DECREASING DISPARITIES IN DEPRESSION CARE

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DECREASING DISPARITIES IN DEPRESSION CARE

• A Core Curriculum for Change

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Learning Objectives

• The goal of this presentation is to introduce
  participants to
• The definitions of mental health and mental
  illness
• The epidemiology of mental illness
• The epidemiology and surrounding characteristics
  of depressive disorders, including
• Suicide rates
• Relationship with comorbid diseases and substance
  abuse
• Individual, societal, and economic costs and
  impacts
• Topics covered in depth in the accompanying
  modules, including
• Current practices in depression care
• Depression care in a racially and ethnically
  diverse population
• Racial and ethnic disparities in depression care
• Transcultural issues in depression care

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IntroductionMental Illness

• Mental health and illness occur along a continuum
• Mental Health
• A state of successful performance of mental
  function, resulting in productive activities,
  fulfilling relationships with other people, and
  the ability to adapt to change and to cope with
  adversity.
• Mental Illness
• Refers collectively to all diagnosable mental
  disorders. Mental disorders are health conditions
  that are characterized by alterations in
  thinking, mood, or behavior (or some combination
  thereof) associated with distress and/or impaired
  functioning.

US Dept. of Health and Human Services. Mental
Health a Report of the Surgeon General.
Rockville, MD 1999.
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Epidemiology of Mental Illness

• Mental disorders are estimated to affect as many
  as 44 million adults in the United States1
• 1 in 5 Americans has a diagnosable mental
  disorder each year1
• However, only 28.5 of people with psychiatric
  disorders seek mental health/addiction treatment
  services2

• US Dept. of Health and Human Services. Mental
  Health a Report of the Surgeon General.
• Rockville, MD 1999.
• 2. Regier DA. Arch Gen Psychiatry. 19935085.

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Epidemiology of Mental Illness (cont)

• 8.6 of US individuals self-report mental
  distress
• Self-reported mental distress was highest in
  individuals with the following characteristics

Adapted from Morb Mortal Wkly Rep Surveill Summ.
199847(16)325.
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Epidemiology of Mental Illness (cont)
Based on Kessler RC. Arch Gen Psychiatry.
200562617.
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Introduction to Depressive Disorders

• Depressive disorders are mood disorders that
  include
• Dysthymia
• Major depressive disorder (MDD)
• Bipolar depression (as a part of Bipolar
  Disorder)
• Complex disease processes that are difficult to
  identify and treat
• Depression imposes a significant burden on the
  patients
• Quality of life
• Ability to maintain normal personal and working
  relationships
• Self-esteem

American Psychiatric Association. DSM-IV-TR.
Washington, DC APA 2000.
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Epidemiology of Depressive Disorders

• Depressive disorders are common
• 4.88.6 of patients seen in primary care1
• 4th most common source of disability worldwide2
• Prevalence of MDD and dysthymia
• MDD 6.73
• Lifetime risk Women,1025 Men, 5124
• Age of onset Any age average age is 20s4
• Dysthymia4 1.5
• Women gt men
• Lifetime risk 6
• Early insidious onset, chronic course

• Katon W. Gen Hosp Psychiatry. 199214237.
• Ustun TB. Br J Psychiatry. 2004184386.
• Kessler RC. Arch Gen Psychiatry. 200562617.
• American Psychiatric Association. DSM-IV-TR.
  Washington, DC APA 2000.

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Epidemiology of Depressive Disorders (cont)

• Bipolar disorder
• Prevalence 0.41.61
• 1015 of adolescents diagnosed with MDD will
  develop BD
• Age of onset early adulthood1
• Long-term illness requiring lifelong
  management1,2
• Patients frequently experience several episodes
  of depression before a manic episode occurs3
• 1015 of patients with BD commit suicide1,3
• Bipolar disorder should always be considered in
  the differential diagnosis of depression3

• American Psychiatric Association. DSM-IV-TR.
  Washington, DC APA 2000362.
• NIMH 2002. Available at http//www.nimh.nih.gov/p
  ublicat/NIMHbipolar.pdf.
• American Psychiatric Association. Am J
  Psychiatry. 2002159 (4 Suppl)4.

