It’s Complicated: Recognizing Depression in Patients With Uncontrolled Chronic Diseases - Annals of Internal Medicine: Fresh Look Blog

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Wednesday, January 3, 2018

It’s Complicated: Recognizing Depression in Patients With Uncontrolled Chronic Diseases

I didn’t recognize him at first—I mean, we had never met. But I had seen his preappointment labs (A1C of almost 16%, GFR decreasing to stage 3b CKD), and I was worried about this guy. When he had missed his appointment, I really started to worry, wondering what else might plague this “38-year-old man with type 2 diabetes with diabetic nephropathy.” The day after his appointment, as clinic was about to close, there he was: a young guy, well-dressed, quietly getting the 5th degree from a staff member, who was explaining why he could not be seen this late in the day. I couldn’t see his diabetes, his nephropathy, or his peripheral neuropathy, which I later found extended almost to his knees. With tears in his eyes, he said he was sorry but he had mixed up his days and missed his visit.

He was beginning to look more familiar. I had recently read the Annals In the Clinic article on depression, which had highlighted not only the prevalence of depression (up to 40% in some patient populations) but also noted that “the presence of depression significantly affects the prevalence, cost, and outcomes of many common comorbidities, particularly diabetes” (1). It reviews the 2016 USPSTF guideline (2), which suggests that “clinicians should consider screening patients with identified risk factors or who present with unexplained somatic symptoms, chronic pain, anxiety, substance misuse, or nonresponse to effective treatments for medical conditions” (emphasis added).

The comorbidity of mood disorders, particularly depression, and uncontrolled medical conditions is common enough to make it into a guideline. ACP even has policy recommending integration of mental and behavioral health resources into primary care settings and expanding reimbursement for these illnesses (3). Even Congress supported this movement, with both chambers passing bipartisan mental health bills this year.

How, then, do depressed patients still go unnoticed? The most common reason I hear from colleagues is that they do not have the resources to support the patient after the diagnosis. The USPSTF guideline acknowledges this by recommending depression screening “be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up” (2). I am lucky now to work in a place that does have those systems, but I trained in areas that did not—frequently diagnosing depression in patients whom I knew could not afford even a $4 antidepressant, whose community lacked affordable psychologists or psychiatrists for cognitive behavioral therapy, and whose lives prevented them from seeking regular treatment from any source.

This is not uncommon. It is estimated that the current mental health workforce meets less than half of the nation’s need for care in Health Provider Shortage Areas (4). Without dedicated mental health professionals, communities are leaning more heavily on primary care doctors, but this takes time, and time is money. To bill the most for time, we think in ICD-10 codes, categorizing patients into their highest complexity disease. And yet, in an era of ICD-10 codes related to ironing (yes, the laundry chore), there is still no way to attribute uncontrolled medical illnesses to untreated mental health disorders in my billing or coding. They are considered separate problems, separate diseases processes, separate billing codes, and still in many places, separate doctors’ offices.

When I finally recognized this patient, I knew he was lucky. In my current clinic, the psychologists are a phone call away for same-day access to care. They have encouraged primary care physicians to diagnose and initiate pharmacologic therapy for uncomplicated mood disorders. I teach my own residents how to screen and diagnose depression and anxiety, and how to choose and start a selective serotonin reuptake inhibitor (the same Annals article has a great table, comparing side effect profiles and evidence for various medications). The burden is on us as primary care physicians to open our eyes, open our schedules, and open our mouths to advocate for patients like mine, who—regardless of whether I can bill him as such—was recognized and treated as a 38-year-old man with major depressive disorder, severe without psychosis complicating type 2 diabetes with diabetic nephropathy.

References
  1. McCarron RM, Vanderlip ER, Rado J. In the clinic. Depression. Ann Intern Med. 2016;165:ITC49-ITC64. [PMID: 27699401] doi:10.7326/AITC201610040
  2. Siu AL; U.S. Preventive Services Task Force. Screening for depression in children and adolescents: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2016;164:360-6. [PMID: 26858097] doi:10.7326/M15-2957
  3. Crowley RA, Kirschner N; Health and Public Policy Committee of the American College of Physicians. The integration of care for mental health, substance abuse, and other behavioral health conditions into primary care: executive summary of an American College of Physicians position paper. Ann Intern Med. 2015;163:298-9. [PMID: 26121401] doi:10.7326/M15-0510
  4. Kaiser Family Foundation. Mental Health Care Health Professional Shortage Areas. Accessed at http://kff.org/other/state-indicator/mental-health-care-health-professional-shortage-areas-hpsas/ on 2 August 2017.

4 comments:

  1. As I understand the Michael E. DeBakey VA Medical Center which serves as the primary health care provider for almost 130000 veterans cannot offer them the first line treatemnt CBT! In this case, what about therapeutic eduction for diabetes too? Too costly???
    Poor deprivated US doctors who must pill to bill for surviving.
    Last, the use of SSRIs or SNRIs-the most commonly used antidepressant subclass increased risk of type 2 diabetes that intensified with increasing duration of use, cumulative dose, and average daily dose.doi: 10.1001/jamapediatrics.2017.2896

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    1. Thanks for reading! I'm sorry if you've had a bad experience at any health care facilities. One of the reasons I like working in my current location is because our same-day and continuity teams all perform CBT and other mental health therapies you describe. We're able to initiate these therapies the same day we primary care providers diagnose them in clinic, and that allows us to avoid medications, as we were able to do for quite a while in this patient, while he was stabilized. Thank you for your interest in our blog and in our veterans' health!

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  2. Nicely written Dr. Candler. I think that addressing the access issues to appropriate care for mental health issues is incredibly important. If we don't care for our patients in a patient centered comprehensive manner, their health will not improve. How to meet these needs is the big question? Do you have any big hairy audacious ideas as to how to move the needle here?

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    1. Great question, Dr. Hingle! I don't know if there's a one-size-fits-all answer out there, but I do like the patient-centered medical home model that the VA and other systems have adopted. It allows patients to be cared for by a team that all feels equal responsibility and ownership of that care practice. That means we have open lines of communication with our team members and patients, and we can be creative with our care plans so each patient gets the right amount of each resource. That, of course, requires resources--people, time, and money. I'm lucky to work in a place that values its patients --and provider teams!--enough to have invested in many of those things. However, there are other systems that simply cannot afford them right now because of things like billing models, physician shortages, patients' lack of access to affordable health coverage. Not sure there's an easy fix to those, either, but I'm excited for some of the recent APMs being developed because of MACRA...time will tell if there's ever a "right" answer. Likely not since each patient and each practice is so different. I think this concept of encouraging multiple styles is prudent. We'll see what rolls out of it. Thanks for reading!

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