Depression guidelines help chronically ill
Depression guidelines help chronically ill
Behavioral issues can exacerbate conditions
Kaiser Permanente, one of the country’s largest integrated health care organizations, has developed guidelines for incorporating depression management into its disease management programs.
The organization’s Care Management Institute (CMI) is among the first organizations in the nation to earn disease management certification for depression from the National Committee for Quality Assurance (NCQA).
The organization also received disease management certification for its diabetes, asthma, and heart failure programs.
Kaiser developed its first depression management guidelines in 1999 to help improve care for patients who have a diagnosis of depression, according to David Price, MD, depression clinical lead at CMI.
"We know that in the primary care setting, anywhere from 20% to 60% of the patients who come into a primary care physician’s office have a behavioral health issue, including depression," he reports. Patients who have chronic diseases such as heart disease, chronic pain, and diabetes along with major depression disorder do far worse as far as clinical outcomes are concerned than patients who do not have depression disorder, Price adds.
"Patients with major depressive disorder and other chronic medical conditions don’t function as well, they utilize the health care system much more, and they don’t get the same benefit from treatment as patients without major depression disorder, he says.
The Kaiser Care Management Institute’s goal
is to come up with dynamic models of care that can be used throughout the Kaiser system. Each region adapts the program to meet its own individual needs.
"We are here to be a resource to help our clinicians better understand the evidence in diagnosing, treating, and managing the care of people with depression," says Maryam Firouzian, MBA, depression project manager at the Kaiser Permanente’s Care Management Institute, in Oakland, CA.
For instance, one region is considering integrating the depression disease management program into their diabetes disease management program. Another is screening congestive heart failure patients for depression.
"We recognize that the resources could be used differently in different regions and are working with the regions to help them adapt them to their needs," Price says.
In addition to the guidelines, the CMI Depression Care Program includes tools that case managers can use to screen patients for depression as well as treatment recommendations for physicians and other clinicians.
When a care manager talks to patients, she asks them two questions: In the last four weeks, have you felt depressed? In the last four weeks, have you lost interest in activities you used to enjoy?
If the answer to either question is "yes," the care manager has a menu of seven screening instruments she can use to further screen and appropriately diagnose the patients for depression.
"We included tools we reviewed and found to have high accuracy. Because we recognize that different people may have their favorites, we included tools with similar accuracy in diagnosing and allow the care managers to pick out what they like," Price says.
When a care manager determines that a member may be suffering from depression, he or she alerts the primary care physician.
"What they do then depends on the local setting. If the care manager is in the same office with the physician, she may see him or her in person. If not, she will contact the primary care physician by telephone," Price says.
Generally, the next step is for the physician to make sure the diagnosis was correct. From there, the protocols vary based on the severity of the depression and the comorbid condition, Price says, adding that treatment often is a collaborative process between the patient care manager and the physician.
The CMI tracks outcomes annually and has preliminary data for the 2001 report period that supports the benefit of the depression screening and treatment, Firouzian says.
For instance, in the case of diabetics with depression disorder, those who received treatment spent fewer days in the hospital than those who were not treated, she adds.
"One of our goals is to specifically measure the accuracy of the diagnosis of major depression. We are hoping that the guidelines will help us diagnose depression more accurately," she says.
Evidence-based recommendations
Kaiser’s depression guidelines are based
on systematic reviews and analysis of clinical evidence in combination with the experience and knowledge of the health plan’s depression experts where evidence is lacking, according to Price.
A group of clinicians from across the Kaiser regions met to develop the guidelines, including primary care physicians, psychiatrists, nurses, psychologists, pharmacists, and other behavioral health specialists.
The work group generated a list of about 90 questions it wanted to answer about the diagnosis of depression and its treatment in the primary case setting, then selected a list of about 30 questions to work on Price says.
"We performed a systematic literature review of all the studies that were relevant to each question. We assembled the articles, analyzed them, put them into evidence tables and, as a group, met to review the evidence," Price adds. The group developed a number of evidence-based recommendations for the treatment and diagnosis of depression.
"There were a number of questions where there was insufficient information available to label the recommendations as evidence-based. In these situations, we therefore developed a number of consensus-based recommendations," Price says.
The guidelines, recommendations, rationale, and analyses filled a large binder, which the committee reduced to a six-page trifold card with clinical algorithms to help clinicians recognize and treat major depression disorder.
The first depression guidelines were developed in 1999 and revised in 2001. They will be examined and updated by a committee of about 20 members this year, Firouzian says.
Kaiser Permanente, one of the countrys largest integrated health care organizations, has developed guidelines for incorporating depression management into its disease management programs.Subscribe Now for Access
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