It is no surprise that a high percentage of people with chronic illnesses also suffer from depression. Yet, according to studies cited in The Journal of the American Medical Association (JAMA), depression is often under-diagnosed in primary care settings, and if recognized, is often not treated according to evidence-based, standardized guidelines.* This bodes especially dangerous for people with chronic illness, as depression worsens the prognosis for other coexisting medical problems and may even lead to suicide.** Cambridge Health Alliance (CHA), which already has a long-standing commitment to mental health care, is taking steps to further improve the treatment of patients with depression in the primary care environment, which includes patients with chronic illnesses.

CHA based its work in a depression model of care that incorporates American Psychiatric Association guidelines. Backed by a Pursuing Perfection grant from The Robert Wood Johnson Foundation, CHA then hired Kristin Wagner, clinical nurse specialist in mental health, to lead the project. Wagner works with primary care practitioners (PCPs), patients, and care managers and uses a multi-faceted approach that includes:

• Providing tools that PCPs can use to easily identify and screen patients with depression;
• Training staff and providers on treating depression utilizing evidence-based decision support; and
• Providing supportive counseling and education to patients outside of their PCP visit to improve self care, such as taking medications and following their treatment plans.

Barriers to change
An array of both practice and patient barriers exists to diagnosing and treating patients with depression. In the practice, barriers include:

• PCP pressure and incentives to see as many patients as possible, limiting time per patient;
• Long waiting lists for the psychiatry department;
• Psychiatric and medical practice existing as separate systems; and
• Overburdened support and nursing staff who are reluctant to take on new duties such as mental health screening and care management.

Patient barriers include:

• Language (CHA has a large immigrant population);
• Physical distress;
• Shame associated with the stigma of mental health problems and concerns about confidentiality;
• An inability of some people to know that their feelings indicate depression;
• Cultural values regarding receiving counseling or taking medication; Lack of motivation and engagement (a classic symptom of depression); and
• Receiving treatment outside of the PCP’s knowledge (due to the above-mentioned stigma), creating potential for adverse medication interactions.

Overall, it is difficult for conversations to arise in the primary care office regarding depression that would allow PCPs to intervene effectively.

Finding solutions
Wagner’s first agenda item was to provide a way to capture and screen patients that have depression, without infringing on physicians’ time. To do this, she has patients fill out a short questionnaire called a Patient Health Questionnaire (PHQ9) that can be administered in the waiting room. Patients then give the form to their PCP in the visit.

If the PCP sees that the patient screens positive for depression (depicted by a high score on the PHQ9), he/she uses a more detailed questionnaire to determine whether the patient is appropriate to treat in primary care or should be referred to psychiatry. This second questionnaire, developed by Wagner, ensures the reliability that all PCPs are asking the same questions, and helps the PCP in that he/she does not have to recall these questions for every patient.

The PCP uses the form as a note in the patient’s record, eliminating the need to record the information twice. The PCP then faxes the form to Wagner who inputs the information into a budding registry and follows up with the patient directly.

In this pilot phase, Wagner calls patients on a weekly basis, offering them support, education (especially regarding medication side effects), and answers to their questions and concerns. She also refers them to other community services if needed. “I want to listen to each patient so I can work with them where they are. One size does not fit all when it comes to mental health treatment,” says Wagner.

Patients report being pleasantly surprised to receive weekly phone calls. “Wow, you really care!” said one patient. “I don’t get this time to talk in the [PCP’s] office,” said another. Another patient told Wagner that she would not have taken the medication or gone to therapy if it was not for the calls to her home and follow-up. Providers/PCPs themselves report glowing results, which Wagner hopes will be contagious.

Staff reaction
PCPs at CHA have had mixed reactions to the project. Some felt hesitant to change the current way they were handling their patients. Others immediately became champions of the pilot.

Wagner found that nurses without a psychiatric background were not entirely comfortable dealing with mental health issues. Conversely, social workers were not versed in the medical issues. So, she is cross-training both, with the eventual goal of hiring nurses as case managers. “We need to change job descriptions and get some things off the nurses’ plates before they can take this on,” says Wagner.

Next steps
Future plans at CHA include working on redesigning roles and responsibilities among nurses, social workers, and administrative staff. Wagner hopes that better health outcomes for patients will entice reimbursement from insurance companies. With PCPs enjoying more focused time with their patients, and nurses and administrative staff becoming more involved in the mental health care for patients, patients’ overall care can be optimized. The process, she believes, will not only help patients, but staff as well.

* Glass. Awareness about depression. Journal of the American Medical Association. 2003; 289(23): 3169.

** Rollman, Hanusa, Lowe, Gilbert, Kapoor, Schulberg. A randomized trial using computerized decision support to improve treatment of major depression in primary care. Journal of General Internal Medicine. 2002; 17:493-503.