AcademyHealth annual research meeting 2009
Th Th
The
Three-headed
Threeh d dC
Culprit
l it ffor th
the
Marginalization
ag a a o o
of Depression
ep ess o Ca
Care
e
From the NIH DEED project
Presenter:
Seong--Yi Baik, PhD
Seong
University of Louisville
June 30
30, 2009
1
Authors
Junius J.
J Gonzales,
Gonzales MD,
MD MBA
Louis de la Parte Florida Mental Health Institute and School of
Mental Health Studies, University of South Florida, Tampa, FL
Barbara J. Bowers, PhD, RN
University of WisconsinWisconsin-Madison School of Nursing
Jean Spann Anthony, PhD, RN
Universityy of Cincinnati College
g of Nursing
g
Jeffrey L. Susman, MD
University of Cincinnati Family Medicine
2
Consultants
Benjamin F. Crabtree, PhD
University of Medicine & Dentistry of New Jersey Robert Wood
Johnson Medical School Department
p
of Family
y Medicine
Joseph J. Gallo,
Gallo, MD, MPH
University of Pennsylvania Family Practice and Community
Medicine
Phyllis C
C. Panzano
Panzano, PhD
Decision Support Services, Inc. Columbus, OH
3
The Challenge (I)
The ideal world is that all the doctors have all the
time in the world to focus on screening for
depression and after screening and diagnosing
then, evaluating and treating. And that’s the ideal
world…
The real world is that you’re trying to manage that in
addition to managing their high blood pressure,
high cholesterol
cholesterol, diabetes
diabetes, and sometimes six to
twelve other conditions in that one visit, and trying
to do a good job with that
that.
---Interview
--Interview 69 (Family Physician)
4
The Challenge (II)
Once you try to broach depression, then you really
see, like in their body language, “No, that’s not
what it is,
is I am not depressed.
depressed ” They may not
come out and say that but just you know the way
they’re
they
re sitting, the body language, that they’re
they re
not really in agreement –Interview 13 (FP).
5
Focus for Today
To understand realreal-world factors for the
marginalization of depression care
To uncover factors explaining
p
g the g
gap
p between idealized and realrealworld depression management
6
D
i iin P
i
C
Depression
Primary
Care
More than half of pts seek mental health care
Provider patient
Provider,
patient, system factors
Educational, quality improvement, and
interventions based on chronic care model
Focus on larger, more organized systems, less
on smallll practices
ti
Limited enduring effects in the “real world”
7
DEED Project
Describing the Enigma of Evaluating Depression
How can we create an enduring
g effect?
Grounded theory to build system bottombottom-up
–
–
–
–
Generate “Theory
Theory from data”
data
How medicine is (vs. should be) practiced
From the perspective of the system users
System for people not vice versa
8
C
t lF
k
Conceptual
Framework
Clinical decisiondecision-making is:
– A process
p
– At least two parties (often more)
– Context
Context--dependent
p
When makes sense
sense, then more likely to
adopt into everyday practice to be
“sustainable”
sustainable
9
Methods
Study Team and Design
Study team
– Inter
Inter--disciplinary
– Multi
Multi--ethnic
– PhD, MD, RN
– Interviews and filed notes byy three PhD cocoinvestigators
Mixed methods with q
qualitative focus
70 Cases
– Each case: interview
interview, two surveys
surveys, field notes
Three focus groups (n=24)
10
Methods
Interviews
In--depth, in
In
in--person interview
–
–
–
–
–
Semi
Semi--structured with unstructured probes and follow
follow--up
Audiotaped and transcribed
30 to 120 minutes (mostly 60
60--70 minutes)
“No right or wrong answers”
“Want to understand primary care practice from your
perspective
perspective”
– Evolved based on onon-going analysis of preceding data
– Scenarios for later interviews
11
Methods
Surveys Field Notes,
Surveys,
Notes
& Focus Groups
Two surveys
– Attitudes on psychosocial care (Ashworth, 1984)
– Current practices on treatment/referral
Investigator field notes
– Practice assessment, organization
Focus groups
– Confirming and disconfirming,
disconfirming member check
12
Methods
The final sample
28 FPs,
FPs 28 GIs
GIs, and 14 NPs
Diverse gender, ethnicity, years of practice
– 54% W,
W 32%AA,
32%AA 12% Asian
Asian, 2% Latino
– 23 men, 47 women
– 1-30 yyears of practice
p
52 PC offices in midmid-west, urban and sub
sub--rural
– Ranging
g g from p
private solo p
practice to fedfed-q
qualified
community health centers
– 18 out of 52 offices: primarily serve AA patients
13
Methods
Analysis
Qualitative: Grounded Theory (Strauss 1987)
– Open, Axial, & Selective coding
– Line by line to paragraph by paragraph
– Resolving disagreement in interpretation
– Theoretical memos
– “Grounded” in data
– NVivo 2
Quantitative:
– Descriptive statistics (SPSS)
– Rasch Analysis
14
Results
Theme
Depression Care: “Burdensome”
Burdensome
– Challenging and time
time--consuming condition
– Does not fit into today’s
today s acuteacute- and productivity
productivity-oriented primary care environment
– “Crowded
Crowded out”
out by less burdensome clinical
conditions
No differences found among the three clinician
groups
MultiM lti-level
Multi
le el factors : Clinical
Clinical, ssystem,
stem societal
15
Results
Why is Depression Burdensome (I)?
