DEPRESSION IN PRIMARY CARE, PSYCHIATRY AND PUBLIC HEALTH: AN INTEGRATED APPROACH
Health systems worldwide remain quite fragmented, affecting access to preventive and curative health care services, quality and costs. Strengthening health systems is a global challenge for all countries regardless of their income. According to the World Health Organization essential components of well functioning health systems, namely leadership and governance, human resources, services, health information systems, finances, products and medical technologies, are essential for the functioning and strengthening of health systems (1). An integrated approach to depression in family medicine, public health and psychiatry can be catalytic regarding access to preventive and curative services, to the quality of these services, optimization of costs and not least to ensure real- time transfer of results of applied research in clinical practice and public health.
CHALLENGES AND OPPORTUNITIES
P R E V E N T I O N , D E T E C T I O N A N D E A R LYINTERVENTION
Systematic application in primary health care systems of screening methods for early detection of depression and appropriate intervention, especially in the stages with minor and minimum severity is sine qua non for providing timely and effective, secondary prevention. Most of the public health approaches, in family medicine and even in psychiatry, in many countries of the world addresses mainly the treatment of patients with moderate, severe and very severe depression. Usually at this late stage, secondary consequences of the disease and of comorbidity with other diseases already exist, particularly cardiovascular diseases, diabetes and cancer, making interventions more complex and with an increased level of refractoriness. Systems of prevention, early detection and intervention, need, therefore a higher attention and priority(1)
Surveillance – ongoing, systematic collection, analysis, and interpretation of depression-related data, essential to the planning, implementation, and evaluation of practices addressing depression, closely integrated with the timely dissemination of these data to those responsible for prevention and control- is essential for the success of interventions to address this public health challenge. They also have added value in the early and simultaneous treatment of comorbidities.
Few countries in the world have developed systems and
tools for depression surveillance. In the United States of America, within The Behavioral Risk Factor Surveillance System managed by the Center for Diseases Control and Prevention in Atlanta, the surveillance component for depression is optional, while others addressing risk factors such as alcohol and immunizations are essential/mandatory. At the EU (European Union) level
there is no depression related surveillance system, the database European Community Health Indicators include only indicators related to prevalence of chronic depression (based on declaration by patients) (1).
ACCESS TO APPROPRIATE TREATMENT AND FAMILY MEDICINE
Although many interventions for depression are effective, these often consist primarily of medications. Furthermore, of the approximately 350 million people estimated to be affected with depression worldwide, less than half (in some countries less than 10%) receive and have access to effective treatment, according to the World Health Organization, although it is available. Family medicine professionals have a primordial role for increasing access to treatment.
An international collaborative study was launched by World Psychiatric Association (WPA) non- communicable diseases and integrated care Task Force in
2012, involving India, Iran, Romania and Slovenia. The Romanian component was coordinated by the National Center for Mental Health and the Fight against Drugs in Romania, with the participation of family medicine and public health specialists, which used as a screening tool for depression questionnaire PHQ9. Preliminary results showed that of 662 patients who visited the family doctors offices, 41.7% had depressive symptoms (score PHQ9> 5) and only 9.53% of the 662 were referred to the psychiatrists. Not all patients referred to psychiatrist had PHQ9 score> 5, those with depressive symptoms who were not referred to psychiatrists remained under the care of the family doctor.
Limiting factors for the cases of depression, nevertheless, persist. They include, no routine use screening methods for depression, though readily available, concise, therefore time effective and inexpensive; exclusive attention paid to the patient’s physical signs and symptoms; a reluctance to “tag” a patient as having a mental health problems; the concern about the time needed for consultations for the doctor; the lack of potential involvement in the screening task of other members of the health team (2).
FINANCING AND COORDINATION
Relatively recent European studies (3) on depression and suicides and their economic impact, reveal the costs of depression estimated in 2004 at € 250 per capita or € 118 billion in EU 25 and EFTA 10. Direct costs, such as costs for health care have been responsible only for a minor part of all economic costs. A majority of the costs, about 65% result indirectly from reductions in productivity, such as sick leave, early retirement, and mortality due to suicide (3).
In most countries of the world, including Europe, funding mental health promotion, treatment and rehabilitation services are negligible compared with other health services. In Romania, for example, payment for psychotherapy services is not provided by the National Fund of Health Insurance. Patients who need such services must pay themselves for such services, although outcome scientific studies indicate that combined therapies-cognitive psychotherapy and medications- for the treatment of depression are most effective and cost- effective than either alone.
An additional consideration that may also contribute to the diminishing outcome, duplication of efforts and increasing healthcare costs is the minimal or lack of coordination and integration of activities of different health providers and healthcare systems involved in the prevention and treatment of depression, such as education, social assistance, employers and justice.
CONSEQUENCES: COMORBIDITIES, DISABILITY AND PREMATURE DEATHS
Lack of systematic screenings in primary health care systems, where most of the patients have access for early detection of depression; lack of populations’ surveillance systems to provide timely data for appropriate interventions, minimal integration of primary care, mental health/psychiatry and public health; and other factors such as stigma, shame and discrimination have the effect of increasing comorbidities of non- communicable diseases, resulting in increasing disabilities and premature deaths.
Partial results of the WPA study conducted in 2012 that included Romania showed that among the 662 patients who were seen by the family doctor, a predictor element became apparent among the tested patients. Patients with a score ≥ 10 on the PHQ9 instrument utilized in thisinternational study, were likely to also have cardiovascular comorbidities: Odds Ratio 1.78, 95% confidence interval (1.11-2.86); gastrointestinal comorbidities: Odds Ratio 2.97, 95% confidence interval (1.26-3.09); diabetes mellitus: Odds Ratio 2.06, 95% confidence interval (1.23-3.45); and central nervous system diseases: Odds Ratio 2.64, 95% confidence interval (1.37-5.11).
OPORTUNITIES I N N O VAT I O N : I N T E G R AT E D S C R E E N I N G , SERVICES, TRAINING, HEALTH POLICY
The WPA initiated project in 2012, for depression screening and research in primary care involved a unique collaborative model involving primary care physicians, public health and psychiatry specialists, simultaneously in Romania, Slovenia, India and Iran. It demonstrated the benefits of an integrated approach: more efficient use of resources, opportunities for synergy of interventions, a common framework for future research and innovation of services. This study’s results may be catalytic for follow up national and regional similar studies. They would create a solid base of scientific evidence; to guide new initiatives in integrated training and services; strengthening health systems locally, nationally and globally; and to better inform health policy decisions at national and global levels.
Prevention and early detection of depression, populations’ surveillance, access to appropriate treatment, non-discriminatory financing and the integration of services are challenges facing health systems worldwide. Health systems innovations are needed enabling them to respond effectively to the increasing global burden of disease posed by non-communicable diseases such as depression and the comorbid conditions of cardiovascular disorders, diabetes and cancer leading to premature deaths. The integration of primary care, psychiatry and public health with a focus on non-communicable diseases offers such a model of mutual benefit to populations’ health and to strengthening health systems and to significantly enhance access, quality and diminishing costs
1.Sorel E, Everett A. Psychiatry and primary care integration: Challenges and opportunities. International Review of Psychiatry
2.Actions against depression. Improving mental health and well-being by combating the adverse health, social and economic consequences of depression. European Communities, 2004.
3.Wahlbeck K, Mäkinen M. Prevention of depression and suicide. Consensus paper. Luxembourg: European Communities, 2008.
WPA -World Psichiatric Association
EU – European Union
EFTA-The European Free Trade Association