You are on page 1of 20

Disease Management

Depression
for
DISCLAIMER: The information contained in this annotated bibliography was obtained from the publications listed. The National
Pharmaceutical Council (NPC) has worked to ensure that the annotations accurately reflect the information contained in the
publications, but cannot guarantee the accuracy of the annotations or the publications. There are articles available on the
treatment of depression that are not included in this bibliography, which may include relevant information not covered herein. The
inclusion of any publication in this bibliography does not constitute an endorsement of that publication by NPC or an endorsement
of the services, programs, treatments, or other information contained in such publication.

This bibliography is designed for informational purposes only, and should not be construed as professional advice on any specific
set of facts and circumstances. This bibliography is not intended to be a comprehensive source of disease management services
or programs in the treatment of depression, or a substitute for informed medical advice. If medical advice or other expert
assistance is required, readers are urged to consult a qualified health care provider or other professional. NPC is not responsible
for any claims or losses that may arise from any errors or omissions in the information contained in this bibliography or in the listed
publications, whether caused by NPC or originating in any of the listed publications, or any reliance thereon, whether in a clinical
or other setting.

© June 2003 National Pharmaceutical Council, Inc.


Disease Management for Depression

Introduction Disease management programs are used widely for


many chronic diseases; but the most common
The Centers for Medicare and Medicaid Services diseases include asthma, congestive heart failure,
and the Disease Management Association of America diabetes mellitus, and hypertension. Considerations in
define disease management as a system of selecting a disease for disease management often
coordinated health care interventions and include:2,3
communications for populations with conditions in • Availability of treatment guidelines with consensus
which patient self-care efforts are substantial.1 Disease about what constitutes appropriate and effective
management supports the clinician-patient relationship
care.
and plan of care, and emphasizes prevention of
• Presence of generally recognized problems in
disease-related exacerbations and complications using
therapy that are well documented in the medical
evidence-based guidelines and patient empowerment
literature.
tools.2 Disease management also evaluates clinical,
• Large practice variation and a range of drug
humanistic, and economic outcomes on an ongoing
treatment modalities.
basis with the goal of improving overall health.2,3 The
• Large number of patients with the disease whose
specific goals of disease management include:3
therapy could be improved.
• Improving patient self-care through patient
• Preventable acute events that often are
education, monitoring, and communication.
associated with the chronic disease (e.g.,
• Improving physician performance through
emergency department or urgent care visits).
feedback and/or reports on patient progress in
• Outcomes that can be defined and measured in
compliance with protocols.
standardized and objective ways, and that can be
• Improving communication and coordination of
modified by application of appropriate therapy
services among patients, physicians, disease
(e.g., decreased number of emergency
management organizations, and other providers.
department visits or hospitalizations).
• Improving access to services, including prevention
• The potential for cost savings within a short period
services and prescription drugs as needed.
(e.g., less than 3 years).
The following functions are the main components of
disease management:2,3 Three major not-for-profit organizations whose
• Identification of patient populations. mission is to promote quality health care have
• Use of evidence-based practice guidelines. recognized the contribution of disease management
• Support of adherence to evidence-based medical activities to quality health care by establishing disease
practice guidelines by providing practice management certification or accreditation programs.
guidelines to physicians and other providers, The Joint Commission on Accreditation of Healthcare
reporting on the patient’s progress in compliance Organizations, an independent, not-for-profit
with protocols, and providing support services to organization and the nation’s predominant standard-
assist the physician in monitoring the patient. setting and accrediting body in health care, offers
• Provision of services designed to enhance patient disease-specific care program certification. Program
Disease Management for Depression

self-management and adherence to the patient’s certification is based on an assessment of compliance


treatment plan. with consensus-based national standards, effective use
• Routine reporting and feedback to the health care of established clinical practice guidelines to manage
providers and to the patient. and optimize care, and activities for performance
• Communication and collaboration among providers measurement and improvement.4 The National
and between the patient and the patient’s providers. Committee for Quality Assurance (NCQA) recently
• Collection and analysis of process and outcomes began accrediting disease management programs on
measures, along with a system to make the basis of standards that are patient oriented,
necessary changes based on the findings of those practitioner oriented, or both. It also offers
measures. organizations certification for program design (e.g.,

[1]
content development), systems (e.g., clinical mental illness. It is characterized by depressed mood or
information and other support systems), or patient loss of interest in or pleasure from activities that
contact (i.e., for nurse call centers and other ordinarily are enjoyed (see Appendix A for diagnostic
organizations without comprehensive activities).5 Many criteria for major depression).9 It may be accompanied
disease management organizations were so eager to by severe weight loss or gain, sleep disturbances,
undergo the accreditation or certification process that fatigue, diminished ability to concentrate, and suicidal
they volunteered to do so before the standards were thoughts. The symptoms of depression can have a
finalized.6 profound impact on an individual’s interpersonal, social,
The Utilization Review Accreditation Commission and occupational function, resulting in family discord
(URAC), also known as the American Accreditation and unemployment.
HealthCare Commission, establishes standards for the Depression is very common; 5.8% of American
health care and insurance industry. URAC’s goal is to adults will experience depression sometime in their
promote continuous improvement in the quality and lifetime.8 In any given year, approximately 9.9 million
efficiency of health care delivery by achieving excellence American adults are affected.10 The illness is nearly
among purchasers, providers, and patients through the twice as common in women as in men, and hormonal
establishment of standards, education and factors may contribute to gender differences in
communication programs, and a process of prevalence.10,11 Women who give birth are particularly
accreditation. URAC has accreditation programs for vulnerable to depression during the postpartum
disease management as well as case management, period.11 The risk of depression is up to three times
claims processing, core accreditation, credential more likely in first-degree biological relatives (e.g.,
verification, health call centers, health networks, health daughter, father) of a patient diagnosed with the illness
plans, health provider credentialing, health utilization than in the general population, which suggests a
management, health Web sites, Health Insurance genetic component to the illness.8 Certain medical
Portability and Accountability Act (HIPAA) privacy and conditions (e.g., stroke, Parkinson’s disease, diabetes)
security, independent review organizations, vendor can lead to depression; up to 25% of patients with
certification, and workers’ compensation utilization these medical conditions develop depression.9,11
management. URAC has goals for disease Depression often goes unrecognized and
management accreditation and case management.7 untreated.12 This illness is accurately diagnosed in only
30% to 40% of cases.13 Symptoms often are not
reported to a health care professional because of a lack
Why Focus on Depression? of patient awareness that the symptoms constitute an
To date, disease management programs are more illness or the stigma associated with mental illness.13,14
common for the treatment of asthma, congestive heart Patients and clinicians may fear insurance or
failure, diabetes mellitus, and hypertension because employment discrimination.15 Many people do not seek
many of the considerations outlined in the introduction treatment because they do not recognize that the
clearly apply to these chronic diseases. However, much illness is treatable.11 Some patients (and clinicians) view
attention has turned to depression in recent years depressive symptoms as a natural consequence of
Disease Management for Depression

