By Emil Vernarec
Researchers say we have the tools to deliver better care for people with depression. What's lacking is the mandate for change.
Give the Maine Health Management Coalition high marks for perseverance. One year ago, MHMC asked primary care doctors how they could work together to improve depression care for the group's 70,000 employees. The doctors said they "were too darn busy" for another quality improvement program and that was "the cream of the crop telling us this," recalls Executive Director Doug Libby.
MHMC was undeterred. The coalition of 16 employers and 15 health care organizations searched for programs that would support rather than burden primary care doctors, who are the front line for detecting depression. They found one clear across the country: Kaiser Permanente of Northern California had a clinically proven program it wanted to test in other settings.
The two organizations have since launched a pilot study in which trained nurses will support patients in the early months of antidepressant therapy to ensure that the treatment is having a positive effect. The link with Kaiser has helped stir local enthusiasm for the project, to which MHMC has committed $126,000. "We now have more takers than we can fund," says Libby. In less than a year, MHMC's sustained efforts established a beachhead that could bring better outcomes to a costly illness. (See the box on page 28.)
Mis-organized care
As the Maine experience illustrates, employers are increasingly aware of the need to address depression, their eyes opened by a decade of research that demonstrated major disability and productivity losses. But the most vexing issue has been how to achieve quality depression care. To get a sense of the challenge, consider this goal in the government's "Healthy People 2010" program: In 10 years, boost the treatment rate for adults diagnosed with depression from 23 percent to 50 percent.
MHMC and other employer groups would like to step up the pace of that objective a point quality of care researchers have been pressing for years. "No one questions the need to decrease the disability associated with depression," says Wayne Katon, MD, vice chair of psychiatry at the University of Washington Medical School, in Seattle. "What's alarming is the vast under-recognition and undertreatment of depression in the primary care setting and the lack of adherence to guidelines on good treatments."
Those treatments include better-tolerated antidepressants and psychotherapies developed specifically to treat depression. But current care falls short, Katon says, because it lacks the infrastructure the resources and organization to monitor patients, assess outcomes and target specialty care-that an illness as complex as depression requires. Without appropriate intervention, more than half of patients who suffer one episode of depression will have another, and 80 percent of those will have a third or fourth. "Infrequent, 10 to 15 minute visits with a primary doctor are not sufficient to treat depression," says Katon.
In his two decades of research, much of it in conjunction with the Group Health Cooperative of Puget Sound, Katon has developed models that improve care by creating tighter collaboration between primary care physicians and psychiatrists or psychotherapists. He and Michael Van Korff, associate director of GHC's Center for Health Studies, found that spending an additional $250 to $450 per patient to support such arrangements increased treatment effectiveness from 40 percent to 70 percent. Adding nurse case managers, as does the Kaiser program that MHMC adopted, also has improved outcomes. But these models grew out of the already organized practice settings of GHC and Kaiser, not the independent medical practices that are the norm.
How partners work
Over the past five years, RAND, the nonprofit research center in Santa Monica, Calif., adapted two of these collaborative models-one to improve treatment with antidepressants, one to improve treatment with psychotherapy to create a program called "Partners in Care."
PIC provides the format, training and materials that a managed health care organization would need to improve both forms of treatment without drastically changing the way primary care doctors and psychotherapists usually operate. As such, it presents these models as a simple way to enhance the care that's already being provided or should be.
"The interventions help bring the depression to the doctor's and patient's attention, help them have better knowledge to make decisions with and give them resources to make treatment possible or improve its quality," says PIC's principal investigator, Kenneth Wells, MD, a senior scientist at RAND and professor of psychiatry and biobehavioral sciences at UCLA. "We trained and supported physicians and let them choose with their patients, saying 'Here's what you can do."'
Initial results from a two-year study of the program (The analysis is ongoing.) were published in The Journal of the American Medical Association last January. Six different managed care organizations took part. After one year, patients receiving the enhanced care were less likely to be clinically depressed (42 vs. 51 percent) and more likely to still be employed (90 vs. 85 percent). To the researchers' knowledge, PIC is the first study of its type to include employment as an outcome measure.
