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As many as 20% of the patients who enter a primary care physician’s office suffer from depression, yet most will not receive a diagnosis or adequate treatment for that serious condition. Instead, those patients often return with physical complaints such as backache or fatigue for which no organic cause can be found. The result: unnecessary suffering for patients, frustration for physicians, and billions of dollars in misdirected medical costs and lost work productivity.1
Mental health screening and outcomes assessment tools hold the promise to help physicians alter that bleak picture. Mental health assessment tools are highly sophisticated, widely available and underused, according to outcomes experts.
"The potential is absolutely enormous," says Kenneth Howard, PhD, professor of psychology at Northwestern University in Evanston, IL, and creator of the COMPASS treatment evaluation tool. "The savings involved in both suffering and money in correctly identifying mental illness and getting patients into appropriate treatment is huge."
Primary care physicians can give patients a questionnaire to screen for depression and other mental illness and can administer assessments to determine whether the chosen course of treatment is working. Measurement tools range from simple questionnaires to full-blown software programs.
"It’s a matter of taking the time to do it," says Herbert Schulberg, PhD, professor of psychiatry, psychology, and medicine at the University of Pittsburgh School of Medicine. "In busy practices, physicians often will focus on something else the patient’s talking about rather than the major depression."
Yet Schulberg stresses the importance of both psychosocial discussions with patients and assessment tools. (For more information on psychosocial patterns of patient-physician encounters, see p. 43.)
"The distress and level of disfunction associated with major depression is the equal of that of all kinds of chronic diseases seen by the physician in routine practice," says Schulberg.
To detect depression in patients, Schulberg advises primary care physicians to be attuned to two major symptoms: feeling sad or blue and losing interest in regular activities. "If the patient acknowledges both of those symptoms, there’s a very strong likelihood the patient is experiencing a major depression," says Schulberg.
Screening tools provide a quick method for primary care physicians to check for those and the seven other symptoms of depression: fatigue or loss of energy, feelings of worthlessness, significant weight loss or weight gain, insomnia or increased need for sleep, difficulty concentrating, agitation or lethargy, and thoughts of suicide. Major depression is defined as having five of those nine symptoms over a two-week period, Schulberg says.
Typically, new patients or patients identified as at risk, such as those who have experienced an episode of depression in the past or who suffer from a chronic illness, fill out the screening tool. The form may be given to the patient in the waiting room or administered by the physician during the examination. The physician then uses the answers to guide a clinical interview and confirm a diagnosis, Schulberg says.
Primary Care Evaluation of Mental Disorders (PRIME-MD), developed by Robert L. Spitzer, MD, professor of psychiatry at Columbia University in New York City, and colleagues, is an example of a tool that covers depression as well as alcohol abuse, anxiety and eating disorders, and somatization disorders, or multiple and continued physical complaints without organic basis. "It makes an actual diagnosis, it’s not just a screening tool," says Spitzer. "It facilitates primary care physicians making a specific diagnosis and initiates treatment."
In a study of 1,000 adult patients and 31 primary care physicians, 26% of the patients had a PRIME-MD diagnosis for a specific disorder. Overall, independent mental health professionals agreed with the PRIME-MD diagnosis 88% of the time. Yet about half (48%) of 287 PRIME-MD diagnosed patients had not been previously recognized as having the disorder, although they were "somewhat or fairly well-known" to their physicians. Of the 125 patients with a PRIME-MD diagnosis who were not already being treated, 62% received treatment or a referral.2
With PRIME-MD, patients fill out a one-page screening form and physicians follow up by using another screening form with patients. According to the study, it took physicians an average of 8.4 minutes to complete the PRIME-MD evaluation.2 Spitzer and his colleagues recently developed a six-page patient problem questionnaire, which physicians then review before a clinical interview with the patient. (See sample questions from the questionnaire on p. 41. For contact information, see box on p. 40.)
Even when depression is accurately diagnosed, treatment is often inadequate despite the availability of clinical practice guidelines and medications with proven effectiveness. (For information about guidelines, see source box on p. 40.) In fact, most patients treated with antidepressants do not receive an adequate dose for a long enough period of time.1 For example, Schulberg and his colleagues found that 82% of primary care physicians provided patients with antidepressants to meet the needs of the acute phase of the illness, as defined by clinical practice guidelines of the federal Agency for Health Care Policy and Research in Rockville, MD. In other words, the prescriptions lasted at least one month. However, only 52% of prescriptions received pharmacotherapy during a continuation phase to prevent a relapse.3
"Within six to eight weeks, the patients’ initial symptoms will remit," says Schulberg. "[Physicians] need to continue the patients on the same medication that led to the remission of these symptoms for another six months or so to make sure the episode is fully resolved."