because many of the same considerations apply to aging or a normal reaction to stressful life events. Often,
behavioral health. For example, authoritative guidelines feelings of shame, guilt, or hopelessness may present a
for managing depression have become available barrier to diagnosis.13
recently from the American Psychiatric Association and Failure of health care professionals to detect
other reputable sources (Table 1).8 Up-to-date depression may be due to inadequate training in
information on treatment guidelines from various recognizing the illness.13 About half of patients treated
sources also is available online from the National for depression receive treatment in the primary care
Guideline Clearinghouse (http://www.guideline.gov/ setting, where training and experience in the diagnosis
body_home_nf.asp?view=home). of depression may be limited.13 Physical complaints
Depression is now recognized as a serious chronic may distract primary care providers from making the

[2]
Table 1. Authoritative Guidelines for Managing Depressiona

1. American Psychiatric Association 7. Veterans Health Administration/Department of


Practice guideline for the treatment of patients with Defense
major depression (revision). Available in print (Am J Clinical practice guideline for the management of major
Psychiatry. 2000;157[4 suppl]:1–45) and online at: depressive disorder in adults. 2000. Available in print
http://www.psych.org/clin_res/Depression2e.book.cfm. from the Office of Quality and Performance (10Q),
Veterans Health Administration, Department of Veterans
2. American Society of Health-System Pharmacists Affairs, 810 Vermont Avenue, NW, Washington, DC
(ASHP) 20420, and online at:
ASHP therapeutic position statement on the recognition http://www.guideline.gov/VIEWS/summary.asp?guidelin
and treatment of depression in older adults. Available in e=001811&summary_type=brief_summary&view=brief_s
print (Am J Health-Syst Pharm. 1998;55:2514–2518) ummary&sSearch_string=depression.
and online at:
http://www.ashp.org/bestpractices/TPS/326-330%20- 8. The Expert Consensus Guideline Series
%20Depression.pdf. Treatment of depression in women. Available in print
(Postgrad Med. March 2001;(Spec No):1–107).
3. Texas Department of Mental Health and Mental
Retardation 9. Canadian Psychiatric Association and the
Texas Implementation of Medication Algorithms Canadian Network for Mood and Anxiety
(algorithms and physicians’ manual for major depressive Treatments
disorder). Available online at: Clinical guidelines for the treatment of depressive
http://www.mhmr.state.tx.us/archive/20030829mdtima. disorders. Available in print (Can J Psychiatry. June
html. 2001;46[suppl 1]), with portions available online at:
http://www.canmat.org/managing/index.html.
4. American College of Physicians-American Society
of Internal Medicine 10. North of England Antidepressant Guideline
Pharmacologic treatment of acute major depression Development Group
and dysthymia. Available in print (Ann Intern Med. North of England evidence-based guideline
2000;132:738–742) and online at: development project: summary version of guidelines for
http://www.annals.org/issues/v132n9/full/200005020- the choice of antidepressants for depression in primary
00010.html. care. Available in print (Fam Pract. 1999;16[2]:103–111)
and online at:
5. U.S. Preventive Services Task Force http://www.ncbi.nlm.nih.gov/entrez/utils/fref.fcgi?http://f
Screening for depression: recommendations and ampract.oupjournals.org/cgi/pmidlookup?view=full&pmi
rationale. Available in print (Ann Intern Med. d=10381013.
2002;136:760–764, or through the Agency for
Healthcare Research and Quality Publications 11. Australian National Depression Initiative
Clearinghouse by calling 1-800-358-9295) and online Treating depression: the beyond blue guidelines for
at: http://www.ahrq.gov/clinic/uspstfix.htm. treating depression in primary care. “Not so much what
you do but that you keep doing it.” Available in print
6. American Academy of Child and Adolescent (Med J Aust. 2002;176[suppl]:S77-S83) and online at:
Psychiatry http://www.mja.com.au/public/issues/
Summary of the practice parameters for the 176_10_200502/ell10082_fm.html.
assessment and treatment of children and adolescents
with depressive disorders. Available in print (J Am Acad
Disease Management for Depression

Child Adolesc Psychiatry. November 1998;37:1234-


1238) and online at:
http://www.guideline.gov/VIEWS/summary.asp?guidelin
e=000757&summary_type=brief_summary&view=brief_s
ummary&sSearch_string=depression.

a
Clinical practice is subject to constant change, and the guidelines in this list may become outdated or be superseded by newer ones. The
reader is encouraged to consult the National Guideline Clearinghouse (http://www.guideline.gov/asp/d2.asp?cp=t&ck=t&nx=&fr=f), a public
resource for evidence-based clinical practice guidelines sponsored by the Agency for Healthcare Research and Quality (formerly the Agency
for Health Care Policy and Research) in partnership with the American Medical Association and the American Association of Health Plans, for
the most current guidelines.

