CHAPTER 23: Delivering Depression Care: Services and Settings

INTRODUCTION

Screening, comprehensive assessment, and effective treatments are necessary but not sufficient to adequately treat individuals with depression. They must be paired with effective and efficient systems for delivering the care. Implementation strategies designed to identify, evaluate, and treat patients wherever they present while seamlessly coordinating their care with other members of the health care team is the challenge. Teams of experts who can communicate with each other and coordinate their therapeutic efforts are essential. Furthermore, a population-based orientation is necessary in order to design systems that are scalable and affordable. Incorporating disease registries allows for efficient monitoring and maximizing patient adherence and optimizing treatment outcomes.¹ This requires the use of computerized technologies to enable tracking and monitoring of symptoms, functioning, and satisfaction over time. Computerized treatment also provides greater access by removing the physical barrier to care and thereby enhancing patient engagement in their care.

In this chapter we discuss the provision of care to medically ill patients with depression, models of depression care delivery in medical outpatient settings, and the components of successful, efficient, and cost-effective delivery models. We also address the role of computerization in delivering care to large populations.

THE MEDICAL OUTPATIENT SETTING

In the late 1970s, the first multi-site mental health epidemiological study in the United States identified the primary care system as the “de facto mental health system” for Americans with more prevalent but less severe mental health disorders, including depression.² That trend has continued to the present day.³

Research has underscored the benefit of identifying and treating depression within the primary care setting and a number of promising care models have been developed. Despite this, mental health care in many primary care settings remains suboptimal. The recent Institute of Medicine report, “Improving Quality of Health Care for Mental and Substance Use Conditions”⁴ documented substantial inadequacies in the provision of mental health care, including poor detection, treatment and follow-up care. These findings have documented the need for a wider dissemination of guideline-driven treatment strategies.

According to a recent review, of the 6% to10% of primary care patients who meet diagnostic criteria for MDD, only 50% are accurately diagnosed by primary care providers (PCPs).⁵ Primary care patients who are given antidepressants often receive little education about depression and have infrequent follow-up visits, leading to poor treatment adherence. Poor adherence is common across all classes of prescribed antidepressants: only 25% to 50% of primary care patients continue with antidepressant treatment for the guideline-recommended duration, and 15% never start the medication.⁵

A number of barriers to adherence have been identified, including inadequate monitoring, insufficient patient education about depression and its treatment, and inadequate clinician knowledge and skills.⁶ Stigma, and legal and financial difficulties are also obstacles.

Integrated care models and treatment strategies, such as collaborative care, have been implemented ...