"A relatively mild, free-form of intervention made a difference," says Lisa Rubenstein, MD, a director of provider behavior research at the regional VA system in Los Angeles and author of many of the PIC training materials and design features. As for the additional 5 percent who remained employed, she continues, "That's the tip of the iceberg. There's a tremendously costly history behind it. You don't pick depression up until an employee is on a downhill slide. Valuable employees may be substantially underperforming prior to actually losing their jobs. Add to that the effects on family."
A simple plan
How would PIC roll out if a local hospital system or regional health plan adopted part or all of the program? It first requires a team of individuals-a primary care doctor, a nursing supervisor and a mental health specialist who are willing to become experts and leaders in depression care. Their task is to manage the necessary system changes, educate their colleagues and provide ongoing consultation.
The program also requires "depression nurse specialists" to assist with assessing and case-managing patients roughly one nurse for three or four primary care practice sites.
Finally, to field the psychotherapy arm of the program, any therapists not proficient in brief, structured therapies for depression, such as cognitive-behavioral therapy, will need training. As an incentive for participation, all providers could earn continuing education credits, which are a yearly professional requirement.
In the PIC study, the researchers gave the expert teams two days of training in diagnosing and treating depression according to national guidelines and in implementing a quality improvement program. In turn, the expert teams educated primary care doctors through group or individual instruction and shared practice aids like a stepped flow chart for quickly identifying patients in need of referral to a specialist.
The nurses received one day of training, including role-playing, on how to assess depressive symptoms and educate and monitor patients.
Psychotherapists had three days of training in individual and group cognitive-behavioral therapy plus reviews of taped sessions with patients. RAND has made the training materials available for adaptation by health care organizations, visit www.rand.org.
Once the program is in place, the trained nurse contacts any primary care patient who screens positive for symptoms of depression and conducts an in-depth assessment (45 minutes in the study) using a standardized rating scale. The nurse "activates" the patient as a partner in care by explaining the results of the assessment, the nature of the illness and options for treatment. In the study, both doctor and patient got copies of this and future assessments, and the patient received a brochure and video to reinforce the instruction. Importantly, the nurse helps the patient formulate questions to ask the doctor in the upcoming visit.
As a result of this preparatory session, the patients meet the doctor with some understanding of their illness, and the doctor has a detailed picture of their symptoms. This allows the provider more time to refine the diagnosis and discuss treatment choices.
If doctor and patient choose psychotherapy as treatment, with or without medication, the nurse links the patient with one of the therapists, who may then also serve as a case manager. In the study, both the therapists and patients worked with manuals that structured the psychotherapy.
The nurse follows through with patients who are prescribed antidepressants, to assess symptoms, the tolerability of the medication and the patient's compliance with the treatment. "Most of the nurse's activity is in the initial three months," says Rubenstein, noting that a half-time nurse could cover about 75 patients entering the early phase of treatment, or 100 patients if more of them were in the later stages of the six-month follow-up.
The key with either form of treatment is periodic assessments based on structured symptom measures, which both the patient and primary care doctor receive. Judith Beck, PhD, director of the Beck Institute for Cognitive Therapy, in Bala Cynwyd, Pa., says, "Standard outcomes measures are as invaluable for clinically assessing treatments for depression as they are in any other medical specialty, like evaluating physical therapy for tennis elbow." In the study, patients not improving on medication after six to eight weeks were referred to a psychiatrist.
How much would implementing the PIC interventions cost? Those numbers are currently under review.
The cost factor
Treatment with medication or with cognitive-behavioral therapy brought similar improvements after one year in the PIC study. The recent Surgeon General's Report on mental health says that 75 randomized, controlled trials-the most stringent kind have shown the two treatments are equally effective for mild-to-moderate depression. Other research indicates that combining the two therapies has additive benefits, especially for patients with more severe or chronic forms of depression.
A new study of combination therapy appeared this May in The New England Journal of Medicine. Led by Martin Keller, MD, of Brown University, it focused on difficult-to-treat chronic or recurrent forms of the disorder. The patients, in fact, had suffered from depression on average for 17 years and the majority had sought prior treatment. After three months, 85 percent of those receiving an antidepressant plus 16 to 20 sessions of structured psychotherapy had clinical improvement, compared with 55 percent receiving medication and 52 percent receiving psychotherapy alone. The combination of therapies boosted the rate of remission that is, absence of depressive symptoms by 18 to 20 percentage points.
