News & Politics

Americans Are Depressed. Should They Get Help at Their Primary Care Doctor's Office?

Are new initiatives to treat depression at the doctor's office a way to help Americans' mental health problems? Or do they undercut the value of long-term therapy?

In some ways, depression has gone mainstream. Considering the countless TV and magazine ads touting the latest feel-good medications, celebrities divulging their postpartum struggles, and even studies on the benefits of the kind of ruminative thinking associated with depression, it seems possible--even probable--that the stigma once assigned to this tricky mental illness could eventually shrink away. But until it does and everyone is eager to sign up for therapy, Americans need accessible treatment.

More affordable and convenient treatment options for depression would seem the next logical step, but according to the 2009 National Survey on Drug Use and Health, 60 percent of antidepressants are already being prescribed at a very opportune place: the office of their GP or primary care physicians. It seems like a wonderful idea: treat Americans where they already are. But do these initiative provide a quick-fix that undercuts the value of intensive, long-term psychotherapy, and doesn't solve the underlying factors that cause depression? A recent New York Times story described the reduction of therapy, and its replacement by pill-dispensing:

The switch from talk therapy to medications has swept psychiatric practices and hospitals, leaving many older psychiatrists feeling unhappy and inadequate... Psychiatric hospitals that once offered patients months of talk therapy now discharge them within days with only pills.

Given this changing landscape, integrated care--in which a therapist and physician coordinate shorter-term care for depressed patients--could be as a stop-gap measure that combines medication with counseling. Or it could be a harbinger of doom for old-fashioned talk therapy with its ethos of hard work and life-long commitment to ending depression.

Shift Towards Primary Care

It’s true that this shift toward primary care treatment for depression began taking hold in the late 1980s, with the boom in prescriptions of SSRIs (selective seratonin re-uptake inhibiters), like Prozac. However, it wasn’t until the late 1990s that a group of scientists undertook a closer evaluation of primary care physicians’ recognition and treatment of depression. That group, called the MacArthur Initiative, hoped to strengthen links between primary care physicians and behavioral health providers, such as psychologists and clinical social workers.  

Although they receive some psychology training, many primary care doctors feel unprepared to treat patients with mental health problems because of the time required and the lack of evaluation and screening tools at their disposal, the MacArthur Initiative found. Diagnosis of depression is further complicated by the ambiguity of symptoms--depressed patients often complain of physical symptoms, such as pain or fatigue, that can be mistaken for other illnesses. 

Partly as a result of these roadblocks, the 2009 NSDUH revealed that, among the approximately 1 in 13 Americans aged 18 or older who experienced a major depressive episode in 2008, one-third did not receive any treatment. In addition,prior studies of depressed patients who were treated in a primary care setting revealed that a significant portion didn't find their treatment to be adequate, reporting problems like insufficient dosages or treatment that didn't last long enough.

As such studies were considered and the MacArthur Initiative progressed, doctors arrived at a potential solution: the Three Component Model (3CM). This model comprises a primary care physician, a care manager and a mental health professional (typically psychologists, clinical social workers or master’s level psychology graduates) who work together to develop a patient’s course of treatment. 3CM has been implemented in multiple primary care offices across the United States; Maine Health, Colorado Intermountain Healthcare, and Dr. Wayne Katon’s “Shared Care” in Washington State are particularly successful and ambitious integrated care programs. Additionally, the model has facilitated nearly half a million diagnoses of post traumatic stress disorder among returning soldiers from Iraq and Afghanistan, according to MacArthur Initiative co-chair Allen J. Dietrich of Dartmouth University. 

Taking cues from 3CM, the insurance giant Aetna began implementing integrated care programs for depression about six years ago. According to Dr. Hyong Un, chief psychiatric officer for Aetna, primary care physicians are reimbursed when they screen patients for depression, a practice that is unique to Aetna, and that provides incentive for physicians to carefully conduct the screenings. The results of screenings determine whether a patient receives a referral for behavioral health treatment; three counseling sessions are included in the program, and if more counseling is needed,  it is covered under a mental health benefits plan. 

“We want to make sure that the right people get the prescription and that the right people get psychotherapy,” Dr. Un said. 

To that end, Aetna places behavioral health providers in primary care offices, a practice referred to as co-locating. Primary care physicians with large practices, where there are multiple physicians with demonstrated interest in behavioral health, are sought, Dr. Un said. As for the behavioral care providers, before being embedded in primary care offices, they’re pointed toward training programs that emphasize what Dr. Un calls “primary care-specific issues,” such as nutrition and exercise. Un said Aetna often recommends the Primary Care Behavioral Health programs of the University of Massachusetts.

“Primary care is a very complicated setting,” Dr. Un concedes. “I think, in general, there’s probably an over-utilization of medication and an under-utilization of therapy. We want to initially promote the use of counseling and psychotherapy.” 

