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Managing Depression A Challenge In Primary Care Settings, Study Finds

Leon County Judge John Cooper on June 30, 2022, in a screen grab from The Florida Channel.
Wikimedia Commons
The Florida Channel
Leon County Judge John Cooper on June 30, 2022, in a screen grab from The Florida Channel.

Often referred to as the “common cold of mental health,” depression causes about 8 million doctors’ appointments a year. More than half are with primary care physicians. A new study suggests those doctors may not be the best to treat the condition due to insurance issues, time constraints and other factors.

The paper, published Monday in the March issue of Health Affairs, examines how primary care doctors treat depression. More often than not, according to the study, primary care practices fall short in teaching patients about managing their care and following up regularly to track their progress. That approach is considered most effective for treating chronic illnesses.

That’s important. Most people with depression seek help from their primary care doctors, the study notes. Why? Patients often face “shortages and limitations of access to psychiatrists,” the authors write. For example, patients sometimes have difficulty locating psychiatrists nearby or those who are covered by their insurance plans. Plus, there’s stigma: Patients sometimes feel nervous or ashamed to see a mental health specialist, according to the authors.

Meanwhile, physicians and health experts have increasingly been calling for mental health conditions — such as depression and anxiety — to be treated like physical illnesses. Historically, those have been handled separately and, experts say, without the same attention and care as things like high blood pressure and heart disease.

The researchers compared strategies for treating depression with those used for asthma, diabetes and congestive heart failure. They surveyed more than 1,000 primary care practices across the country to determine how often doctors’ offices used five specific steps — considered “best practices” — to manage patients’ chronic conditions. They include employing nurse care managers, keeping a registry of all patients with a condition that requires regular follow-up, reminding patients to comply with their treatment regimens, teaching them about their illnesses and giving doctors feedback. Those approaches track with recommendations from the Department of Health and Human Services Agency for Healthcare Research and Quality.

On average, the practices surveyed were least likely to follow those protocols when treating depression. About a third kept registries of patients with depression, and the other steps were less commonly used. Less than 10 percent of practices, for instance, reminded patients about their treatments or taught them about the condition.

Doctors were most likely to use those best practices for treating diabetes. Most practices followed at least one of the strategies for managing chronic illness.

“The approach to depression should be like that of other chronic diseases,” said Dr. Harold Pincus, vice chair of psychiatry at Columbia University’s College of Physicians and Surgeons and one of the study’s co-authors. But “by and large, primary care practices don’t have the infrastructure or haven’t chosen to implement those practices for depression.” Pincus is also director of quality and outcomes research at New York Presbyterian Hospital.

That’s a problem, said Dr. Tara Bishop, an associate professor of healthcare policy and research at Weill Cornell Medical College, the study’s main author. Effectively treating any chronic illness requires working with patients beyond single visits. For depression, that means things like following up to see if medication is working, or if a dose should be adjusted.

“When we treat high blood pressure, the blood pressure may start at 150 over 95, and then it’s monitored over time until it gets to a level that’s being aimed for,” said Dr. Jeffrey Borenstein, president of the Brain and Behavior Research Foundation. The foundation funds mental health research but was not involved with this study. “If somebody has depression, their symptoms need to be monitored until it gets to a level that the depression is lifted.”

Depression can contribute to other health problems, like pulmonary disease or diabetes, Bishop said. It can make people less productive at work or less able to have healthy relationships. Unchecked, it can result in suicide.

“If we actually treat depression as a chronic illness and use the level of tools we’re using for diabetes, then we’ll be able to better treat patients — and help them live healthier lives and more productive lives,” she said.

The study didn’t delve into why the gap exists between depression and other medical conditions. But the authors pointed to potential explanations. One is that there’s been a decades-long push to improve how doctors treat diabetes — an effort that has almost been “the poster child” for how to monitor and treat a long-term illness, Pincus said.

And there are time pressures. Diagnosing a patient with depression — and following up regularly — can take more time than a diabetes blood test or insulin check. Cramming that into a 15-minute visit can get difficult, Bishop said, especially as doctors are increasingly asked to do more with less time.

Plus, she said, while there’s been an effort nationally for the medical profession to better address mental wellness, individual physicians may still struggle.

“It’s almost like a subconscious divide of mental health issues versus physical health issues,” she said. That may also contribute to why the treatment of depression sometimes falls short.

Some cited money as a key obstacle. Dr. Wanda Filer, president of the American Academy of Family Physicians, noted that, despite federal law, it’s still difficult to get insurers to pay for mental health care. That circumstance, she said, could discourage or impede primary care doctors from taking a comprehensive approach to treating it.

“Most depression cases we can manage quite easily — family physicians are well-trained to manage this particular condition,” said Filer, also a practicing family doctor in York, Pennsylvania. The problem is that “there are all these barriers to improving mental health.”

But Bishop said that, as doctors and policymakers take a broader interest in the issue, those barriers could come down and change how doctors practice.

“We’re starting to realize that mental health care, and depression in particular, are very important illnesses. They affect a large part of our population, and they have a lot of repercussions for patients and society,” she said.

Kaiser Health News (KHN) is a nonprofit national health policy news service.