[3]
diagnosis.13,15 Health care professionals may lack the usually as a result of suicide; up to 15% of patients
confidence to ask the patient about symptoms specific hospitalized for depression commit suicide.25
to mood or may hesitate to broach the subject because In 1990, the estimated annual costs of depression in
of pressure to minimize time spent with the patient.13,15 the United States amounted to $43.7 billion, including
Clinicians’ beliefs and attitudes (e.g., understanding of $12.4 billion for direct costs, $7.5 billion for mortality
the effectiveness of antidepressant drug therapy, costs (costs due to suicide), and $23.8 billion for
misconceptions about the extent to which patients bear morbidity costs (costs arising from workplace
some responsibility for their illness) also may influence absenteeism and reduced workplace productivity).26
the likelihood of diagnosis.13 Detection may depend on Employers increasingly recognize the impact of
a clinician’s level of skill in interviewing and depression in the workplace.20,22,23 However, convincing
communicating with patients.13 employers of the cost-effectiveness of drug therapy for
Treatment of depression often is inadequate despite depression can be a challenge because of the high
the availability of effective therapies and a high rate of cost of this therapy.21,27 In the 2002 Novartis Pharmacy
health service utilization by patients with depression.16–18 Benefit Report, antidepressants represented the most
In a 4-year study of elderly enrollees in an HMO, only costly and widely prescribed drug class (among 32
12% to 25% of patients with clinically significant drug classes evaluated) with respect to HMO spending
depressive symptoms received treatment for depression, and use.28 Therapy for depression has the potential to
and fewer than half of patients receiving antidepressant reduce the indirect costs of illness.29 It could save
drug therapy received an adequate trial of an appropriate employers an estimated $93 per patient in reduced
dosage.19 In a survey of younger adults with depression, disability costs in the first 30 days after initiation of
fewer than 10% received appropriate medication therapy, and this figure does not reflect cost savings to
management and follow-up visits.17 the employer from reduced workplace absenteeism
and improved productivity.30 Antidepressant drug
The large gap between best care and usual care for
therapy improves workplace performance, with a
depression (i.e., inadequate detection and treatment of
response within 4 weeks after initiating therapy.31 The
depression) serves as an impetus to apply disease
natural history of depression and the methods used to
management strategies to the treatment of depression.
manage depression are outlined in Appendix B.
Education and training of health care providers to
improve detection and treatment could help fill this gap.
The availability of new and improved tools for use by
primary care physicians to diagnose and treat
Current Status of Disease
depression and self-administered screening tools for Management Programs for
patients have led to increased interest in depression Depression
disease management.20 The importance of a person’s mental health to
Depression increasingly is a focus of disease overall health and quality of life and the need for mental
management initiatives because of its large economic health services to restore and maintain mental health
impact. It is a chronic illness with recurrent acute are increasingly recognized by the government and the
episodes that are costly.21 Depression is the leading private sector. Policy makers also have gained a greater
Disease Management for Depression

cause of short- and long-term disability in the United understanding of the high prevalence and chronic
States—persons with untreated depression report a nature of depression and the role of antidepressant
larger number of days spent in bed and days of drug therapy in managing the illness on a long-term
disability or restricted activity than the general basis. Mental health utilization (the percentage of
population.10,22–25 Depression also is associated with members receiving services, inpatient discharges, and
higher than average rates of physical illness and health average length of stay), follow-up after hospitalization
care utilization.25 Health care costs are higher for for mental illness, and antidepressant medication
depressed patients than for patients without management are among the NCQA 2002 Health Plan
depression, even after adjusting for medical morbidity.18 Employer Data and Information Set (commonly referred
Mortality rates are increased in depressed patients, to as HEDIS) measures, which apply to Medicaid and

[4]
Medicare recipients as well as participants in Group Health Cooperative of Puget
commercial health plans.43 Sound (Seattle, WA)
Disease management strategies have great potential Group Health Cooperative of Puget Sound, an HMO
to improve therapeutic outcomes for patients with with more than 450,000 members in western Washington
depression. However, the management of depression state, has been a national leader in implementing disease
presents a challenge to many health care providers management for patients with depression.16 The disease
because it usually is first seen in the primary care management program at Group Health Cooperative has
evolved over the past decade, during which various
setting due to of a lack of access to specialty care or
strategies were used to improve the accuracy of
the stigma associated with seeking treatment from a
diagnosis and optimize acute-phase management.16
mental health professional.42
Models for collaborative management of depression by
Primary care providers usually have limited time to
primary care physicians and specialists were evaluated in
spend with patients and what time is available often is
randomized controlled trials.44,45
inadequate for patients with multiple chronic illnesses.13 In
Consultation Liaison Primary Care Collaborative
a managed care system, depression often competes with
Model. In a 12-month trial, 217 patients with
other chronic disease states and conditions for limited
depression who agreed to receive antidepressant drug
health care dollars.14 Clinicians must prioritize their time, therapy were randomized to receive a multifaceted
and patients may be forced to set priorities for their needs. intervention or usual care by the primary care
Patients may be reluctant to accept the diagnosis of physician.44 The multifaceted intervention entailed
depression, and access to medications also may be a frequent, intensive visits over the first 4–6 weeks of
barrier to successful treatment.14 Failure to adhere to treatment (the first and third visits were with the primary
drug therapy and follow up with clinic visits care physician and the second and fourth visits were
compromises patient outcomes. with a psychiatrist). Patients (and family members as
Although there can be some challenges in managing appropriate) were educated about the biology of
depression through a disease management program, depression and its etiology and treatment (e.g.,
many disease management vendors have taken on the behavioral therapies, antidepressant drug therapy).
challenge and have seen great success. Some of the Videotaped and written educational materials also were
experiences to date with depression disease provided. Patients were asked to complete a
management programs are described here. questionnaire about adverse effects from drug therapy
and any concerns for subsequent discussion with the
primary care physician; completing this questionnaire
Depression Disease Management was designed to encourage the patient to assume an
active role in his or her treatment.16 Adherence to drug
Programs therapy (e.g., refill frequency) was monitored during the
Cedars-Sinai Medical Center continuation and maintenance phases of treatment.
(Los Angeles, CA) At the start of the study, primary care physicians
The clinics of Cedars-Sinai Medical Center are participated in a half day workshop on the diagnosis
exploring new educational initiatives for treating and treatment of depression and study methods.44 The
Disease Management for Depression

depression in patients with cardiovascular disease. psychiatrist assisted the primary care physician with
Their past disease management programs involving modification of drug therapy when severe adverse
hypertension, hyperlipidemia, diabetes, asthma, and effects occurred or response to drug therapy was
the anticoagulation therapy have shown strong cost- inadequate. Either the primary care physician or the
savings results. For additional information, see Disease psychiatrist could make changes to the drug dosage or
Management News, March 25, 2001 (page 5), or type of drug after oral consultation. Psychiatrists
contact Jeff Borenstein, MD, at Cedars-Sinai Medical provided the primary care physicians with oral and
Care Foundation (310) 247-7700, ext. 502. written feedback about patient progress. Monthly
conferences involving the primary care physicians and
psychiatrists were conducted to discuss cases.44