Aetna’s integrated care program, while heavily influenced by 3CM, improved upon it by heightening convenience and immediacy, both essential to effective mental health treatment, Un suggested. Often, the stigma and anxiety associated with seeking therapy discourages patients from following through on referrals to mental health providers. In Aetna’s program, because counselors and therapists are onsite, “The primary care physician can usually tell if the patient doesn’t make it to the therapist,” Dr. Un said. 

Keeping the Therapist and Physician in the Same Place

That practice of keeping the therapist and physician in the same place, or co-locating has also proven successful elsewhere, according to a 2000 study cited in the paper "Integrated Primary Care: Organizing the Evidence" by Alexander Blount, Ed.D., who leads primary care behavioral health programs at the University of Massachusetts. In the study of a medicine residency practice based in Fitchburg, MA, 100 patients referred by primary care physicians to behavioral health providers were tracked; when the primary care physician physically introduced the patient to the onsite behavioral health provider, 76 percent of patients kept the first therapy appointment, while only 44 percent of patients kept the first appointment if an introduction was not made. 

Studies of 3CM have also shown that the program offers a significant improvement in treatment for depression, compared to treatment in a standard primary care setting. Patient satisfaction from Aetna's integrated care program is approximately fifteen percent better than standard primary care after six months of treatment, for example. Additionally, the paper "Integrated Primary Care: Organizing the Evidence" cites a 1995 study of patients with major depression showing 74 percent experienced clinical improvement in an integrated care setting, while just 44 percent improved in a standard primary care setting. 

However, despite its benefits, 3CM sometimes fails to consider insight from a crucial segment of the behavioral health community: psychiatrists. In programs like Aetna’s, the primary care doctor consults with onsite behavioral health providers to determine whether extended counseling and therapy are required, or whether a psychiatrist should be consulted. Often, however, the onsite behavioral health provider conducts counseling, and the primary care doctor provides the medication, Un explained. Psychiatrists are often “too busy” to be involved onsite, according to Un. 

Enough Therapy?

Still, the deeper problem with integrated care may not be the issue of medication, but rather the quality and intensity of therapy patients receive, suggests Dr. Hannah Hahn, a clinical psychologist practicing in New York City. Hahn pointed to the September 2010 Harvard Mental Health Letter suggesting that psychodynamic therapy, which she practices, may be a more effective long-term treatment for depression than cognitive behavioral therapy, a newer and more commonly practiced method.  The difference between the two therapies mirrors, to some extent, the difference between integrated care programs and standalone behavioral care providers: one may be more accessible and cost-effective, but is the quality of treatment as high as with the other option? 

“Cognitive behavioral therapy changes behavior, but it doesn’t change the internal processing of thoughts and emotions,” Hahn said. 

The open format and long-term nature of psychodynamic therapy create a complex patient-doctor dynamic whose outcome has been difficult to concretely assess. However, with the results of multiple recent studies cited by Harvard, (including analysis by The Journal of the American Medical Association, the Archives of General Psychology and the Cochrane Collaboration) psychodynamic therapy is now considered an effective evidence-based treatment for depression, offering benefits that endure and even increase over time.

In cognitive behavioral therapy, discussion is led by the clinician, whereas in psychodynamic therapy, patients are encouraged to discuss thoughts and emotions freely in hopes of discovering insight into their actions. Hahn worries the integrated care setting may offer less time for patients to participate in intensive therapy, psychodynamic or otherwise, which may decrease their chances of effecting long-lasting changes in their lives. 

Hahn noted the influence of mental health parity an act passed in the 1990s, which requires some insurance to devote as much coverage to mental health as physical health. The measure has increased costs to insurance companies, which are now required to cover a full year, up to 52 sessions, of therapy for some patients, instead of the previous limit of 30 or so annual sessions. As a result, Hahn said, over the past year, she and many of her colleagues have fielded phone reviews from penny-pinching insurers claiming therapy sessions are not “medically necessary” for certain patients, and should be stopped. The Harvard report, too, questions whether long-term psychodynamic therapy can be a practical, cost-effective option considering today’s thorny reimbursement framework. 

“In our society, where everything is so fast, people really need to be able to sit down and take the time they need,” Hahn said. “When they’re hurried through three or four sessions, maybe they’ll feel better in the short term, but it may not give them a way of really changing their lives from the inside.” 

Creating change, of course, requires different strategies for different patients. Therapy in not an exact science, and there are no guarantees. Dietrich said, “People with depression tend to relapse. It's a very difficult thing. Some see a psychiatrist and get better, and some don't.” 

Sarah Amandolare is a freelance writer. She often covers travel for publications including New York magazine, Budget Travel and Fodor's guidebooks. Read more of Sarah's writing here: http://sarahamandolare.tumblr.com/.
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