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Depressive Disorders and Comorbid Diseases

• Patients with several medical complaints have an
  increased probability of a coexisting depressive
  or anxiety disorder1
• Patients with depression often have histories of
  chronic medical conditions2,3 such as
• Cardiovascular disease
• Diabetes mellitus
• Chronic pain disorders (eg, fibromyalgia)
• Arthritis
• Stroke
• Cancer

• Kroenke K. Primary Care Comp J Clin Psych.
  20035(suppl7)11.
• Aina Y. J Am Osteopath Assoc. 2006106(5 suppl
  2)S9.
• Chapman DP. Prev Chronic Dis. 20052(1)A14.

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Depressive Disorders and Comorbid Diseases (cont)

• Can significantly increase morbidity and
  mortality in the presence of other disease states
• Patients who have had a heart attack and suffer
  from depression may have 3x greater risk of death
  at 6 months compared with non-depressed
  patients1
• Depression has been associated with increased
  hyperglycemia in diabetic patients2
• Depression is associated with increased risk of
  coronary heart disease (CHD) incidence in both
  men and women, as well as CHD mortality in men3

• Frasure-Smith N. JAMA. 19932701819.
• Lustman PJ. Diabetes Care. 200023(7)934.
• Ferketich AK. Arch Intern Med. 2000160(9)1261.

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Somatization of Depressive Disorders

• Patients may express psychological distress
  through bodily symptoms
• Common in all cultural groups and societies
• Depression can be displayed as low energy,
  insomnia, and physical pain, while mood symptoms
  are minimized
• Can indicate
• Physical or mental illness
• Interpersonal conflict
• Cultural idiom of distress
• Metaphor for experience or emotion
• Role positioning within the family unit or
  society
• Physicians must be aware of this when screening
  patients

Kirmayer LJ, Dao THT, Smith A. Somatization and
psychologization Understanding cultural idioms
of distress. In Okpaku SO (ed). Clinical
Methods in Transcultural Psychiatry. Washington,
DC American Psychiatric Press 1998233.
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Depressive Disorders and Substance Abuse

• Associations between independent mood or anxiety
  disorders and substance abuse disorders are
  significant1
• Patients with addiction disorders and lifetime
  major depression are significantly more likely to
  relapse into drug-dependent behavior at 6-year
  follow-up than those without major depression.2

• Grant BF. Arch Gen Psychiatry. 200461807.
• Landheim AS. BMC Psychiatry. 2006644.

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Suicide and Depression

• Patients with depression have a high risk of
  suicide
• 11th leading cause of death among Americans1
• 3rd leading cause among adolescents
• Claims gt30,000 Americans each year2
• Suicide risk must always be assessed and
  documented2
• A high percentage of patients who commit suicide
  visit their primary care physician in the
  preceding few months2

• Arias E. Deaths Final Data for 2001. National
  Vital Statistics Reports. Available at
  http//www.cdc.gov/nchs/data/nvsr/nvsr52/nvsr52_03
  .pdf.
• Goldberg RJ. Practical Guide to the Care of the
  Psychiatric Patient. 2nd ed. St. Louis, MO
  Mosby 1998229.

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2003 US Suicide Rates per 100,000
Death rates are known to be underestimated for
these populations

• National Center for Health Statistics. Health,
  United States, 2005. http//www.cdc.gov/nchs/data/
  hus/hus05.pdf046
• US DHHS. Mental Health Culture, Race, and
  Ethnicity Fact Sheets. 2001. http//mentalhealth.
  samhsa.gov/cre/.

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The Cost and Impact of Depressive Disorders

• Economic burden on US society1
• Significant annual costs 83.1 billion in 2000
• Direct medical costs 26.1 billion (31)
• Suicide-related mortality costs 5.4 billion
  (7)
• Workplace costs 51.5 billion (62)
• 4th leading cause of disease burden2
• Accounted for 4.4 of total disability-adjusted
  life years (DALYs) in the year 2000
• Responsible for almost 12 of all total years
  lived with disability worldwide

• Greenberg PE. J Clin Psychiatry.
  200364(12)1465.
• Üstün TB. Br J Psychiatry. 2004184386.

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The Cost and Impact of Depressive Disorders (cont)

• Health care costs for patients with depressive
  disorders1
• Show a 1.5- to 2- fold increase over those of
  patients without depression
• Increased cost stems from higher usage of general
  medical services, not mental health services
• However, long-term management is more cost
  effective than acute care2
• Results in more depression-free days
• More cost effective than smoking cessation
  counseling or treatment for hypertension or high
  cholesterol

• Simon G. Am J Psychiatry. 1995152352.
• Rost K. Ann Fam Med. 200537.

