Depression management lags, but PCPs may hold the key

In January, the U.S. Preventive Services Task Force (USPSTF) modified its prior guidance, recommending that primary care physicians screen adults for depression only if the capacity exists to diagnose, treat and follow up with patients.

The most frequent primary care intervention for depression is use of pharmacology, specifically a selective serotonin reuptake inhibitor (SSRI), according to Rodger S. Kessler, PhD, research associate professor, department of family medicine at the University of Vermont College of Medicine.  

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“But there are at least four trials in the last 10 years that suggest that, unless the patient is moderately or severely depressed, the use of an SSRI was no better than placebo,” Kessler says. “So the most common treatment given to the largest number of patients who are screened as depressed is an ineffective intervention. Despite the Task Force’s recommendations, the resources are not there.”

Primary care physicians commonly screen their patients for depression, but still underuse established and effective care management practices compared to other chronic illnesses like diabetes, asthma, and congestive heart failure, according to a recent study published in Health Affairs.

According to study author Tara Bishop, MD, MPH, associate professor of medicine and healthcare policy and research, Weill Cornell Medical College, over half of the eight million ambulatory care visits a year for depression are made to primary care physicians.  

People come to their doctors for depression because they may not have access to psychiatrists or psychologists, their psychiatrists don’t take insurance, or patients feel stigma in seeking mental health treatment.

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When they assessed depression treatment at 802 U.S. primary care practices, researchers found that larger practices used an average of only one of five disease management practices (disease registries, nurse care managers, feedback of quality data to physicians, patient reminders and patient education coordinators) and smaller practices even fewer.   

Next: Searching for the care model that fits

Bishop suggests policies that incentivize depression care like other chronic diseases such as diabetes. “The goal is to lessen the burden of care for physicians, to see if some of the burden can be moved to nurse care managers, but to do this you need resources,” Bishop says.   

Searching for the care model that fits    

One promising practice model, called the Collaborative Care Model, integrates mental health practitioners into primary care practices and has been used successfully to improve depression outcomes over usual care in more than 80 randomized controlled trials.

Patrick Courneya, MD, a family practitioner and executive vice president and chief medical officer at Kaiser Permanente, is piloting embedded behavioral health specialists in several primary care settings. Nurses and team members, such as social workers, are important conduits to patients and their symptoms.

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“We recognize that many illnesses are associated with mental health conditions,” Courneya says. According to Courneya, patients can die up to 25 years earlier when they have severe and persistent mental health conditions. “There is training throughout the team, as well as training in emergency departments to recognize depressive symptoms,” says Courneya.

While large self-contained healthcare systems such as Kaiser, the Veterans Administration and the Department of Defense have developed rigorous interventions, integrating behavioral treatment for depression is more challenging for a small, resource-constrained primary practices.

According to Kessler, lack of resources, attitude, culture and training are all barriers to integrating behavioral health into primary care treatment. Yet the majority of depressed patients could benefit from behavioral intervention. “That is a primary care function, absolutely,” Kessler says.

According to Kessler, we know the impact of the chronic care model as it relates to mental health issues via results of the IMPACT (Improving Mood – Promoting Access to Collaborative Treatment for Late Life Depression) trial at the University of Washington.  “Most clearly, the chronic care model focused on depression in primary care will, in fact reduce depression,” Kessler says. “Although it didn’t in the DIAMOND (Depression Improvement Across Minnesota, Offering a New Direction) initiative; maybe it will reduce anxiety. It does not appear to have correlates in objective disease reduction.”

Next: Implementation

Implementing the chronic care model requires at minimum, a care manager, behavioral health clinicians, plus administrative time. “Now, if you can do that in the small subset of patients in contrast to the behavioral need in primary care, there is a high probability you can, if well done, reduce depression,” Kessler says.  

In his group’s research so far, Kessler has identified only a few systems around the country that integrate behavior health into primary care well. For smaller primary care practices, Kessler suggests a contrasting model to the chronic care model-the Primary Care Behavioral Health Model-as it acknowledges that resource-constrained practices have to treat complex and chronic patients.