Say Hello to the National Network of Depression Centers

gredenDr. John Greden. M.D.
Executive Director of the University of Michigan Comprehensive Depression Center

Can you imagine 21 leading institutions collaborating on diagnosis and treatment of mood disorders? That’s the National Network of Depression Centers, affecting and advocating for mental health care. What does the NNDC mean for people living with depression or bipolar disorder and their families? Dr. John Greden met with CFYM to talk about the NNDC’s role, concerns, and impacts.

Say Hello to the National Network of Depression Centers

CFYM: Tell us about the NNDC and why it was formed.

JG: The NNDC is a national network of mood disorder specialists from psychiatry, psychology, social work, nursing, etc. To make real progress in the understanding and successful, sustainable treatment of mood disorders, we must

  • initiate a more robust approach on how we diagnose, study and treat patients and,
  • influence the policies put in place on researching and treating mood disorders

To do all that, a national collaborative network with the resources for widespread, longitudinal follow-up that has the ability to bring research findings into the community is required. At the NNDC we seek to model the collaborative networks for cancer, heart disease, and diabetes care, and emphasize why the same level of effort and funding is necessary to improve the lives of people living with mood disorders.

CFYM: Why do you put such an emphasis on policy?

JG: You can’t modify research or clinical delivery if you can’t make changes in policy. We need policies that move away from short-term research grants and that support a change of approach in how we measure outcomes. Think about cancer: we all talk in terms of “five-year survival” and patients are studied and followed for that long to make sure we really know the treatments have made a difference. But in mental health, we only do eight-or twelve-week studies. That’s not enough to understand if we are really making a difference: can the patient successfully live alone or return to work or return to a process of happiness?

CFYM: So your major focus on policy is in changing how research is done?

JG: That’s not at all the only part. We have to influence policies so that insurers pay to treat a patient fully, including covering interdisciplinary approaches like those utilized by NNDC members. We also need policies to encourage routine screening and early diagnosis of mood disorders, so that they are detected and treated in ages 15-24, the peak starting age for mood disorders. Addressing mood disorders at earlier ages makes absolute sense from public health, budgetary, and treatment perspectives. One in every six people will develop a mood disorder, and every patient who can be identified earlier in the process can be helped sooner and will be treated less expensively.

CFYM: What else is a priority for you?

JG: Collaborative care in the community is a significant platform for us because most mental health care is provided by non-psychiatrists. We are working to develop a comprehensive approach that enables researchers with new findings to promptly translate these to the various providers of treatments and services, including primary care medical professionals, social workers, teachers, religious leaders, and others in order to improve patient outcomes.  Rural and remote areas struggle even more; they have few primary care physicians, let alone psychiatrists.

Although telemedicine is one method to provide care, our more robust approach not only embeds clinicians where care is being delivered but also brings care managers from those communities to NNDC centers. At these centers they learn about approaches to treatment as they are being pioneered. When they bring that experience back to their communities, they become more efficient in translating new care techniques to the clinic setting.

CFYM: You’re talking about a lot of quite radical changes in the way mental health care is funded, researched, and implemented. Are changes this significant really the way forward?

JG: Definitely. Presumably, the 600 members of the NNDC believe so. The approaches that we currently use to treat mood disorders are just not working, or at least not working well. Let’s look at suicide rates: if the current approach is working, why are suicide rates not coming down? Why are the costs of  treating people still the same? Why is care not reaching so many of the people who need it? Why do 30-40% of patients not respond to the treatments we currently have available and develop “Treatment Resistance”?

There are mental health practitioners who are “married” to one idea of therapy—“it must be psychotherapy” or “it must be medications”—yet we have evidence that a combination of psychotherapy and medication is almost always the best approach. It’s important to recognize that interdisciplinary partnerships are crucial, and to keep building the body of evidence to ensure that the best approaches are adopted.  “Partner or Perish.”

We treat mental health issues in an episodic way, even though we know that mood disorders are going to be with a patient for a lifetime and may recur even with the best therapy. Also, everyone needs to routinely measure outcomes to have solid evidence of treatment benefit. We have to get past the mentality of clinicians who say, “I can tell how a patient is doing by just talking to him/her,” because that’s not an objective measurement and fails to generalize. In NNDC Centers, we are measuring the outcomes of all the approaches to treatment and outreach that we take, including the collaborative care model. The care providers in the communities where we embed collaborative care almost always plead that the program continue, but who will pay for it? Our aim is to get reimbursement for this approach throughout the country by showing it is cost- and treatment-effective.

Return to CFYM on Thursday to learn more about how NNDC can capitalize on its large network to maximize research in treating mood disorders.