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Benefits of Depression Care

• Appropriate screening, timely diagnosis, and
  individualized treatment may
• Halt or slow progression of disease1
• Help avoid long-term interpersonal and
  psychosocial problems1
• Decrease risk/severity or increase functional
  improvement of comorbid illness2
• eg, lower HbA1c levels in diabetic patients
• Help avoid substance abuse and suicidal behavior1
  
• Lead to more positive outcomes1

• Saluja G. Arch Pediatr Adolesc Med. 2004158760.
  
• Aina Y. J Am Osteopath Assoc. 2006106(5 suppl
  2)S9.

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Current Practices in Depression Care

• Best practices in depression care include
• Routine screening
• Early diagnosis
• Effective, individualized management
• Physicians must be well informed about
• Treatment choices Increasingly vast, including
  pharmacotherapy, psychotherapy, ECT, and a
  combination approach
• Current and updated information (eg, drug
  warnings)
• Established guidelines (eg, DSM-IV-TR, APA
  guidelines)
• Patients individual socioeconomic status,
  preferences, and psychosocial and cultural
  context
• For more information on current standards of
  care, see the accompanying curriculum, Current
  Practices in the Diagnosis and Treatment of
  Depression

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Depression Care Occurs in a Diverse Population
US Census 2000 Percentage of Racial/Ethnic Groups

• Disparities in depression care are discussed in
  the accompanying curriculum, Disparities in the
  Diagnosis and Treatment of Depression

US Census Bureau Census 2000. Available at
http//www.census.gov/ Press-Release/www/2001/demo
profile.html.
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Depression CareTranscultural Psychiatry

• A cross-cultural approach to mental health
  problems that recognizes the relevance of social,
  cultural, and ethnic factors, such as the
  following, to the etiology and treatment of
  disease
• See the accompanying curricula
• Disparities in the Diagnosis and Treatment of
  Depression
• Transcultural Issues in the Diagnosis and
  Treatment of Depression

• Ethnicity and race
• Country of origin
• Language
• Gender
• Age
• Marital status

• Sexual orientation
• Religious/spiritual beliefs
• Socioeconomic status
• Education
• Migration history
• Level of acculturation

Ton H, Lim RF. The assessment of culturally
diverse individuals. In Lim, RF (ed). Clinical
Manual of Psychiatry. Arlington, VA American
Psychiatric Publishing, 2006.
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Racial and Ethnic Disparities in Depression Care

• Discrepancies in mental health care quality exist
• Racial and ethnic minorities experience greater
  gaps of care
• More incidents of unequal treatment in mental
  health care services
• than in other areas of medicine
• US Surgeon Generals Report, Mental Health
  Culture, Race, and EthnicityA Supplemental to
  Mental Health A Report of the Surgeon General
  (2001), states that racial and ethnic minorities
• Are more likely to have lower socioeconomic
  status, which has been linked to increased
  incidence of mental illness
• Likely to experience poorer quality of mental
  health
• For additional information on disparities and
  cultural issues in depression care, see the
  accompanying curricula
• Disparities in the Diagnosis and Treatment of
  Depression
• Transcultural Issues in the Diagnosis and
  Treatment of Depression

US Dept of Health and Human Services. Mental
Health Culture, Race, and EthnicityA Supplement
to Mental Health A Report of the Surgeon
General. Rockville, MD 2001.
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Barriers to Quality Mental Health Care

• Patient barriers1,2
• Mistrust
• Communication difficulties, including limited
  health literacy
• Stigmas surrounding mental illness
• Perceived poor physician-patient relationship
• Socioeconomic status, including access to care
• Physician barriers1
• Time
• Prejudice and/or stereotyping
• Inadequate cultural competence
• Failure to provide appropriate treatment
• See the accompanying curricula
• Disparities in the Diagnosis and Treatment of
  Depression
• Transcultural Issues in the Diagnosis and
  Treatment of Depression

• US Dept of Health and Human Services. Mental
  Health Culture, Race, and Ethnicity
• A Supplement to Mental Health A Report of the
  Surgeon General. Rockville, MD 2001.
• 2.Boulware LE. Public Health Rep.
  2003118358-365.

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Decreasing Disparities in Depression Care

• In order to improve depression care, physicians
  should strive to provide
• Improved detection, diagnosis, and treatment
• An individualized approach to care
• Cultural humility and respect
• Awareness of ethnopsychopharmacology
• Culturally sensitive psychotherapy
• Community involvement and partnerships
• Multilingual capabilities

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