Little things indicate a patient has depression

Diagnosis is common in the chronically ill

A patient whose chronic illness you are managing is not likely to tell you that he or she is depressed.

Instead, you may hear little comments here and there that indicate something is going on with the patient besides just the physical illness, says Sam Toney, MD, a board-certified psychiatrist and founder of Tampa, FL-based CMS Healthcare Integrated Inc.

"What the nurse case manager often will hear is little cues. The member doesn’t come out and say they’re depressed. Instead, little things may trigger the case manager’s thought process," Toney says.

Members may say, "I feel tired all the time," or "I don’t feel like doing anything."

Or they may comment that they don’t see any reason to do a certain thing any more.

For instance, a patient may tell the case manager that he no longer enjoys going to baseball games to see his grandson play.

"In general, case management nurses have a good feel for the patient because of the one-on-one relationship they develop with the patient. They are in touch with everything that’s happening with the patient," Toney says.

Common comorbidity

Depressive disorder is a fairly common disease that should not be taken lightly. "The literature suggests that with most chronic illnesses, the rate of a depression comorbidity is 25%-35%. We are beginning to see that there is in fact a high frequency in our chronically ill patients," he says.

Undiagnosed and untreated depression makes complying with a disease management plan an uphill battle, Toney adds.

"If a disease management program is treating only the disease and not the entire person, you lost the opportunity for an increased impact," he says.

Case managers whose contact with patients is by telephone must have great listening skills, compared to the clinician in the office sitting face-to-face with the patient.

"Half of the cues the case managers receive are from intonation or the way the patient responds to questions. It’s amazing how nurses can pick up on that," Toney says.

The CMS integrated care system combines case management and disease management of both medical and behavioral conditions.

The computer-based system includes a depression screen that case managers can apply when a member mentions something that may indicate depressive disorder.

The nurses may discuss the case with the CMS medical directors or talk to the patient about being evaluated.

"Some members are not as open as others to the concept of having depressive disorder. Because case management is a one-on-one relationship, the nurse can choose the right direction. Depending on where we are in rapport, the nurses talk to the patients about opening up the possibility of being evaluated for depression," Toney says.

Depression screening

The CMS nurse case managers are trained to stress the fact that chronic and catastrophic illnesses can have a devastating effect on the body, including the central nervous system, which can lead to a chemical imbalance and illness.

"We’ve had very good results with that approach. We’ve had the patient open up to the possibility of being evaluated for a confirmatory diagnosis," Toney says.

The CMS depression screen picks up the possibility of a diagnosis of depression.

"It enables the primary care physician to look at the possibility of depressive disorder without having to refer the patient to a behavioral health professional in case there is resistance," Toney says.

The next step is to confirm the diagnosis and then look at the appropriateness of enrolling the patient into the program, Toney adds.

"When the case managers pick up the cue from the patient that things aren’t going the way the patient would like, they can switch very quickly to the depression screen. They can word the questions in simple lay terms so that members will answer in a way that they don’t realize they are defining that they are depressed," says Cheri Lattimer, RN, the company’s vice president of medical management.

For instance, the progression of questions may be:

Patient: I’m so tired all the time.

Case manager: Are you having trouble sleeping? Do you think it’s not related to your diabetes?

If the patient answers yes, the nurse goes on to ask questions about whether the patient has problems eating that might not be related to their disease and if they are enjoying things less.

"We created it to be a nonthreatening screening but one that would provide enough information so that the case manager can take it to the physician," Toney adds.

CMS case managers are not necessarily from behavioral health backgrounds. Their specialties run the gamut from heart disease, diabetes, and cancer.

"But they can pick up cues that something else is going on, and this gives them the support to evaluate the need for a further assessment," Toney says.

The CMS system includes a list of questions that indicate a risk of a comorbidity of depression if the patient answers them positively.

When this occurs, the system puts in a task list that enables the nurse case managers to continue to monitor the target patients.

"These are the tools that the nurses need today. There are so many patients and so little time, but our system literally keeps them moving and constantly evaluating," Toney says.

CMS was developed to integrate medical and behavioral health care, Toney says.

"Case managers do a wonderful job of identifying patients and getting them into the most appropriate level or care, but there are a lot of gaps between the systems and tools. They need a system that enables the claims side and the network side to function together efficiently and effectively," he adds.