[5]
Compared with usual care, the intervention was speculated that further improvement in cost-
associated with significantly greater patient adherence effectiveness of the intervention might be achieved if
to antidepressant drug therapy, patient satisfaction with the intervention was reserved for patients with an
overall quality of care and antidepressant drug therapy, inadequate response after 6 to 8 weeks of usual care.16
and improvement in depressive symptoms.44 Telephone Counseling and Computerized
Brief Therapy Primary Care Model. A multifaceted Monitoring. The effectiveness of conducting disease
intervention involving antidepressant drug therapy and management interventions by using telephone calls to
cognitive-behavioral treatment was evaluated in 153 patients instead of clinic visits was studied. In a pilot
patients with depression.45 Patients were randomized to study, 28 patients initiating antidepressant drug therapy
receive the intervention or usual care by the primary care received written information about depression and six
physician. Patients in the intervention group participated weekly telephone counseling and support sessions by a
in four to six sessions with a psychologist over the first 2 trained therapist (the intervention). The transtheoretical
months of the study. Cognitive-behavioral treatment and model of behavioral change (i.e., stages of change, such
counseling on the importance of medication adherence as contemplation) and cognitive-behavioral strategies
were provided in these sessions. Cognitive-behavioral were used to enhance patient self-management and
treatment was designed to promote the use of adaptive coping skills.47 After 3 months and 6 months, patients in
coping strategies and encourage the patient to adopt the intervention group had significantly fewer depressive
positive thought patterns and activities instead of symptoms than did a group of 94 patients receiving
negative ones. The psychologists met with a psychiatrist usual care. Patient adherence was twice as likely in the
on a weekly basis to discuss each patient’s medication intervention group as in the usual-care group. The
adherence and response. The psychiatrist made number of clinic visits did not differ significantly between
recommendations to the primary care physician for the two groups (i.e., the benefits associated with the
dosage adjustments as needed. Primary care physicians intervention did not require extra visits).48
participated in training on drug therapy and cognitive- The use of computerized systems for providing
behavioral treatment for depression at the start of the feedback to primary care physicians about
study. Videotapes and written materials about antidepressant dosages and prescription refills, follow-
depression and its treatment were provided to patients. up visit frequency (i.e., adequacy), and algorithm-based
Patient medication adherence, satisfaction with recommendations for treatment (an approach referred
quality of care for depression and antidepressant drug to as feedback) was evaluated alone and in
therapy, and improvement in depressive symptoms combination with care management in a 6-month,
were significantly greater in patients in the intervention randomized, controlled trial of 613 patients who were
group than in patients in the usual-care group.45 initiating antidepressant drug therapy.49 Care
Cost-Effectiveness of Collaborative Care. The management entailed telephone calls to patients by a
success of the Consultation Liaison Primary Care care manager at the initiation of therapy and 8 weeks
Collaborative Model and the Brief Therapy Primary Care and 16 weeks later to discuss antidepressant drug
Model was attributed to patient education, physician therapy, adverse effects, and response. Feedback
training, the reorganization of care, and the availability provided to primary care physicians included treatment
Disease Management for Depression

of information systems to facilitate tracking and sharing recommendations on the basis of a computerized
of key patient data.16 An analysis of costs associated algorithm that took into consideration actual and
with the two models revealed that the intervention was recommended antidepressant dosages and follow-up
associated with a modest increase in the cost- visit frequency. Usual care was used as a control.
effectiveness of treating depression compared with Patients in the feedback group were no more likely
usual care, despite increased costs due to the need for to receive appropriate antidepressant drug therapy or
extra visits by the intervention group.46 The costs for experience at least moderate improvement in
each patient successfully treated were approximately depressive symptoms than patients in the usual-care
$1700 to $1800 in the intervention group and $1950 to group. However, patients in the feedback group who
$2150 in the usual-care group. The investigators received care management were more likely to receive

[6]
appropriate antidepressant drug therapy and diabetes, asthma, chronic obstructive pulmonary
experience improvement in depressive symptoms than disease, and many other chronic conditions.
were those in the usual-care group. The incremental The company is collaborating with the Department of
costs per patient were $22 for the feedback approach Veterans Affairs to develop a disease management
and $83 for feedback plus care management.49 program for depression. The use of telemedicine to
Relapse Prevention. Recent disease management communicate with patients will be an integral
efforts at Group Health Cooperative have addressed component of this program and will include reminders to
patients with persistent depression who are at high risk take medications and to keep scheduled appointments.
for relapse. In a randomized trial, 386 patients with For additional information about the Health Hero
depression who had recovered to a large extent after 8 Network, go to http://www.healthhero.com/index.html.
weeks of treatment but who were at high risk for relapse
were randomized to a relapse prevention program or Heritage Information Systems Inc.
usual care.50 The relapse prevention program was (Richmond, VA)
designed to promote medication adherence and Heritage Information Systems Inc. is a privately held
increase patient self-monitoring of symptoms and consulting company providing clinical management and
recognition of the prodromal symptoms that precede a pharmacy cost containment services to government
relapse. The program involved two primary care visits programs, insurance companies, and large employers.
with a depression specialist (a psychologist, a nurse The company serves 10 state Medicaid programs,
with a master’s degree in psychosocial nursing, or a several national commercial insurers, 5 Blue Cross Blue
social worker) and three telephone calls over a 1-year Shield licensees, and some of the largest employer
period. A written relapse prevention plan was devised groups in the country.
for each patient. Primary care physicians received A mail-based disease management program to
intermittent reports about patient progress. improve the treatment of depression by reducing
Medication adherence, the use of an adequate physician practice variation was implemented. Heritage
dosage, and refill frequency were significantly better in Information Systems educated physicians to better use
the intervention group than in the usual-care group. clinical practice guidelines. This educational intervention
Depressive symptoms also were significantly improved led to substantial cost savings; physicians prescribed
in the intervention group at the end of the study. more appropriate treatments that were more cost-
However, the number of episodes of relapse was no effective. Education of the physicians also led to
different in the two groups.50 The investigators improved medication adherence by patients.
speculated that more intensive relapse prevention Educational information along with treatment guideline
interventions may be required to reduce relapse rates. information was mailed to physicians of patients with
Future disease management efforts at Group Health excessively long or short antidepressant drug therapy,
Cooperative will address relapse prevention. possible drug interactions, and nonadherence
problems. For additional information, see Disease
Health Hero Network, Inc. (Mountain Management News, March 10, 2001 (pages 3 and 5),
View, CA) or go to http://www.heritage-info.com.
Involving patients in their care is critical to effectively
Disease Management for Depression

managing a chronic illness. Health Hero Network, a Kaiser Permanente Care Management
technology company, has designed the Health Hero Institute (Oakland, CA)
Platform, a group of electronic devices that health care The Care Management Institute was created in 1997
providers can use to send patients reminders to take to help Kaiser Permanente improve the quality of care
their medicine, provide them with feedback on their and health outcomes for its members. Depression,
progress, and provide tips for managing their disease asthma, cardiovascular disease, diabetes mellitus, elder
more effectively. This empowers patients to feel more in care, heart failure, chronic pain, and cancer were the
control and to practice better self-care. Health Hero clinical priorities because they represented an
Network customers are using Health Hero solutions for opportunity to improve care for members of the HMO.
programs in heart failure, cardiovascular disease, Kaiser Permanente received certification from the