Your Turn

  • Have you benefited from collaborative treatment?
  • Have you experienced challenges or obstacles to this approach?
  • How can payors better support collaborative treatment?

10 comments
kimgallen
kimgallen

I think Care Managers being educated is vital. I hold a license in chemical dependency counseling, yet I hold two more in insurance. Primarily, my goal is to assure that I can help coordinate care between providers, as well as direct people to resources in the community for help. As we both know, asking individuals to collaborate is tough, as they do not know where to go. Providers themselves, such as primary care doctors seldom really understand mental health medications as they interface with other meds, in my opinion. Nor do they understand a "triggering situation" like clients with PTSD being in MRI machines etc… I think that an MD talking with a psychiatrist to help with such situations is useful. We all must "collaborate or die" as they say, though I mean that from a provider perspective. In terms of reimbursement models and collaborate, I think the managed behavioral health companies do attempt to manage relationships between their medical side and their behavioral health side. They do need to cover interdisciplinary work and training for anyone on their networks, in my opinion. In regard to the National Network of Depression Centers, this sounds very good. We must capitalize on your large network and maximize research in treating mood disorders. I think the same holds true for PTSD, as research should continue in the area of the basic impact of trauma and how it develops reactions that mimic symptoms. 

troygirl1
troygirl1

Happy to read about some "progressive" thinking when it comes to mental illness. I've suffered from depression on & off for 10 yrs. Numerous relapses with short periods of my true self..depression free. I never know how long the healthy times will last. It borders on bipolar without extreme highs & lows. I have lots of energy, organizational skills, multi-tasking abilities all of which are totally lacking during relapses. My symptoms & side effects are numerous when I'm severely depressed yet my experiences fall on deaf ears within the psychology/psychiatric community. I feel that others could benefit by what I've been through (I was certain I was dying) during these episodes. No one ever said to me, "Your experiences are somewhat typical, you're not dying, they will pass." Instead I was left more frightened than ever and withdrawing even more.  3 hospitalizations, early retirement, every available medication, cognitive, individual, group therapies-all would help for a short time but then....relapse time. I've thought about joining clinical trials but I don't qualify. Seems like any progress in depression treatments results in multiple steps backwards. The medical community is running in circles while patients are barely hanging on. If not for my strong faith and support from close friends you wouldn't be reading this now.

Gail Goodman
Gail Goodman

Hello,

    It is such a positive step to hear about an organization that is focusing on psychiatrists for treatment of mood disorders. Psychologists simply do not have the expertise needed for successful therapy, as you stated a combination of therapy and medication.

careforyourmind
careforyourmind moderator

Dr. Greden makes a good point. If research for brain disorders were funded at the same level as other physical conditions, we could make some major breakthroughs. Why aren’t they? Perhaps it’s because we don’t speak out and demand it. Sign the petition below asking the President and Congress to fund mental health research. The goal of the project is to deliver a petition with massive national support to the President and Congress.

https://www.change.org/petitions/to-the-president-and-congress-fund-research-to-cure-mental-illness


Portiaspeace
Portiaspeace

Dr. Greden and his colleagues are finally framing mental health research, and ultimately living well, so that it can work for people who have experienced debilitating symptoms. I would love to see that transformed view reflected in the name of the network so if I, or my friends or family, were searching the internet we'd be called to inquire further. 

I don't want to learn more about depression--I want to know about wellness. So why not call this the National Network of Depression Wellness Centers? After all, wellness is the primary goal. Otherwise, on the outside, NNDC sounds like just more of the same old same old illness model.

kimgallen
kimgallen

 In terms of how payors may better support collaborative treatment for mood disorders, in my opinion, just as providers must accept that purchasers and payors need adequate documentation about how their health dollars are spent and understand that it is vitally important to be clear about what patient functioning was achieved, payors must grasp that most behavioral health providers either operate in relative isolation and are not measuring treatment outcomes, or providers operate in larger groups that are not trained in measuring outcomes. The solution will require better communication and low-cost training for health providers. 

As a past Administrator of a 32-bed chemical dependency treatment facility, I know that behavioral health providers' day-to-day concerns are largely dealing with benefit restrictions, utilization review and other tight reimbursement policies. The overall feeling is that mental health is controlled by distribution channels like insurers and by policy, and not by quality care. Though I think that most behavioral health providers would agree that working with chronic conditions like mood disorders requires collaboration between behavioral health providers and managed care delivery systems, typically, there is still an adversarial relationship there. This kind of relationship results in fragmented communication, resulting in inconsistent quality measures, or no measured outcomes, due to lack of communication and lack of training related to how to best report outcomes. Also, there is inadequate transfer of computerized client records. 

