Promoting Psychology. Supporting Psychologists.

Indiana Psychological Association News

PsychByte: Depression in Primary Care



Depression in Primary Care

In January, the U.S. Preventive Services Task Force (USPSTF) updated its recommendations to include routine screening for depression of the general adult population, as well as pregnant and postpartum women (Siu, 2016). The American College of Preventive Medicine (ACPM) supports this recommendation, noting that all primary care practices should have such systems of care in place (Nimalasuriya, 2009). With the knowledge that reliable systems for diagnosis, follow-up, and treatment modification result in better patient outcomes, the Institute for Clinical Systems Improvement produced an evidence-based review to serve as a guideline for implementing such supports (Trangle et al., 2016). The document is available to download here.
 
At any given time, 9% of the population has a depressive disorder, and 3.4% has major depression (Strine, 2008). In a 12-month time period, 6.6% of the U.S. population will have experienced major depression, while 16.6% of the population will experience depression in their lifetime (Kessler, 2005). Major depression is a treatable cause of pain, suffering, disability and death, yet primary care clinicians detect the disease in only one-third to one-half of their patients who have it (Williams Jr, 2002; Schonfeld, 1997).
 
More than 80% of patients with depression have a medical comorbidity (Klinkman, 2003). In a WHO study of more than 240,000 people across 60 countries, depression was shown to produce the greatest decrease in quality of health compared to several other chronic diseases. Health scores worsened when depression was a comorbid condition, and the most disabling combination was depression and diabetes (Moussavi, 2007). Additionally, major depression was second only to back and neck pain for having the greatest effect on prevalence of disability days, at an estimated 386.6 million days per year in the U.S. population (Merikangas, 2007).
 
Usual care for depression in the primary care setting has resulted in only about half of depressed adults getting treated (Kessler, 2005) and only 20-40% showing substantial improvement over 12 months (Unützer, 2002; Katon, 1999). Approximately 70-80% of antidepressants are prescribed in primary care, making it critical that physicians know how to use them and have a system that supports best practices (Mojtabai, 2008).
 
In light of this, psychologists are well-positioned to play a critical role in primary care medical settings in the following ways (APA Center for Psychology and Health, 2014):
  • Psychologists recognize and treat mental and behavioral health disorders earlier, often saving significant costs, decreasing the load on medical providers, and delivering services in an approach desired by many patients.
  • Psychologists provide an array of individual, group, and family interventions effective for depression, anxiety, pain, and adjustment issues surrounding chronic illness. Psychologists also provide support to address family needs, enhance communication, and promote recovery.
  • Formal assessment and diagnostic services delivered by psychologists provide a thorough, standardized approach to understanding the patient’s presenting problem, thereby enabling appropriate treatment planning and intervention. Implementation of evidence-based treatment modalities by psychologists has been shown to improve both physical and mental health.
  • Research has also shown a “cost offset of 20 to 40 percent for primary care patients who receive behavioral health services.” Access to behavioral health services during medical visits likewise improves treatment adherence, which has been associated with $105 billion in annual avoidable health care costs.
  • Psychologists have a strong research foundation and can contribute to the design, implementation, and evaluation of behavioral interventions that improve patients’ treatment compliance and overall health management.

References:

APA Center for Psychology and Health (2014). Primary care: How psychologists can contribute. Briefing Series on the Role of Psychology in Health Care. Washington, DC: American Psychological Association.

Auxier, A., Farley, T., & Seifert, K. (2011). Establishing an integrated care practice in a community health center. Professional Psychology: Research and Practice, 42, 391-397.

Blount, A., Schoenbaum, M., Kathol, R., Rollman, B. R., Thomas, M., O’Donohue, W., et al. (2007). The economics of behavioral health services in medical settings: A summary of the evidence. Professional Psychology: Research and Practice, 38, 290-297.

Collins, C., Hewson, D. L., Munger, R., & Wade, T. (2010). Evolving models of behavioral health integration in primary care. New York, NY: Milbank Memorial Fund.