[7]
NCQA for design of a depression disease management The Merck-Medco Experience (West
program in September 2002. Non-compliant patients Point, PA)
were identified and targeted interventions encouraged Merck-Medco, a pharmacy benefits management
improved treatment compliance. The percentage of (PBM) company, developed Transitions to Better
patients starting antidepressant drug therapy who had Health, a depression disease management program
at least three follow-up visits within the first 12 weeks designed to optimize the cost-effective use of
of therapy and the percentages of patients continuing antidepressant drug therapies and clinical outcomes.21
antidepressant drug therapy for at least 3 months and The program was available to pharmacy benefits
at least 6 months increased between 1998 and 1999 at management clients, who decided whether to offer it to
Kaiser Permanente. For additional information, go to plan members. Plan members (i.e., patients) decided
http://www.kpcmi.org. whether to participate and authorize the release of
personal data. Member prescription claims data (and
Keystone Health Plan Central (Camp Hill, PA) medical claims data, if available) were reviewed, and
Keystone Health Plan Central is a 225,000-member, one or more of three interventions was offered as
jointly owned subsidiary of Capital Blue Cross and appropriate.
Pennsylvania Blue Shield. Its depression disease One intervention was designed to identify and
management program dates back to 1998. Screening recognize undiagnosed or untreated depression.
scales and depression practice guidelines are Prescription claims data for certain types of
distributed to primary care providers. Then, anonymous medications (e.g., certain analgesics) and, if available,
telephone and Internet-based depression screening medical claims data were used to identify the plan
mechanisms are offered. Patient education materials members who are responsible for the highest 10% of
about the illness and the importance of medication plan costs because of the link between depression and
adherence are given to providers and patients. For high medical resource use. Patients who had agreed to
additional information see Disease Management News, participate in the program were screened for
May 10, 2001 (pages 1, 6, and 7), contact Devora depressive symptoms by telephone interview
Sherfy at Keystone Health Plan Central (717) 730-1941, conducted by a trained psychiatric nurse. Physicians
or go to http://www.pahealthcoverage.com/ were promptly notified if the patient appeared to meet
keystonecentral.html. the criteria for depression based on this screening.
Published information from authoritative sources,
LifeMasters Supported SelfCare (Irvine, CA) including diagnostic criteria and treatment guidelines,
LifeMasters Supported SelfCare is an interactive was provided to the physician. Follow-up phone calls to
disease management company that provides tools the physician were made within one week to offer
such as health education, training in self-monitoring, decision support based on the treatment guidelines.
and personalized coaching. Timely, clinically-validated Additional follow-up contact with physicians took place
information is provided to physicians to prevent serious 35 to 50 days later to ascertain the outcome if
medical episodes that can result in unnecessary antidepressant drug therapy was not initiated.
emergency department visits and hospitalizations. The second intervention was designed to improve
In the past, LifeMasters managed depression as a patient medication adherence and avoid premature
Disease Management for Depression

comorbidity with other diseases, but it recently launched discontinuation of drug therapy, relapse, and costly
a stand-alone depression program. The program hospitalization. Patients filling a new prescription for an
focuses on primary care providers and newly diagnosed antidepressant for a first episode or recurrence of
patients. A nurse call center and other support tools will depression were contacted by telephone to obtain
be used to monitor patients to ensure adherence to authorization to participate. Patients who agreed to
medication regimens and to prevent relapse. For participate received five education and support calls
additional information, see Disease Management News, from a psychiatric nurse over a 12-month period. If
May 10, 2001 (pages 1, 6, and 7), contact Jeffrey Davis, needed, a pharmacist provided counseling on adverse
MD, at LifeMasters Supported SelfCare (650) 941-1066, effects from drug therapy. Educational mailings and
or go to http://www.lifemasters.net. behavioral reinforcement also were provided.

[8]
The third intervention encouraged physicians to depression disease management program. The
prescribe antidepressant drug therapy for an adequate program helps primary care providers use better
but not excessive duration, in accordance with screening tools for depression. Another component of
authoritative treatment guidelines. After a year of the program is TxAlert, a reminder system that
treatment, the physician was asked to indicate whether generates a review of claims and pharmacy data using
the patient was a candidate for maintenance therapy or national treatment standards. TxAlert allowed
tapering and discontinuation of drug therapy. Written PARTNERS to alert physicians when patients were not
treatment guidelines that govern this determination taking their medication as prescribed. The goals of the
were provided to the physician. program included increased medication adherence and
The information system capabilities of the PBM use of counseling by behavioral health providers. For
facilitated this disease management program and additional information, see Disease Management News
enabled plans to monitor NCQA HEDIS indicators.21 May 10, 2001 (page 6) or contact Patricia Kirkpatrick at
For example, prescription refill frequency was readily PARTNERS Health Plan (219) 236-7720.
monitored. Results from the program to date are
limited. Undiagnosed depression was detected in 9% Pfizer Inc. (New York, NY)
of screened patients. The rate at which new Pfizer Inc., a pharmaceutical company, oversees the
antidepressant prescriptions for first episodes or Prime-MD® Today program, which uses a diagnostic
recurrences were refilled at least once (presumably instrument to help primary care physicians recognize
reflecting medication adherence) increased by 20%. the symptoms of depression, as well as anxiety,
Nearly 5% of patients monitored 18 months after alcohol, eating, and somatoform disorders. The Prime-
starting antidepressant therapy had discontinued it MD® Patient Health Questionnaire (PHQ-9) is a
(presumably reflecting avoidance of unnecessary use). validated self-administered diagnostic instrument, which
Additional experience with the program is needed to evolved from the Prime-MD diagnostic instrument
evaluate the impact on patient outcomes and costs. administered by physicians. A depression self-quiz for
consumer use is also available at http://www.zoloft.com/
PacifiCare Behavioral Health (Laguna index.asp?pageid=4. For additional information about
Hills, CA) Prime-MD Today, go to http://www.zoloft.com/psd/
PacifiCare Behavioral Health, a wholly owned healthmanagement/primemd.pdf.
subsidiary of PacifiCare Health Systems, provides
behavioral health services to members in 10 states and Protocol Driven Healthcare Inc.
Guam. In 1999, the company developed Taking Charge (Bernardsville, NJ)
of Depression, a disease management program for Protocol Driven Healthcare Inc. develops and
patients with depression that emphasizes self- markets health application software and services that
management. A patient self-care resource kit with an are used to deliver health, wellness, and disease
information booklet about depression, medications, and management programs. The company provides an
lifestyle changes, and physician encounter cards for Internet-based patient education and self-care program
patient use in discussions during physician visits is for depression to help patients adhere to medication
provided to patients. Patients have monthly telephone regimens and allow physicians to provide better
Disease Management for Depression

contact with counselors to ensure adherence with patient-specific information. For more information, go to
medications and scheduled visits. Medication http://www.pdhi.com/.
adherence is monitored through prescription refill
activity and phone calls to the patient. For additional RAND Health (Santa Monica, CA)
information, see Disease Management Advisor, July RAND Health is the nation’s largest private health
2000;6(7):110-111, or go to http://www.pbhi.com. care research organization. RAND Health’s Partners in
Care program is an integrated approach to improving
PARTNERS Health Plan (South Bend, IN) care for depression in primary care. The program uses
PARTNERS Health Plan is a regional health plan that collaborative care and is suitable for a variety of
developed PARTNERS in Mental Wellness, a practice settings. A study using the program

