take the first dose?

• Do you have any questions or concerns you’d like to discuss?

Participation in patient-to-patient support groups has been reported to improve treatment compliance by nearly 86%, and can reduce in-patient hospitalization.

Additionally, support group participants are 86% more willing to take medications and cope with side effects than are patients who do not participate.

Encourage patient self-care. Effective patient-centered care includes education on self-management techniques to help reinforce treatment adherence. Incorporating activities such as journal-writing and self-monitoring into a treatment plan can inspire patients to take responsibility for their care.

When appropriate, suggest that a family member or loved one attend appointments to provide advocacy and support, and involve them in the development of patient treatment plans.

Collaborative care is critical. Collaborative care among primary care physicians and behavioral health specialists is critical for effective treatment of patients with depression. Studies have reported that collaborative care models increase effectiveness of treatment and reduce the cost of care overall.

Approaches that have been demonstrated to improve patient outcomes in large trials have four common features:

• Use of a validated screening tool such as the Patient Health Questionnaire-9 or the Quick Inventory of Depressive Symptomatology (16-item) Self-Report (QIDS-SR16),

• clinical use of an evidence-based treatment guideline,

• a care manager, and

• collaboration with a psychiatric specialist.

A sample collaborative care plan might include maintaining a list of patients receiving treatment for depression, establishing a plan for providing patient education, contacting the patient at established intervals to ensure compliance, and ensuring follow-up visits and outcomes measurements.

Include continuity of care in your in-office systems. In-office systems can help coordinate care, ensure continuity, and communicate patient status between all treating clinicians.

Frequent, structured monitoring and follow-up with patients, such as phone or email consultations conducted by a nurse or care manager, should be built into any such system.

-Written by Nicole Klemas, ELS

-Reviewed by Larry Culpepper, MD, MPH
Boston University School of Medicine
Boston Medical Center, Boston, Massachusetts

Patient Education Resources

Depression resources:
Anxiety and Depression Association of America

Resources for your patients:
Depression and Bipolar Support Alliance

Patient information fact sheet:
MPR