Clinics try new approach to depression

MINNEAPOLIS - Sherry Claude recalls the first time she saw a doctor for depression. She had been in a "down mood" for three weeks when she worked up the courage to make an appointment.

Her doctor, a general practitioner, brushed aside her concerns.

"He told me I really just had the blues and I should go home and practice some affirmations," she recalled.

For Claude, it took years before she finally got a diagnosis _ bipolar disorder, once known as manic-depression _ and the treatment she needed.

Now 51 and an executive assistant at a Shoreview, Minn., technology company, Claude knows from personal experience how tough it can be to cope with mental illness. But she hopes that's about to change.

Minnesota clinics are starting to overhaul how depression is managed. It's part of a growing movement to control skyrocketing costs of chronic illness in a whole new way: by helping patients choose and stick to healthier lifestyles.

In March, 10 Minnesota clinics joined the first wave of the project, known as DIAMOND (Depression Improvement Across Minnesota, Offering a New Direction). If all goes as planned, it's expected to spread statewide by 2010.

The key is for clinics to hire depression "care managers" _ nurses, social workers or even medical assistants with scant training in mental health. Their job: to call patients routinely and ask if they are taking their medicine, having side effects, getting better or need a treatment change.

Minnesota is the first in the country to adopt it as a voluntary statewide model, through a coalition of health organizations and government agencies. In a rare move, the state and major insurers have agreed to pay clinics a monthly sum _ roughly $50 per patient _ to try to make it work.

It's a level of hand-holding most patients have never experienced, inspired by techniques that have saved money and proved effective in treating diabetes. The idea is that patients are more likely to follow their doctors' advice and get better if someone is coaching them along the way.

Health reformers say the concept could work with a long list of chronic conditions, from high blood pressure to obesity, that are exacerbated by choices made in everyday living.

With depression, studies have shown that it can double the success rate of treatment.

Claude, who lives in Hastings, Minn., served on the DIAMOND advisory committee. She thinks it's perfectly suited for patients with depression, who often have trouble caring for themselves.

"It's very easy to just drop back into the hopelessness," she said. "When you have someone checking in (on you) ... that can mean a world of difference."

TRACKING PATIENTS

Debra Indahl and Dr. Elizabeth Reeve huddled around a computer screen, wondering why a patient skipped an appointment at the Arden Hills, Minn., HealthPartners clinic.

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The woman was on a new antidepressant and due for a follow-up.

Reeve, a psychiatrist, wasn't too worried. "My guess is she's not showing up because she's feeling better," she said. That often happens when antidepressants kick in, especially on a sun-drenched spring day.

Indahl made a note to give the woman a call. Sunshine or no, she would find out how her patient was coping.

A nurse for over 20 years, Indahl is the first "depression care manager" at HealthPartners. Her job, as of March, is to ride herd on patients at the Arden Hills and White Bear Lake clinics diagnosed with depression.

Typically, patients might see a doctor a few times a year. Now Indahl calls between visits, asks how they are doing, offers to meet them in person.

About a third have "opted out," but she hopes they warm to the idea. "It's pretty hard to start talking about something as personal and intimate to your heart as depression with somebody you maybe only met once."

At every patient encounter, Indahl asks the same nine questions _ a depression scorecard known as the Patient Health Questionnaire (PHQ9). It's designed to track their symptoms by a strict numerical rating. Having trouble sleeping? Feeling hopeless? Thinking of hurting yourself? How often?

It's a surprisingly illuminating test, the mental health equivalent of checking a temperature, said Dr. Michael Trangle, a HealthPartners psychiatrist who helped design the DIAMOND project. Over time, the scores can show whether patients are improving.

Scorecards in hand, Indahl meets once a week with Reeve, a consulting psychiatrist, to review her patients.

Reeve hasn't met any of them and doesn't intend to. Her role is behind the scenes, advising Indahl and the clinic's doctors: Perhaps they should try another drug or higher dose. Maybe refer someone to a psychiatrist. "I may make a suggestion. But everything that happens goes back to the primary-care doctor," Reeve said.

It took only half an hour to whip through a dozen cases. Eventually, Indahl expects to handle a caseload of 150 patients or more in this way.

So far, patients seem to love the extra contact, said Trangle. "They're surprised and pleased and tickled pink. Somebody's paying attention."

UNTREATED DEPRESSION

The depression project grew out of some grim statistics.

Of the 15 million Americans with major depression, only about one in five get adequate care, according to a 2003 study in the Journal of the American Medical Association. Roughly half get no treatment at all, said Trangle, an assistant medical director at HealthPartners.

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One of the big challenges is that the vast majority of those with depression are treated by family physicians or internists, not psychiatrists. Many patients don't even realize they're depressed. The symptoms bubble up when they see a doctor for some other complaint.

"It's one of those things that we don't get a lot of our training on, but relative to what we see, it's a huge percentage of our day," said Dr. Tim Hernandez, a family doctor and medical director of Family HealthServices of Minnesota, which has joined DIAMOND.

The most common problem is that doctors start patients on antidepressants and skimp on the follow-up, lacking time to do much more, Trangle said. "They throw a pill at it, and then it's out of their office."

But patients often stop taking medications because of side effects or other distractions, Trangle said. Or they ignore advice to see a therapist or psychiatrist.

"That's one of the big problems in health care _ people quit doing what they're supposed to do to stay healthy," said Reeve. It's a common lament about patients who need to make permanent changes in how they live, and daily decisions to stay on treatment.

That is especially true, said Trangle, when they have depression. "They're particularly vulnerable to being lumps on a log and not following up," he said. "It's part of their disease."
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© 2008, Star Tribune (Minneapolis)