[9]
demonstrated that patients’ mental health and daily by John E. Ware, Jr., PhD, principal developer of the
functioning can be significantly improved by treatment. SF-36®, SF-12®, and SF-8™ health surveys, widely
Favorable outcomes for employers, managed care used health assessment surveys. Internet-based tools
organizations, and insurers, including a reduction in job- for measuring outcomes in patients with depression are
loss rates, were achieved with the use of modest, available from QualityMetric. For more information, go
practical programs in primary care settings. Program to http://www.qualitymetric.com/.
materials are available at
http://www.rand.org/health/pic.products/ or from RAND
Distribution Services by calling (877) 584-8642. The Future of Depression
Management
Tufts Health Plan (Boston, MA)
Disease management—an important approach to
Tufts Health Plan was founded in 1979 as a not-for-
integrated care—has been shown to improve patient
profit HMO. It has expanded into a family of
outcomes and quality of life while potentially reducing
companies, offering a full array of health care coverage
overall costs. Applying the key components of disease
options to individuals and employer groups. Depression
management to the treatment of depression can help
is among the mental health disease management
ensure successful treatment. Disease management is a
programs offered by the Tufts Health Plan. The
useful, efficient approach to health care. It has
depression program focuses on patients in the primary
continued to gain widespread acceptance over the past
care setting. Patient education materials about the
10 years, and health plans that provide multiple
illness and medications are provided by mail and on the
services to patients who need coordinated services are
Internet. For additional information, go to
seeing the most success in their chronically ill patients.
http://www.tufts-healthplan.com/.

Challenges in Managing Depression


The management of depression does present
Additional Depression Disease challenges to clinicians. Depression usually is treated in the
Management Resources primary care setting because of a lack of access to
Eli Lilly and Company (Indianapolis, IN) specialty care or the stigma associated with seeking
Eli Lilly and Company, a pharmaceutical company, treatment from a mental health professional.42 Changes in
provides Internet-based patient information about the the financing and structure of the health care system
treatment of depression and information about where to during the 1990s affected patterns of referral of patients to
seek treatment. A Zung scale self-assessment test is specialists.14 In the early 1990s, referral was uncommon
available online at: http://www.prozac.com/. because of the negative economic impact on primary care
providers under a capitation system (i.e., the primary care
Forest Laboratories (St. Louis, MO) provider bore the cost for referrals).14 In the late 1990s,
Forest Laboratories, a pharmaceutical company, referral became more common with the establishment of
provides Internet-based patient information about the managed behavioral health organizations.14 Nevertheless,
treatment of depression. In addition, a physician locator only one in five patients with major depression is treated
Disease Management for Depression

(by zip code) and a depression self-rating (i.e., by a mental health specialist.51
screening) test are available online at: The structure of managed care systems increases
http://apps.redidata.com/forest/ reliance on primary care providers for mental health
surv/survey.asp?one=&two=&three=&four=&wherefrom services. However, the primary care system is more effective
=WEBSITE&missing=true&accept=on. in managing acute illnesses than chronic conditions such as
depression.42 Primary care providers have limited time to
QualityMetric Inc. (Lincoln, RI) spend with patients and what time is available often is
QualityMetric Inc., an independent, privately held inadequate for patients with chronic illnesses.13 In a
corporation, is a provider of health outcomes managed care system, depression often competes with
assessment tools. The company was founded in 1997 other disease states and conditions for limited health care

[10]
dollars.14 Clinicians must prioritize their time, and patients
may be forced to set priorities for their needs.52
The physician-patient relationship typically is not long
Table 2.
lasting because of frequent changes in health
Mental Health Associations
insurance, especially in patients who change employers
with Information for the Public
frequently.14 Mental health “carve outs” (i.e.,
subcontracting of mental health services to mental American Psychiatric Association
1000 Wilson Boulevard, Suite 1825
health providers separate from other health care Arlington, VA 22209-3901
services) may result in fragmented care.14 Continuity of (888) 357-7924
care for patients with depression usually is lacking. http://www.psych.org
In addition, some patients may be reluctant to
accept the diagnosis of depression; and access to National Alliance for the Mentally Ill
medication can be a barrier to successful treatment.14 Colonial Place Three
2107 Wilson Boulevard, Suite 300
Failure to adhere to drug therapy and follow up with
Arlington, VA 22201
clinic visits also compromises patient outcomes. (703) 524-7600
Help Line: 800-950-NAMI [6264]
Strategies for Overcoming Barriers to http://www.nami.org
Managing Depression
Strategies to overcome barriers to managing National Institute of Mental Health
depression include developing educational campaigns 6001 Executive Boulevard, Room 8184, MSC 9663
for the public to reduce the stigma associated with the Bethesda, MD 20892-9663
(866) 615-NIMH[6464]
treatment of depression and other mental illnesses.16,53 http://www.nimh.nih.gov/publicat/depression.cfm
Many mental health associations (Table 2) have
undertaken such efforts.54
National Mental Health Association
Education and training of primary care providers in
2001 North Beauregard Street,12th Floor
communication skills and the use of screening tools Alexandria, VA 22311
can improve the detection rate of depression.15,55,56 (800) 969-NMHA[6642]
http://nmha.org
Health systems can be redesigned to increase
collaboration between primary care providers and
specialists in the management of patients with
depression (e.g., using collaborative management Patient education should motivate patients to
models) without compromising cost-effectiveness.
assume a more active role in their own care and
Rebundling resources and delegating responsibility
improve their self-management skills and adherence to
(e.g., patient education tasks that can be performed by
prescribed therapy. The use of information systems can
nurses) can make such collaborations economically
help promote patient adherence and improve outcomes
feasible.52 Information systems can be developed to
by tracking prescription refill and clinic visit frequency
facilitate communication among providers and tracking
and timing, and by identifying patients who discontinue
of patient data and outcomes. Identifying patients at
drug therapy prematurely. Telephone calls to patients
Disease Management for Depression

high risk for relapse or recurrence so that they can


receive maintenance therapy and other relapse (especially those whose adherence is poor) may result
prevention strategies (e.g., patient education, extra in better adherence and outcomes.
clinic visits, follow-up phone calls) and patients at low Health management is a strategy that has been
risk for relapse or recurrence so they can discontinue advocated as an alternative to disease management.14
therapy (after tapering) optimizes the use of limited The patient (not the disease) is the focus of this
resources. Outcomes-based performance standards approach; patients are partners in care and they
should be established to provide a basis for health negotiate priorities with the physician and managed
plans to compare operational successes (e.g., relapse care organization. Quality-of-life measures are used to a
rates in patients with depression).53 greater extent than disease-specific measures in

