Psychiatry, Primary Care Unite To Improve Depression Care

Psychiatry and primary care practices are the real-world laboratories in an unprecedented collaboration that is seeking to revolutionize depression screening and treatment.

As part of the National Depression Management Leadership Initiative, a group of 38 physicians—20 psychiatrists and 18 primary care physicians—has begun administering a depression screening and monitoring tool known as the Patient Health Questionnaire-9 (PHQ-9) to patients.

The initiative is designed so that the physicians can make small changes in their practices over time that facilitate the administration of the PHQ-9 as part of routine clinical care.

Among the participants are psychiatrists, internists, and family practice physicians recruited through the practice research networks of the American Psychiatric Institute for Research and Education (APIRE), American College of Physicians, and American Academy of Family Physicians.

Physicians and study leaders met for the first time at a learning session held in Chicago in early April, which served as an orientation to the initiative and included suggestions about how to integrate the PHQ-9 into participants' practices with increasing numbers of patients.

Participants will come together for two more learning sessions with the initiative's leaders over the next year to discuss their experiences and share ideas about how to expand use of the instrument so that it becomes a routine part of all medical care.

Different Goals for Psychiatry, Primary Care

The initiative is divided into two tracks—one for psychiatrists and one for primary care physicians.

Though an overarching goal of the initiative is to improve depression screening, monitoring, and treatment for all patients, psychiatrists will focus on helping researchers to understand how the PHQ-9 facilitates depression treatment, according to David Katzelnick, M.D., primary care physicians will help study leaders understand the barriers to widespread dissemination of the PHQ-9.

Katzelnick is a clinical professor of psychiatry at the University of Wisconsin Medical School in Madison and distinguished scientist at the Madison Institute of Medicine. He heads the initiative with Paul Nutting, M.D., M.S.P.H., director of research at the Center for Research Strategies LLC and a clinical professor of family medicine at the University of Colorado Health Sciences Center.

The PHQ-9 is an inventory of depression symptoms based on each of the nine DSM-IV criteria for depression (Original article: see box). Each of the nine items is scored along a continuum from 0 to 3, so the highest possible score on the instrument is 27, which indicates severe depression.

In addition to tracking patients' PHQ-9 scores longitudinally, physicians will note how the instrument's scores affected their treatment decisions for each patient. Study leaders will then analyze the data provided by the physicians to determine whether and to what extent the PHQ-9 was helpful in monitoring and treating depression.

“Our goal is to increase the availability of effective treatment for depression and to improve clinical-management practices for the treatment of depression,” said Katzelnick at the Chicago learning session. “We are on the edge of discovering the impact of systematically monitoring depression.”

According to Darrel Regier, M.D., M.P.H., APIRE's executive director, the PHQ-9 has been well tested in primary care settings. “Each of the studies found that you can substantially improve depression outcomes using the PHQ-9,” he told physicians at the learning session.

Regier developed the depression-management initiative with Katzelnick and the co-principal investigators for the psychiatry track, Henry Chung, M.D., and Madhukar Trivedi, M.D.

Making Change Permanent

Regier said he hoped to discover “how we take a technology that people aren't necessarily trained in and introduce it in a manner that will change the way physicians practice.”

Regardless of medical specialty, Regier explained, when physicians incorporate some element of change as part of a clinical trial, “as soon as the study stops, people revert to the same patterns of practice. The challenge is for all of us to get over that hump.”

Regier and Katzelnick noted that diabetes care improved dramatically with the introduction of the hemoglobin A1C test, which provides physicians with a standard measurement with which to measure blood glucose levels over time.

“We thought, `Why can't we have a metric like that for depression?,'” Katzelnick said.

Ideally, a PHQ-9 score will facilitate dialogue between primary care doctors and psychiatrists and become as easily understandable by both physicians and patients as a blood-pressure reading.

When primary care physicians refer patients with severe or treatment-resistant depression to psychiatrists, there is plenty of room for miscommunication, Regier noted. The lack of any standardized depression measurement in clinical practice “diminishes the ability of primary care physicians to communicate effectively with psychiatrists” on the severity of a patient's depression or whether the patient is responding to treatment.

“At this point, it's all guesswork,” Regier said. “We hear, `The patient looks more depressed,' but we have no way of knowing how much more depressed.”

Initiative leaders touted additional benefits of the PHQ-9. For instance, Regier pointed out that it is an important tool for monitoring suicidality in patients with depression.

The initiative also seeks to educate patients about the symptoms and overall management of depression, said Trivedi. In addition to being co-principal investigator of the psychiatry track, Trivedi is co-principal investigator of the Sequenced Treatment Alternatives to Relieve Depression trial, which is based at the University of Texas Southwestern Medical Center in Dallas, and director of the depression algorithm for the Texas Medication Algorithm Project.

“If patients begin to monitor their symptoms with physicians on an ongoing basis, they become partners in the treatment rather than just bystanders,” he noted, and tend to be more proactive about notifying their physicians when depressive symptoms return or worsen.

Measuring depression severity with the PHQ-9 could also help physicians treat patients more effectively.

“Many times I've placed a patient on an antidepressant, and the patient comes back in a few weeks and tells me, `I think I'm feeling a little better,' and we go on to something else,” said Nutting. “But if we had an objective way to measure depression severity, we might discover that [a patient's] PHQ-9 score only dropped from 20 to 18. We can do better than that.”

Chung agreed that the PHQ-9 will help physicians “target treatments” to achieve more desirable outcomes.

“For 20 years, we have had a depression guideline that tells us to consider augmenting or changing treatment if symptoms are not reduced by 50 percent.”

Chung asked, “How do you measure a 50 percent reduction? Do we ask our patients, `Are you one-half better?'” The PHQ-9 will allow for“ tailored treatment planning and better management to remission,” he said.

Chung said he also sees the PHQ-9 as a “critical” way to achieve mental health coverage parity for all Americans.

“I think it is hard to advocate for parity when we don't have outcomes demonstrating what we know we can achieve in the real world,” he emphasized.

Funding for the project is being provided by the American Psychiatric Foundation through unrestricted educational grants from AstraZeneca International, Eli Lilly and Co., Lilly Foundation, Forest Laboratories Inc., Pfizer Inc., Sanofi Aventis, and Wyeth.

More information about the initiative is available by contacting Farifteh Duffy, Ph.D., by e-mail at [email protected] or phone at (800) 713-7123. ▪