Michael E. Thase, M.D.
Professor of Psychiatry
Director, Mood and Anxiety Disorders Treatment and Research Program
University of Pennsylvania Perelman School of Medicine
Depression affects more than 15 million Americans and it’s the leading underlying factor for people who attempt suicide. Only half of Americans diagnosed with major depression receive treatment. Because earlier diagnosis and treatment improve outcomes, mental health screenings should be a top priority.
We need to do a better job of identifying and treating people with depression. Research shows that screenings in primary care practices are a key part of the solution. Depression screenings are simple questionnaires that doctors can provide for patients. The U.S. Preventive Services Task Force recommends that primary care screenings be implemented for all adults.
While screenings are the first step, treatment is the second, and there’s no reason why accessing treatment shouldn’t be a quicker, more effective process for the majority of patients.
Some argue that primary care providers (PCPs) don’t have the time, resources, or expertise to deal with patients who screen positive for depression, but there are several ways clinicians — and the system itself — can improve access to care, streamline depression treatment, and help patients get better sooner.
Straightforward depression can be easy to treat
With our society’s current level of knowledge and resources, treating low-grade or moderate depression can be a fairly easy process. This type of depression — which affects the majority of patients — can be treated without a psychiatrist or extensive mental health expertise. For the small minority of patients who need more intensive care, PCPs are the gateway to a specialist.
Mandatory screenings are the first step
Using simple, easy-to-administer tools like the Patient Health Questionnaires (PHQ-2 and PHQ-9), primary care providers can complete a depression screening in just a few minutes. When a patient screens positive, the PCP can either initiate treatment or help the patient access the resources he or she needs.
If a patient is suicidal or suffering from a more severe mental health issue like bipolar disorder or a psychotic break, the PCP can help the patient access specialized care. To that end, every general practitioner’s office should have a list of mental health specialists on hand for patient referrals. That way, they can offer patients a quick pipeline to expert care.
For patients who aren’t in immediate danger, the primary care doctor can get started with treatment right away. Studies show that patients prefer to be treated in a primary care setting and, with the current array of time-tested — and affordable — antidepressant medications, doctors are able to treat the majority of cases.
As far as choosing a medication, PCPs don’t need to be experts in psychopharmacology. If the patient has had effective care for depression previously, the doctor can and should start with that same medication: here, the best predictor for the future is the past. (Similarly, if a medication has proved ineffective in the past, it should not be the first approach to treatment.) Family history is also an indicator. If three of a patient’s family members have been successful on one medication, for example, there’s a good possibility that the same drug will prove effective for them.
Providing resources: therapy and online tools
Helping patients learn more about depression is also an important part of the process. Doctors can direct them towards free online resources such as the Families for Depression Awareness website or the National Institute of Mental Health website.
For those patients who prefer therapy, PCPs can offer a referral. While it takes some time and effort for a doctor to create a database of recommended therapists, such a list will help patients find and secure an appointment with a provider much more quickly than they’re likely to do on their own.
If in-person therapy isn’t an option due to cost, insurance, or availability issues, there are reputable online therapy providers and mental health training tools that can help patients learn many of the skills taught in Cognitive Behavioral Therapy (CBT) and other similar behavioral health paradigms. These educational programs help people learn some of the more pragmatic tools taught in therapy including problem solving, the importance of staying active, increasing time spent in rewarding activities, etc. Many of these online services and tools are available at a low cost or may be available free through a provider, health plan, insurer, or employee assistance program (EAP).
The system needs to step up
While providers can use these strategies to provide faster and more effective care, they can’t do it all alone.
A growing body of research shows that depression case management, often provided by nurses or social workers, significantly improves treatment outcomes. While care managers or online materials can supplement case management time, doctors simply can’t assess and treat a person with depression in a typical seven-minute patient visit. Studies show that the more frequent the follow up and the longer the visit lasts, the better patients typically do. It’s up to the healthcare system to allow clinicians more time for patient appointments and scale back on the demand for physicians to see so many patients in one day.
In addition, incentivizing screenings would go a long way toward making them standard in every primary care office. A modest uptick in reimbursement by insurers will make physicians more likely to incorporate them into their often harried patient visits.
The system should also build in two-week assessments for patients who’ve screened positive for depression. Patients with easier to treat depressive disorders are noticeably better at two weeks into treatment. If a patient experiences little to no improvement after two weeks, the likelihood of the current medication being effective is just 10%. PCPs can then make a dosage change, try a different medication, or suggest an alternative treatment method. A quick and flexible approach to evaluating medication effectiveness would save time and money for the patient — and the system.
All in all, mandatory screenings and streamlining the care process would go a long way in helping patients get faster, more effective treatment for depression. There’s no need for so many people to suffer for so long; we can and must do better.
Read all the posts in this series!
- Depression Treatment: It’s About You
- What You Know Affects Treatment
- Response, Remission, Recovery: What Are Your Depression Treatment Goals?
- Why You Deserve Shared Decision Making
- Shared Decision Making – with Families – Yields Better Outcomes
- How to Get the Best, Most Appropriate, Tailored for You Depression Treatment
- How to Address Other Issues in Depression Treatment
- Faster and Easier Approaches for Improving Patients’ Depression Treatment Outcomes
- When Primary Care Providers Treat Depression – Tips for Engagement
- How to Help a Loved One with a Mood Disorder: The FFDA Action Plan
- Does Your Family Know Your Mental Health Care Preferences?
- How does your primary care provider address your mental health care needs, if at all?
- How do you think we can improve the health care system to better support PCPs doing mental health care?
Dr. Thase joined the faculty of the Perelman School of Medicine at the University of Pennsylvania in 2007 as Professor of Psychiatry and Chief of the Mood and Anxiety Disorders Section after more than 27 years at the University of Pittsburgh Medical Center and the Western Psychiatric Institute and Clinic. Dr. Thase’s research focuses on the assessment and treatment of mood disorders, including studies of the differential therapeutics of both depression and bipolar affective disorder.
A 1979 graduate of the Ohio State University College of Medicine, Dr. Thase is a Distinguished Life Fellow of the American Psychiatric Association, a Founding Fellow of the Academy of Cognitive Therapy, President-Elect of the American Society of Clinical Psychopharmacology, and a member of the Executive Committee of the Board of Directors of the National Network of Depression Centers. He has been elected to the membership of the American College of Psychiatrists and is a Fellow of the American College of Neuropsychopharmacology.
This lightly-edited archived post was originally developed in collaboration with the National Network of Depression Centers.