[11]
evaluating outcomes. Physician efficiency in detecting conditions because of the structure of the health care
and triaging mental illnesses and prioritizing time is system and patient attitudes and behavior. However,
increased through the use of ReACT, a strategy that many vendors are taking on the challenge of
entails recognizing the presence of distress, assessing implementing depression disease management
the type and severity of the problem, categorizing the programs and seeing success.
problem, and treating the problem. Support staff and Strategies to overcome barriers to managing
various technologies (e.g., information systems, depression include training of health care providers in
telephone interviews, interactive voice response detection and diagnosis of the illness, increasing
systems) are used to optimize efficiency. Collaboration collaboration among primary care providers and
between primary care providers and mental health specialists, and providing patient education to increase
specialists is emphasized. motivation, self-management skills, and adherence to
the treatment regimen.
Disease management can improve patient outcomes
Conclusion and quality of life while potentially reducing overall health
Depression is a costly mental illness that often goes care costs. It is key to integrating care. As more health
undetected or inadequately treated.9,10,15,56 Disease care payers incorporate disease management principles
management programs for depression are not as well into the delivery of care, we will begin to see many more
established as those for other chronic medical depression disease management programs.
Disease Management for Depression

[12]
Appendix A. Diagnostic Criteria for Major Depression

A. Five (or more) of the following symptoms have been (6) fatigue or loss of energy nearly every day
present during the same 2-week period and represent a (7) feelings of worthlessness or excessive or
change from previous functioning; at least one of the inappropriate guilt (which may be delusional) nearly
symptoms is either (1) depressed mood or (2) loss of every day (not merely self-reproach or guilt about
interest or pleasure. being sick)
(8) diminished ability to think or concentrate, or
Note: Do not include symptoms that are clearly due to a indecisiveness, nearly every day (either by
general medical condition, or mood-incongruent delusions or subjective account or as observed by others)
hallucinations. (9) recurrent thoughts of death (not just fear of dying),
recurrent suicidal ideation without a specific plan, or
(1) depressed mood most of the day, nearly every day, a suicide attempt or a specific plan for committing
as indicated by either subjective report (e.g., feels suicide
sad or empty) or observation made by others (e.g.,
appears tearful). Note: In children and adolescents, B. The symptoms do not meet criteria for a Mixed Episode.
can be irritable mood. C. The symptoms cause clinically significant distress or
(2) markedly diminished interest or pleasure in all, or impairment in social, occupational, or other important
almost all, activities most of the day, nearly every areas of functioning.
day (as indicated by either subjective account or D. The symptoms are not due to the direct physiological
observation made by others) effects of a substance (e.g., a drug of abuse, a
(3) significant weight loss when not dieting or weight medication) or a general medical condition (e.g.,
gain (e.g., a change of more than 5% of body hypothyroidism).
weight in a month), or decrease or increase in E. The symptoms are not better accounted for by
appetite nearly every day. Note: In children, bereavement, i.e., after the loss of a loved one, the
consider failure to make expected weight gains. symptoms persist for longer than 2 months or are
(4) insomnia or hypersomnia nearly every day characterized by marked functional impairment, morbid
(5) psychomotor agitation or retardation nearly every preoccupation with worthlessness, suicidal ideation,
day (observable by others, not merely subjective psychotic symptoms, or psychomotor retardation.
feelings of restlessness or being slowed down)

Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Copyright 2000
American Psychiatric Association.

Disease Management for Depression

[13]
Appendix B.
Natural History, Management, and Treatment of Depression
episodes; 50% to 75% of patients respond to antidepressant

D
epression usually first manifests when a person is in
her or his late 20s, although the onset can occur at drug therapy.8 Because the response rates are similar among
any age.8 Untreated episodes usually last for 6–24 the available agents, selection of an antidepressant agent
months.8,25 Depression has a variable course.8,25 About two usually is made on the basis of safety, tolerability, patient
thirds of untreated patients have only a single episode and preference, and cost.8
return to their previous level of functioning (i.e., achieve Regular and consistent monitoring—a key component of
spontaneous remission).25 However, residual symptoms and disease management—of antidepressant drug therapy is
impairment of interpersonal, social, and occupational critical to managing depression successfully. Accurate patient
functioning persist in 20% to 35% of cases.8 Approximately monitoring helps to ensure that the health care provider
50% to 85% of patients have at least one more episode (i.e., selects a drug with maximum therapeutic effect and minimal
a recurrence), usually within 2 or 3 years.8 adverse effects and also helps to ensure proper dose
titration. Regular monitoring of the patient and provision of
The goals of treatment for depression in the acute phase feedback to the health care provider can address any
are to eliminate all symptoms and restore psychosocial potential problems with adverse effects and efficacy at an
function (i.e., achieve remission).32,33 Prevention of relapse early stage. Early intervention also can resolve issues that
(i.e., a return of symptoms before full recovery within 6 could affect compliance. Patient monitoring is key in the early
months after remission) is the primary goal of treatment stages of the treatment process. Disease management
during the continuation phase. Prevention of recurrence (a programs can help to ensure successful treatment.
new episode following a full recovery) is the goal of
maintenance therapy.32 Psychotherapy
Various types of psychotherapy have been used to treat
Initial therapeutic options in the acute phase of a depression, including cognitive-behavioral therapy,
depressive episode are pharmacotherapy, psychotherapy, or interpersonal therapy, psychodynamic psychotherapy,
both.8 Considerations in choosing among these options problem-solving therapy and other behavior therapies, and
include symptom severity, patient preference, and past marital, family, and group therapy.8,37 Cognitive-behavioral
response of the patient and family members to therapy and interpersonal therapy are the two forms of
antidepressant therapy.8 Demographic variables (e.g., age, psychotherapy with the most documentation of benefit in
sex, marital status) are not good predictors of treatment treating depression.8 Cognitive-behavioral therapy challenges
outcome.34 Antidepressant drug therapy should be provided and reverses irrational beliefs and distorted attitudes toward
for patients with moderate or severe symptoms and, if the self, the environment, and the future.8 It helps patients
preferred by the patient, may be used for mild symptoms as change negative styles of thinking and behaving.11
well.8 Psychotherapy alone may be considered for patients
with mild or moderate symptoms.8 Combination Interpersonal therapy focuses on disturbed relationships
pharmacotherapy and psychotherapy is sometimes used for that cause and exacerbate depressive symptoms.11 It
patients with psychosocial or interpersonal problems, or a facilitates mourning after losses, resolves role disputes and
personality disorder and moderate or severe depression.8 transitions, and overcomes deficits in social skills to reduce
social isolation and increase social support.8
Pharmacotherapy
Depression has been attributed in part to the depletion Cognitive-behavioral therapy has been found to be as
of neurotransmitters (norepinephrine, serotonin, dopamine, or effective as (or perhaps even more effective than)
Disease Management for Depression