As with PIC, this study has assessed the cost-effectiveness of the treatments, but no data could be revealed before its publication. Bill Crown, vice president of outcomes research and econometrics at the MEDSTAT Group, in Boston, conducted the cost analysis. He explains that though treatment costs were higher, combination therapy yielded significantly greater savings in indirect costs, as measured by the number of depression-free days patients had and the reduction in functional impairment.
Of course, the very mention of psychotherapy raises alarms on all sides about mental health care costs and access to such care. According to a recent survey (See the box on page 32.), the most frequent fee a PhD level therapist gets for one session is $100 if paid directly by the patient and $70 if paid by a managed care plan. Many benefit plans control costs by limiting the number of visits for psychotherapy. In 1999, the annual Kaiser Family Foundation/Health Research and Educational Trust employer survey found that nearly 40 percent of employees covered by HMOs were allowed only 20 visits or less.
As for the cost of medication, Scott-Levin Associates estimates that antidepressant therapy with the newer brand drugs averages about $80 per month. It could get even cheaper when Prozac goes off-patent. But contrary to popular images, these medications are not magic pills. Though they are a recommended first-line treatment for depression, 30 to 50 percent of patients don't respond to the first drug chosen, according to the Surgeon General's report. Further, as the report points out, just because the drugs relieve the symptoms of depression, it doesn't mean they resolve the underlying causes. That role is claimed by psychotherapy. Both PIC and the chronic depression study used variations of cognitive therapy, the most studied form for depression. "Its greatest value may be its effectiveness in preventing relapse," says Judith Beck.
The next step
Do the lessons of clinical studies reach employers who purchase mental health coverage for workers? "Carveout" plans like PacifiCare Behavioral Health in San Fernando, Calif., and Magellan Behavioral Health, in Columbia, Md., have developed programs that follow the collaborative care models. PacifiCare even gave several dozen mental health specialists training in cognitive therapy.
But the plan's Corporate Medical Director, Jerome Vaccaro, MD, explains that he hears employers say, "Yes, depression disability is real, and improving care is good for society, but can I afford the premium increases?" Quality of care advocates answer with examples like the case study in last fall's Health Affairs. To reduce its health care costs, especially for outpatient mental health, a large corporation raised employees' deductibles and copays and let its health plan conduct more utilization reviews. The employer's mental health expenditures per user fell 38 percent. But, the savings was offset by a 37 percent increase in employees' use of nonmental health services and a 22 percent rise in number of sick days.
As MHMC's efforts exemplify, employers do acknowledge the need to address depression or else face the costly fallout from workers not getting care they need. "The hope is that stabilizing employment rates will further motivate employers to contract with health care providers that can show improved outcomes," says Wells. "The next step is to get businesses interested, to improve access to care. It's not just a cost issue, but one of priorities."
Adds Bob Brook, MD, president of RAND Health, "There are so many good tools. The problem is there's no sales force, no system and no mandate for change. Employers need to be fully engaged in these issues."
Maine coalition shows what collaboration can do
"In 1999, we spent $1.6 million to cover the three top-selling antidepressants," says one employer in the Maine Health Management Coalition, "but we have no idea how effective that's been."
Questions like those moved MHMC to convene a steering group on depression one year ago. The mixed employer-provider coalition, headquartered in Portland, sought participation from all who have a stake in mental health care: purchasers of group coverage, hospitals, health plans, primary care doctors, therapists and consumers, represented by the regional National Alliance for the Mentally Ill.
According to Doug Libby, MHMC executive director, the task force proposed both employer and primary care interventions. Among them:
From these efforts, the group hopes to identify the approaches and benefit designs that get the best results.
All eyes will certainly be on the group's depression management project, which it began this month with the help of Kaiser Permanente of North California. The Maine Health Information Center, which manages the coalition's database, is overseeing the pilot study. Brian Pearson, senior director of research, says the center will track outcomes such as patients' improvement in symptoms and quality of life, satisfaction with care and the effect of treatment on their work performance. If the gains are convincing, the coalition may extend the reach of the program.
Behind MHMC's efforts is a confidence that getting better care for people with depression will in the long run reduce its overall medical costs and protect against the productivity losses associated with the disorder.
Emil Vernarec, former managing editor of B&H, now writes for a sibling publication, RN. parts I and II of this series appeared in April and June.
Reprinted with permission from Business & Health 2000, Medical Economics Co., Montvail, N. J.
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