1. Falling Through the Cracks Teaching Residents Continuity in the Treatment of Depression Elaine Willerton, Ph.D. Steven Zuckerman, Ph.D. Peggy Wiedmann, M.D.

2. Who We Are  Urban multi-cultural practice with 30,000 OPV/yr  Patients seen by 24 FM residents and 10 faculty.  2-3 fellows from Center for Family Health whose counseling practices usually filled w/in 1 month of working at our FPC Ravenswood Family Health Center

3.  16 % of all people develop depression at some time during their lives,  Large percentage of patients with depression, anxiety and other psychiatric conditions in our practices  Depression increasingly considered a chronic illness, similar to DM or HTN What We Know

4.  Few patients on antidepressant had ever seen a psychiatrist  Most - initial and ongoing medication from a primary care physician  Many were taking meds chronically, sometimes over decades  Some saw therapist presently or intermittently

5. Our Concerns  Some of us had a general sense that our patients were counting on us to identify and treat their depression and that we were not living up to their expectations.

6. What we suspected  We suspected we often failed to identify depression in our patients who came in with multiple medical problems and new complaints that needed to be addressed.  There was no time to ask about depression with so many competing demands, even though this would be the most important time to ask.

7. What we suspected  We thought that our follow- up on depression was most likely inadequate.  We only were able to follow up on patients who actually made and kept their follow- up appointments with us. So many did not.  Didn’t know how often patients were following through with referrals to therapists. (National rate <50%)

8. What we didn’t know  -How good a job we were doing at identifying and treating depression?  -How many of our patients had chronic or recurrent depression, how good was our ongoing care?  -How many of our patients with depression were taking their prescribed meds, going to referrals to therapists, or returning to our clinic for follow- up with us?

9. What we didn’t know  Were we missing some depression exacerbations because  Either patients came in with physical complaints when their depression was getting worse,  Or did they not come in at all when they felt worse?  Did a chronic disease management approach to depression make sense in our practice?

10. What we needed  We needed a care management team working to identify and manage depression among our patients.  Training in skills appropriate to a family physicians’ practice.

11. Depression Project  Now we will hear about our “depression project”  Steven Zuckerman- Director of our Depression Project and  Elaine Willerton – Project Coordinator.

12. Background  Funding - Illinois Department of Health  2 Objectives: Screening, diagnosis and treatment program for depressed patients Training residents to effectively screen, diagnose and treat depression

13. Key Personnel  Project Supervisor (faculty)  Project Coordinator (10 hours / week)  Project Assistant (4 – 7 hours / week)

14. Laying the Groundwork  Training  Screening protocols  Treatment plans  Putting things in place

15. Adult Screening  PHQ-9 & patient questionnaire  Depression symptoms  Somatic complaints (chronic pain, G.I. complaints, insomnia, fatigue)  Invitation to participate in “depression project”

16. Treatment Planning  Patient questionnaire History of bipolar, therapy, hospitalization, medication, suicidal ideation  Progress note “Why do you think you are depressed?” Substance use Therapy Diet exercise Medication

17. Patient Follow-up  Each patient periodically contacted via phone  Phone protocol & documentation

18. 2) Project Assistant follows up with patient by telephone and documents findings. 3) Project Coordinator and Supervisor review case notes and provide feedback to physician. 4) Physician is equipped with depression narrative to assist in follow up treatment. 1) Physician evaluates depression; If depression criteria is met, enrolls patient in project.

19. Follow-up Themes  Medication  Counseling / Therapy  Family Problems  Origin of depression  New information

20. Participants  N = 122; Females = 94; Males = 28 Not Included:  Not depressed (7)  Declined participation at first call (11)  Never reached (28)  No consent to call (67)

21. Project Initiatives  Psychiatric consultation & treatment  Behavioral Health Presentations  Practice wide depression screening  Mental health awareness month

22. Psychiatric Consultation  1 afternoon per week psychiatrist and resident see patients in family practice clinic

23. Behavioral Health Bilingual Presentations  “Beyond the Blues” support group  Managing Stress  Love Relationships  Shaping Positive Behavior in Children

24. Practice wide depression screening  PHQ-2 for every adult patient (not pregnant or postpartum)  If either question “YES” then administer PHQ-9  Examination of medical records

25. Practice wide screening  15% successfully screened (259)  55% screened negative (142)  45% answered one or both questions YES (117) 22% indicated 1 symptom (59) 23% indicated both symptoms (60)

26. 74 also got a PHQ-9

27. Results  49% had an existing diagnosis of depression or related affective disorder noted in their chart  51% did not have any mention of previous diagnosis  The PHQ-2 score was significantly correlated with having an existing diagnosis.  Having an existing diagnosis was significantly correlated with having an existing treatment plan.

