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The stigma surrounding depression makes it difficult to get patients into treatment. Once they begin, they often quit when they’re feeling better but are not well. Physicians sometimes misdiagnose the disease to start with, and communication with their patients on the subject may be lacking. The result: Most patients get only about three months of treatment when clinical research shows they need at least nine to 12 months, according to guidelines published by the Rockville, MD-based Agency for Health Care Policy and Research (AHCPR).
One disease management company, funded by a pharmaceutical manufacturer partner, has begun a systematic program designed to keep patients in a year-long treatment. Called ProPartners, it is a nationwide project involving 7,000 physicians and more than 25,000 Prozac-treated patients that seeks to show that outcomes can be improved by motivating patients and supporting their physicians.
ProPartners, which started in 1995 and is nearing the end of its first outcomes study, is funded by Indianapolis-based Eli Lilly and Company, makers of Prozac. Hastings Healthcare Group, a disease management company in Pennington, NJ, developed and administers the program. Hastings develops self-care tools to identify factors that drive individual patient behavior and to change that behavior to improve outcomes. In the case of ProPartners, such behavioral modification is key, says Richard Patterson, executive vice president at Hastings and managing director of the company’s Outcomes Management Division. "It’s very important for patients to be involved," he says. "The majority of relapses and recurrences are because the patient doesn’t complete or continue therapy."
The components of the program include patient questionnaires, individualized action plans for patients to follow, clinical reports for physicians, and educational material. Physicians enroll patients for a one-year period, the only requirement is that the patient must be taking Prozac. Ideally, disease management would apply to all patients regardless of their therapy, but that can be difficult to fund. Managed care organizations, Patterson notes, often can’t or won’t pay to develop programs like ProPartners, but drug companies will if they can link the program to a specific product.
When patients begin the program, they receive a range of educational materials in print and video that define depression, explain how it affects people’s lives and, perhaps most importantly, assert the fact that depression is a disease and not a weakness, Patterson says. Materials also are offered to patients’ family members, who may contribute to treatment problems by their lack of understanding of the disease.
Patients periodically complete questionnaires about symptoms, lifestyle, and feelings. Hastings analyzes the data and prepares an individualized report that gives patients feedback on specific actions they can take to get well. The responses, Patterson says, differ depending on where the patient is in the treatment process. For example, a severely affected patient may be advised to continue taking the medication and communicate frequently with the physician. A patient who has begun to feel symptom relief and is better able to participate in treatment may receive advice on stress management, good sleep habits, or cognitive restructuring exercises to overcome negative thought processes. The report also lists issues the patient should discuss with the physician.
"This is the information the patient would get from the physician if the physician had 45 minutes to give and was well-trained in advising patients on self-care," Patterson explains. "Some physicians are good at counseling, but they just can’t spend enough time."
The data from the patient’s questionnaire is also fed back to the physician in a one-page summary report. The report lists the AHCPR guidelines that relate to that patient’s specific situation. That way, physicians don’t have to waste time trying to remember or look up guidelines. Instead, they can use the report as a kind of second opinion about the patient and use their professional judgment to proceed, Patterson says. The program is designed to reduce demands on physicians and supplement their management of the disease, not replace it.
Five hundred patients are involved in the first ProPartners outcomes study, scheduled to be completed this summer. Half of the patients are taking Prozac and participating in ProPartners; the other half are on Prozac but not enrolled in the program. The companies think the study will show that ProPartners, combined with standard medical treatment, increases patient compliance and prevents recurrence of depression. Eli Lilly also is running a similar program in the United Kingdom and Switzerland. Because of regulations in those countries, the international program is not specific to Prozac patients, Murphy says.