This is not the experience I had with cancer of the thyroid. A nurse noticed a lump in my throat, so I showed it to my dentist who could clearly see it. He in turn, called a specialist. The specialist gave me an accurate screening and referred me to an expert surgeon. From that point forward, my payors paid for the least invasive surgery. They stepped me down and continued to share payment for providers that did follow me through my "five year window" period and all med management. They even continued to help manage my health and wellness when I moved to another city, following me through mailings, asking how I was doing. I am now on a lower level of meds, have had no return cancer and am in excellent physical condition. Numerous research studies are conducted at the clinic I go to for annual, routine screenings. 

 In terms of my mood disorder, there have been no clinical measures at all that have been conducted post-discharge from any hospitalization I have had. The only screens I have are the typical blood levels for medicine. In addition, my care has not been "uniform" in any way, in terms of therapy. For one, I pay totally out-of-pocket, so I may stay well, as the payors "capitate" what they pay for OP. Due to total lack of uniformity and private pay, reports of my treatment outcomes would reflect no particular standard and are typically not utilized.

In terms of being alive, no past provider or system has bothered to ask me that question, at this time. If I hear of another patient dying, that is usually reported informally to me by other

 patients. 

In addition, there are no integrated clinical networks that I have been a part of. My medical health providers do not communicate with my behavioral health providers. I largely perform the function of managing and carrying my own records, thus assuring everyone is "on the same page". This includes carrying the records of the meds I have taken (which have been many), that have not worked, as there is no computerized data base on my care that transfers handily.

Payors can better support collaborative treatment by working in a team-like fashion with behavioral health providers. One way would be to offer low-cost trainings on how to measure outcomes. (The one I selected to attend as an Administrator is one I had to pay for, myself. It wound up costing me about 2K, with travel etc…) 

Also, all providers must be trained on how to use an interdisciplinary approach, and move beyond the attitude of just trying to survive, though certainly I understand that due to strict cost containment, many providers feel driven to work only with private pay, resulting in working in relative isolation. 

The lack of training in computerized systems has also caused the system not to work. The solution for this is to have training on integrated systems, resulting in computerized reports that are easily sent between medical providers and mental providers. There also needs to be affordable online trainings related to standardized forms, uniform records, HIPPA regs and the like. 

Regular MD's and ER's need to have training on appropriate screening tools like SBIRT, or the Beck Depression Screen, to help with early referrals related to MH. 

Also, they need training that may reduce any form of stigma. 

Also, today's environment, it is vitally important for medical records to be passed readily along, with appropriate confidentiality. 

Payors need to grasp that preventive and immediate healthcare is mandatory for cost containment and quality outcomes. Providers need training in measuring outcomes. Computerized systems and records need uniformity. MD's need training and tools to assess chemical dependency and dual disorders, and need to make referrals in a prompt and appropriate fashion. All of this will require collaboration between payors, providers and policy-makers. 

Anndelusia
Anndelusia

I wonder if you have ever looked at the possibility of borderline personality disorder, the most widespread mental illness no one's ever heard of?

StephenBonin
StephenBonin

Gail,

We are comforting and challenging each other as we share our experiences.

Having started treatment with psychologists and psychiatrists in 1986, I can report one terrible experience with a psychiatrist who tried to be a psychologist as well. I stayed with him several years, primarily because it was being paid for by the Diocese of Jackson, Missippi; I was the victim of sexual abuse.

Overall, I was unhappy with him from about 2004 to 2006. One factor that made it hard to change was that he was continually voted a "Best Doctor" for the city's magazine.

Now, commencing 6 months ago, I have a tremendous relationship with a psychiatrist. Through telemed is an adjunct fact, I believe. Also, I have had a therapeutic relationship with a psychologist since 2009 that just keeps getting better.

I do believe that my perseverence in toward wellness, thus growth in humility, factors in.

Thanks for sharing.

Stephen Bonin

StephenBonin
StephenBonin

I signed the petition, and am so glad to have another good link as an advocate-in-training. Thank you.

Stephen Bonin

StephenBonin
StephenBonin

Portiaspeace,

Your assertion, "I want to know about wellness" invigorates me!

As a 10-year member of Navarro County Depression and Bipolar Support Alliance, south of Dallas, reading BP and Esperanza magazines and the outstanding pamphlets by DBSA, I know what you are talkiing about!

A lot is written about being proactive in wellness--diligently tending to our physical, mental, emotional and intellectual needs.

I started experiencing symptoms of depression in 1979. Now I am doing better than ever. Besides meds regulated by a psychiatrist, I eat and sleep well, exercise (walk fast) and get regular sunshine, pray on my own and participate in a church family, read edifying works. With my psyuchologist, support group, and this online community of advocates-in-training, I am growing in leaps and bounds iin confidence of my intelligence and wisdom.

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