28. ON THE PLEASURES AND PERILS OF REIFICATION

29. THE REIFICATION OF DEPRESSION “I HAVE MY GOOD DAYS AND MY BAD DAYS. I DON’T GO OUT BY MYSELF. I DON’T LIKE PEOPLE. THIS JUST ISN’T LIKE ME.”

30. REIFYING DEPRESSION “I NOW FEEL THAT I KNOW HOW TO TAKE A FIRST STEP WHEN I DISCOVER THAT A PATIENT MAY BE DEPRESSED. THIS MAKES ME FEEL LESS AFRAID TO SCREEN.” --a resident

31. DEPRESSION UNREIFIED “I DON’T FEEL LIKE I’VE ACCEPTED THAT I’M DEPRESSED. I’VE FELT LIKE THIS FOR THE LAST FIVE YEARS. IT’S BEEN ON AND OFF. I’M SO USED TO IT THAT IT’S NOT REALLY APPARENT TO ME ANY MORE. IT IS WHAT IT IS.”

32. REIFYING DEPRESSION “I’VE STRUGGLED WITH DEPRESSION FOR A LONG TIME, STARTING WHEN I WAS AROUND 12 OR 13….I’M A PERSON THAT THINKS THAT I CAN DO EVERYTHING BY MYSELF. POST-PARTUM DEPRESSION WAS THE WORST DEPRESSION I’VE EVER EXPERIENCED….ONCE I GOT HELP I REALIZED THAT IT WAS OKAY TO TALK ABOUT IT. IT WASN’T AS ABNORMAL AS I THOUGHT IT WAS. MY PERCEPTION OF DEPRESSION HAS CHANGED A LOT.”

33. ON CONTINUITY “I THINK IT’S A GOOD IDEA TO HAVE SOMEONE CHECKING ON YOU TO MAKE SURE THAT YOU DON’T FALL THROUGH THE CRACKS.”

34. PATIENTS PERCEPTIONS OF FAMILY DOCTORS WHO ASK ABOUT DEPRESSION “AS FAR AS THAT GOES, SHE’S EXCELLENT. SHE HELPED ME TO SEE WHAT I WAS GOING THROUGH. I WAS SKEPTICAL ABOUT TAKING PILLS, BUT ITS HELPED. SHE SAT ME DOWN FOR GOOD 30 TO 40 MINUTES AND TALKED TO ME ABOUT IT.”

35. PATIENT PERCEPTIONS OF FPs “IT’S BEEN VERY EASY FOR ME TO TALK WITH HER WHICH HASN’T BEEN THE CASE WITH OTHER DOCTORS I’VE SEEN IN THE PAST. ALSO SHE WAS VERY UNDERSTANDING ABOUT MY HESITANCE TO START MEDICATION.”

36. PATIENT PERCEPTIONS OF FPs “SHE’S BEEN LIKE MY BACKBONE, BECAUSE I’VE BEEN SEEING HER FOR YEARS. SHE KEEPS AN EYE ON ME. I’M VERY COMFORTABLE WITH HER AND SHE’S EASY TO TALK TO.” “THAT’S MY GIRL. SHE’S COOL BEANS!”

37. RESIDENTS ON CONTINUITY “THE PROJECT TOOK A LOT OF THE PRESSURE OFF MY FOLLOW-UP CONCERNS. I APPRECIATED HAVING THE PHONE CONTACT IN BETWEEN VISITS, BECAUSE IT MADE ME FEEL BETTER IF A PATIENT MISSED VISITS OR NEVER CAME BACK.”

38. PATIENTS PERCEPTIONS OF PROJECT PHONE CALLS “I LIKE TALKING TO YOU AND I’VE LOOKED FORWARD TO YOUR CALLS. I LIKE KNOWING THAT SOMEONE OUTSIDE OF MY FAMILY CARES.” “I’M GLAD THAT YOU’VE BEEN CALLING AND CHECKING IN ON ME. I’TS GOOD TO LET YOUR FEELINGS GO TO SOMEONE THAT YOU DON’T KNOW, BECAUSE THEY CAN’T JUDGE YOU.”

39. PATIENT PERCEPTIONS OF PROJECT PHONE CALLS “IT’S WEIRD, BUT IT’S ALSO NICE TO HAVE SOMEONE RANDOMLY CALL ME BECAUSE I DON’T USUALLY GET TO EXPRESS MYSELF ABOUT THIS STUFF. BUT SOMETIMES IT ALSO FEELS SORT OF IMPERSONAL.”

40. SUCCESSES AND FAILURES OF REIFICATION “I DON’T KNOW IF YOU’VE EVER BEEN DEPRESSED, BUT EVERYTHING IS HUGE AND HEAVY AND OVERWHELMING.”

41. SUCCESSFUL REIFICATION “IT’S BEEN MUCH BETTER. I’VE LOST A LITTLE WEIGHT, BUT I’M STILL TRYING TO LOSE MORE. I REALLY DON’T FEEL DEPRESSED ANY MORE.”