Undertreatment is compounded by a striking lack of adherence by patients. Some quit taking medication because they feel better and believe they are "well," says Schulberg, without realizing they could relapse. Others decide the treatments aren’t working. And although newer antidepressants, such as Prozac, produce fewer side effects than the older tricyclics, patients sometimes stop taking medicine because of digestive or other problems. Overall, as many as 50% of patients drop out of pharmacotherapy within three months.3
The answer is better education, both for physicians and patients, says Schulberg.
Federally funded public information campaigns have improved the public understanding of mental illness. And primary care physicians are now the largest prescribers of antidepressants, says Robert M.A. Hirschfeld, MD, chair of the National Depressive and Manic-Depressive Association consensus panel based in Chicago.
"There is a much better understanding and recognition in primary care settings than there once was," says Hirschfeld, who is also professor and chairman of the department of psychiatry and behavioral sciences at the University of Texas Medical Branch in Galveston. "But we still have a very long way to go."
Outcomes measures allow physicians and other clinicians to test the effectiveness of their treatment. Howard developed the COMPASS Treatment Assessment System as a way to provide systematic feedback to psychiatrists, physicians, and other mental health providers. The assessment tools use information from patients and clinicians to create an index score, which encompasses measurements of patient symptoms and functioning. (See sample COMPASS questions on p. 42. For contact information on COMPASS, see box on p. 40.)
"To ensure quality care, you need to monitor care," says Howard. "Rather than asking, How did we do [after treatment]?’ COMPASS asks, How are we doing? Should we modify care in some way?’"
"If you’re feeling as demoralized, hopeless, or pessimistic as you did when you started, then you’re in the wrong treatment," he says.
Compass Information Systems of King of Prussia, PA, offers measurement systems for outpatient, intensive, and primary care settings. Physicians or other clinicians using the COMPASS system fax the questionnaire and, within minutes, receive a treatment progress report. The primary care version includes information on medication side effects and need for referral. The primary care form also can be used to screen for depression. The Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL, recently included COMPASS on its list of performance measurement systems that can be used in the accreditation process.
The COMPASS analyses are based on patient profiles, a database of more than 15,000 patients, and the "phase model of sequence of change in mental health" or what happens when a patient goes through the stages of recovery, explains Howard.
"What changes first [after treatment] is the patient’s morale," says Howard. "What changes next are the symptoms. What changes after that is their ability to function maintain a marriage, get along with co-workers.
"These things are causally sequenced," he says. "You have to feel better before you get better, you have to get better before you function better."
If the patient isn’t improving after treatment, whether it is psychotherapy or medication, then the treatment needs to change, says Howard.
Outcomes measurement tools also can supplement clinical interviews to determine how the patient views his or her condition. The Behavior and Symptom Identification Scale (BASIS-32), an outcomes measurement tool designed for mental health professionals to use with inpatients or outpatients, is geared toward this patient perspective, rather than diagnosis, says Susan V. Eisen, PhD, assistant director of the department of mental health services research at McLean Hospital in Belmont, MA.
BASIS-32 can be used with a range of illnesses, from depression to schizophrenia. It provides scores in five categories: relation to self/others, daily living skills, depression/anxiety, impulsive/addictive behavior, and psychosis.
The patient-oriented questionnaire represents the "increasing emphasis on the role of the consumer in his or her own treatment plan and outcomes," says Eisen, who is also an assistant professor in the department of psychiatry at Harvard Medical School in Boston.
"It highlights areas that are important to the patient and their needs for treatment, as opposed to what the clinician sees as the need for treatment," she says.
At McLean Hospital in Belmont, MA, where Eisen and her colleagues developed the BASIS-32, it is used as a quality indicator. Patients complete the questionnaire at admission and discharge, and consistently report an improvement in all categories. (See chart, inserted in this issue.) McLean Hospital also monitors patient satisfaction, readmission within 30 days of discharge, and harmful events, such as medication errors.
Tools like the BASIS-32 and COMPASS give mental health clinicians a point of reference for monitoring treatment, much the way physicians check blood pressure or lab results for other ailments. They become increasingly important as mental health professionals seek to prove their effectiveness and argue for a bigger piece of the health care pie with managed care organizations, mental health outcomes experts say.
Schulberg cautions that any questionnaire or screening tool is just another piece of information for mental health professionals or primary care physicians. Clinicians must maintain weekly or biweekly contact with patients and ultimately must rely on their own clinical judgment. Practice guidelines are available to shape treatment and referral decisions.
Outcomes measurement offers one way to improve diagnosis and treatment, says Schulberg. "[Outcomes measurement] is a step in the right direction," he says. "It becomes a more standardized and empiric way to find out what’s happening with the patient and whether the course of the illness is improving."