Hunter, C. L., Goodie, J. L., Oordt, M. S., & Dobmeyer, A. C. (2009). Integrated behavioral health in primary care: Step-by-step guidance for assessment and intervention. Washington, DC: American Psychological Association.

IMS Institute for Healthcare Informatics. (2013). Avoidable costs in U.S. health care: The $200 billion opportunity from using medicines more responsibly. Retrieved from http://www.imshealth.com/files/web/IMSH%20Institute/Reports/Avoidable_Costs_in%20_US_Healthcare/IHII_AvoidableCosts_2013.pdf

Jortberg, B. T., Miller, B. F., Gabbay, R. A., Sparling, K., & Dickinson, W. P. (2012). Patient-centered medical home: How it affects psychosocial outcomes for diabetes. Current Diabetes Reports, 12, 721-728.

Katon, W., et al. (1999). Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Archives of General Psychiatry, 56, 1109-15.

Katon W. (2012). Collaborative depression care models: From development to dissemination. American Journal of Preventive Medicine, 42, 550-552.

Kessler, R.C., Chiu, W.T., Demler, O., & Walters, E.E. (2005). Prevalence, severity, and comorbidity of 12-month DSM-IV disorders in the national comorbidity survey replication. Archives of General Psychiatry, 62, 617-27.

Klinkman, M.S. (2003). The role of algorithms in the detection and treatment of depression in primary care. Journal of Clinical Psychiatry, 64,19-23.

Mercury, M. G., Kehoe, R., & Tschan, W. (2007). Neuropsychology for the primary care physician. Disease-a-Month, 53, 138-141.

Merikangas KR, Ames M, Cui L, et al. (2007). The impact of comorbidity of mental and physical conditions on role disability in the US adult household population. Archive of General Psychiatry, 64, 1180-88.

Mojtabai R, & Olfson M. (2008). National patterns in antidepressant treatment by psychiatrists and general medical providers: results from the national comorbidity survey replication. Journal of Clinical Psychiatry, 69, 1064-74.

Moussavi S, Chatterji S, Verdes E, et al. (2007). Depression, chronic diseases, and decrements in health: results from the World Health Surveys. Lancet, 370, 851-58.
 
Nimalasuriya K, Compton MT, Guillory VJ. (2009). Screening adults for depression in primary care: a position statement of the American college of preventive medicine. Journal of Family Practice, 58, 535-38.
 
Schonfeld WH, Verboncoeur CJ, Fifer SK, et al. (1997). The functioning and well-being of patients with unrecognized anxiety disorders and major depressive disorder. Journal of Affective Disorders, 43, 105-19.
 
Siu AL, US Preventive Services Task Force (USPSTF), Bibbins-Domingo K, et al. (2016). Screening for depression in adults: U.S. preventive services task force recommendation statement. Journal of the American Medical Association, 315, 380-87.
 
Strine TW, Mokdad AH, Balluz LS, et al. (2008). Depression and anxiety in the United States: findings from the 2006 behavioral risk factor surveillance system. Psychiatric Services, 59, 1383-90.
 
Trangle., M, et al. (2016). Adult Depression in Primary Care. Institute for Clinical Systems Improvement. Updated March 2016.
 
Unützer J, Katon W, Callahan CM, et al. (2002). Collaborative care management of late-life depression in the primary care setting: a randomized controlled trial. Journal of the American Medical Association, 288, 2836-45.
 
Williams Jr JW, Noel PH, Cordes JA, et al. (2002). Is this patient clinically depressed? Journal of the American Medical Association, 287, 1160-70

Contributor:
Natalie Dattilo, Ph.D., MHA, HSPP
Indiana University Health Neuroscience Center
 
"PsychBytes” is a weekly educational resource from the Indiana Psychological Association (IPA) provided for psychologists, their colleagues and their patients.  We hope you will use and share this material!