42. SUCCESSFUL REIFICATION “I WAS ALWAYS ANGRY. EVERYTHING BOTHERED ME.” IN REACTION TO THE PROJECT, SHE GOT MORE PROACTIVE IN DEALING WITH HER DIABETES AND HER FEELINGS OF DEPRESSION ENDED.

43. SUCCESSFUL REIFICATION “I DON’T KNOW IF IT WAS JUST ME HAVING THE CONFIDENCE THAT I WAS DOING WELL, BUT I JUST GRADUALLY WEANED MYSELF OFF. EVERYTHING SEEMS TO HAVE LEVELED OFF.”

44. SUCCESSFUL REIFICATION “I CAN SAY THAT I’VE FELT DEPRESSED FOR THE LAST 15-16 YEARS. I USED TO BRUSH IT OFF AND DENY IT. IT WASN’T AS BAD THEN. IT GOT WORSE WITHIN THE LAST YEAR, BECAUSE OF MY JOB AND SOME RELATIONSHIP ISSUES. THE WORST THING ABOUT IT HAS BEEN NOT HAVING ANYONE TO TALK TO. BUT NOW I’VE REALIZED THAT IT’S OKAY TO OPEN UP.”

45. FAILED REIFICATION “WHEN I WAS TAKING THE MEDICATION, I WOULD GO OUT MORE. I WOULD GO OUT WALKING OR TO THE MUSEUMS. EVEN THOUGH I USUALLY HAD TO GO WITH MY DAUGHTER AND HUSBAND, IT HELPED. NOW THAT I’M NOT ON MEDICATION, I DON’T WANT TO DO ANYTHING.”

46. FAILED REIFICATION: TRAUMA AND HISTORICAL CONSTRAINTS “EVERYDAY IT SEEMS LIKE THERE’S SOMETHING NEW. SO THINGS REALLY AREN’T BETTER. EVERY DAY IS A BATTLE WITH CONSTANT UPS AND DOWNS.”

47. FAILED REIFICATION: TRAUMA AND HISTORICAL CONSTRAINTS “I’M NOT SURE HOW TO ANSWER YOUR QUESTIONS, BECAUSE I DON’T KNOW HOW TO EXPLAIN IT. I THINK THAT WHEN I REMEMBER THINGS FROM MY PAST I JUST START CRYING. THERE ARE SOME THINGS THAT I JUST DON’T WANT TO THINK ABOUT. AFTER I GAVE BIRTH, I STARTED THINKING A LOT ABOUT MY CHILDHOOD AND FELT DEPRESSED.”

48. FAILED REIFICATION: TRAUMA AND HISTORICAL CONSTRAINTS “IT’S BEEN GOING ON FOREVER. I WAS RAISED WITHOUT A FATHER. I WAS ALWAYS WALLOWING IN CRAP. I THINK IT WENT FROM CHILDHOOD ANGST TO AN OCCASIONAL ACUTE DEPRESSION….I’M JUST TIRED OF IT. I’M TIRED OF BRINGING IT TO THE FAMILY AND INFLICTING IT ON THE PEOPLE THAT I LOVE.”

49. EVEN IF NO IMPROVEMENT, CARING STILL APPRECIATED “IT’S BEEN NICE. IT FEELS GOOD THAT SOMEONE CARES.” “IT HAVE BEEN NICE HAVING YOU CALL ME, BECAUSE I DON’T KNOW YOU AND I CAN SAY WHATEVER I WANT. I CAN VENT AND TALK.” “WHEN SOMEONE IS DEPRESSED, IT’S VERY DIFFICULT TO REACH OUT IN ANY WAY…SO THE NOTION THAT SOMEONE WILL CALL YOU EVERY ONCE IN A WHILE HAS BEEN GOOD.”

50. FAILURE OF RESOURCES “I FEEL LIKE MY DEPRESSION IS GETTING WORSE, BECAUSE NOTHING IS HAPPENING. I CAN’T MAKE AN APPOINTMENT WITH A COUNSELOR.”

51. THE IMPACT OF LIMITED RESOURCES ON RESIDENTS “SOMETIMES IT WAS A BURDEN TO SCREEN EVERY PATIENT FOR DEPRESSION. I REALIZE WE DISCOVERED DEPRESSED PATIENTS THIS WAY, BUT IT DEFINITELY TOOK MORE TIME AHEAD OF THE ACTUAL PHYSICIAN VISIT. MANY OF THESE PATIENTS NEEDED THERAPY, BUT NOT PHARMACOLOGIC THERAPY. THIS BECAME A BURDEN FOR DOCS TO FIND THERAPY THAT THEIR INSURANCE WOULD COVER, ESPECIALLY SINCE MANY OF THE PATIENTS WOULDN’T FOLLOW UP AND FIND IT ON THEIR OWN.”

52. QUESTIONS?