Lack of objective evidence
– Depression seen as “personal”
personal ---Stigma
---Stigma
– Rule out other conditions –indirect means to Dx
– No
N clear
l
measure off Tx
T improvement
i
t
– Poor adherence to treatment
– Lengthy
L
h “initial
“i i i l negotiation”
i i ” to diagnose
di
16
Results
Why is Depression Burdensome (II)?
Disjointed nature of MH care system
– Administrative and financial carvecarve-outs
– Lack of accessibility of referral and education
– Inadequate reimbursement for time
– Poor communication between PC and MH
– Poor access to counseling
– Poor access to specialists
17
Results
Why is Depression Burdensome (III)?
Societal stigma of depression
– Patient’s reluctance to accept the diagnosis
– Poor adherence to treatment
– Need to be “courteous”
– Takes relationship
p to convey
y the diagnosis
g
18
Conclusion
Marginalization of depression
Consequence of burden
Tendency to gravitate to more easily addressed
and better “fit”
fit conditions (e.g., DM, HT)
– Better reimbursement
– Better resources (e.g. Diabetes education centers)
– Clear guidelines (JNC VII)
– Clear measurement/less medical uncertaintyy
“Negotiation phase”:
– Unique
q in depression
p
care?
– Not a recognized care process in guidelines
19
Discussion
Negotiation Phase
S
Sometimes
ti
jjustt plant
l
that
h seed
d in
i their
h i head;
head
h d; you may
not fix them that time. If a [new] patient comes in and they
have a lot of health complaints
p
that yyou think could be
attributable to their depression and you can tell that they’re
not open to the diagnosis of depression, I try, giving them
a benefit of doubt,
doubt doing an eval,
eval evaluating them for an
underlying medical disease. And then seeing them back
so that they get comfortable with YOU, and getting,
sometimes
ti
I’ll say ““we’ll
’ll jjustt ki
kind
d off llook
k att th
these thi
things
and we’ll see what we find out here and, you know, see if
you might
y
g have a family
y history
y of depression.--depression.
p
--- Int5(GI)
( )
20
Treatment Phases
Remission Recovery
Seve
erity
“Normalcy”
Symptoms
Response
Progression to
disorder
Syndrome
y
Treatment Phases
O
X
O
X
O
X
p
Relapse
Recurrence
Acute Continuation Maintenance
(6-12 Weeks)(4-5 Months)
(1 Year)
Time
Kupfer DJ. J Clin Psychiatry. 1991;52(suppl 5):28-34; Depression Guideline Panel. Depression
in Primary Care. Vol 2. Treatment of Major Depression. Clinical Practice Guideline No. 5.
Rockville, Md: U.S. Department of Health and Human Services. Public Health Service, Agency
for Health Care Policy and Research; no. 93-0550; 1993
21
Depression Theory: Kupfer’s classical
model vs
vs. DEED
DE
EED
22
Discussion
The Elephant in the Room...
Ideal/Theory
Real-world/Practice
Chronic Care Model
Single
g visit or acute episode
p
One illness/pt/visit
Multiple illnesses/pt/visit
One pill/quick fix
Life management,
multidimensional, complex
Whole person:
mind/body interinter-related
Dichotomized: body or mind
The same as other illnesses
Stigma, burden, unrealistic time
constraints
No g
gap
p between “Providing
g care”
and “Receiving care”
Gap
p between p
providing
g and
receiving care
“Primary care” means
p
,p
personpersoncomprehensive,
centered, continuous,
longitudinal…
Fragmented, assembly line,
episodic,
p
,p
poorly
y coordinated…
23
Discussion
Clinician's
Clinician s Familiarity with the pt
Streamlined depression care process
Familiarity
– What and how
– Frame of reference “it is not you, it is depression”
– Helped to
Gauge how a patient might react to diagnosis
Recognize and comfortably convey the diagnosis,
Eliminate the need for “work“work-up”
Take advantage of the pt’s social support system for
enhancing treatment adherence/outcome
24
Limitations
Small sample size
Interviews, surveys, focus groups
– Reconstructed
R
t t d reality
lit versus actual
t l practice
ti
Self-reported surveys
SelfImpact of practice organization, patient
populations, training
Transferability among patient populations?
25
Implications and Future Research
In a realreal-world primary environment
– Multiple coco-morbidities
– Competing demands
– Constraints on time and resources
Address multiple levels of burden
– Provider/Patient
– System
S t
– Societal
26
Implications and Future Research
Shorten the Negotiation Phase
– Mechanisms by which to increase familiarity
between the provider and the patient
– My doctor knows me!
Address the gap between providing and
g care:
receiving
– Care to the patient vs. with or for the patient
– Supplier
Supplier--induced demand vs. consumerconsumer-initiated
27
Building Sustainable Change:
“Bottom
Bottom--up”
Shift iin thi
thinking:
ki
“G
“Grounded”
d d” iin realreall-world
ld
– “Perfect, ideal” to “sense
“sense--making” system
Cannot have it all –choose what “we” value
One size cannot fit all
– Structure,
Structure process
process, outcome
User’s perspective
Makes sense to the users
Value driven by the users
Making the “elephant” dance...
28
When all else fails
fails…
Questions?
29