a combination) in the central nervous system, although antidepressant drug therapy.8,38 Evidence suggests that
theories about the pathogenesis of depression are still interpersonal therapy and antidepressant drug therapy are
evolving and subject to debate.35,36 Most antidepressant comparable in efficacy.8,39 However, the available comparative
medications inhibit neuronal reuptake of one or more of these data are insufficient to draw conclusions about the relative
neurotransmitters, thereby enhancing neurotransmission. effectiveness of psychotherapy and antidepressant drug
However, the effects of antidepressants are complex and therapies.40
remain to be fully elucidated.
Disease management programs can help improve
The various antidepressant agents and antidepressant access to psychotherapy services, which are critical to
drug classes are comparable in efficacy in treating depressive improving patient self-management skills. This is where the
{Continued on next page}

[14]
Appendix B.
Natural History, Management, and Treatment of Depression (continued)

use of disease management services can be especially therapy.8 The duration of maintenance therapy depends on
beneficial; psychotherapy services often are not part of the prognosis.41 For example, it may be 5 or more years for
mainstream health care services. A disease management patients at high risk for recurrence, and indefinite or lifelong
program can help integrate multiple types of services to for patients with two or three episodes, each of which
optimize patient care and ensure successful treatment of occurred within a year after discontinuing antidepressant
depression. medication.41
Disease management programs facilitate medication
Acute Phase adherence in the maintenance phase and help prevent
Antidepressant drug therapy usually is best initiated relapse and recurrence.
using a small dosage followed by gradual dosage increases
over the initial week or weeks to avoid or minimize adverse Discontinuation of Therapy
effects.8 If a patient does not have at least a moderate The decision to discontinue therapy is based on the risk
improvement in symptoms (i.e., if the patient has no of recurrence.8 The dosage of antidepressants should be
response or a partial response) after 6 to 8 weeks of gradually reduced over a period of at least several weeks
antidepressant drug therapy despite the use of full before discontinuing therapy to allow for the detection of
therapeutic dosages, switching to another antidepressant emerging symptoms or recurrences and to prevent
agent should be considered.8 medication discontinuation syndromes (i.e., withdrawal
symptoms).8 These syndromes may be mistaken for or mask
A goal of disease management is to improve the signs of a relapse because they affect mood, energy, sleep,
coordination of services among the patient, physician, and appetite.8
disease management organization, and other health care
providers. The acute phase of treatment can be a potentially Patients should be monitored for signs of relapse or
volatile phase and is key to successfully treating the patient. recurrence over a period of several months after
Coordinating care across health care providers at this phase discontinuation of therapy.8 Patient counseling should
is critical to successfully managing the patient; disease address the possibility of relapse or recurrence, the early
management programs can help to optimize services so that warning signs, and what to do if these signs occur.
patients can focus on adhering to their new medication
regimen. Disease management can provide services designed to
enhance patient self-management skills. If the health care
Continuation Phase provider and patient decide to discontinue therapy, these
Patients who receive antidepressant drug therapy in the skills enable the patient to reduce his or her risk of relapse
acute phase should continue therapy using the same dosage and recognize the signs and symptoms of relapse and seek
for 16 to 20 weeks after remission is achieved to prevent treatment.
relapse.8 About 25% of patients will relapse within 2 months
if therapy is not continued.8 Antidepressant drug therapy Patient Self-Management
reduces relapse rates by at least 50%.41 Self-management skills (e.g., recognizing the prodromal
symptoms that precede a relapse) are considered vital for
Disease management programs are designed to effectively treating depression.42 Developing a relapse
optimize patient self-management so that patients are prevention plan in the event that prodromal symptoms occur
empowered to adhere to their medication regimens. Disease is recommended.
Disease Management for Depression

management can promote adherence in the continuation


phase to help prevent relapse. Disease management programs have services designed
to enhance patient self-management and help patients
Maintenance Phase adhere to a strict medication and psychotherapy treatment
Continuing antidepressant drug therapy, psychotherapy, plan. Depending on the needs of the patient, disease
or both on a long-term basis after the continuation phase management programs can encourage and facilitate the
may be considered for patients at high risk for recurrence.8 development of critical self-management skills.
Full antidepressant dosages are used for maintenance

The information in this appendix is adapted from the sources in Table 1, found on page 3 of this document.

[15]
References 16. Katon W, Von Korff M, Lin E, et al. Population-based care
of depression: effective disease management strategies
1. Centers for Medicare and Medicaid Services. Discussion to decrease prevalence. Gen Hosp Psychiatry.
of disease management. Available at: 1997;19:169–178.
http://cms.hhs.gov/media/press/release.asp?Counter=41 17. Katz SJ, Kessler RC, Lin E, Wells KB. Medication
8. Accessed October 1, 2002. management of depression in the United States and
2. Disease Management Association of America. Definition Ontario. J Gen Intern Med. 1998;13:77–85.
of disease management. Available at: 18. Simon G, Ormel J, VonKorff M, Barlow W. Health care
http://www.dmaa.org/definition.html. Accessed August costs associated with depressive and anxiety disorders in
28, 2002. primary care. Am J Psychiatry. 1995;152:352–357.
3. National Pharmaceutical Council. Medicaid disease 19. Unutzer J, Simon G, Belin TR, Datt M, Katon W, Patrick
management & health outcomes. Available at: D. Care for depression in HMO patients aged 65 and
http://www.dmnow.org/. Accessed August 1, 2002. older. J Am Geriatr Soc. 2000;48:871–878.
4. Joint Commission on Accreditation of Healthcare 20. Interest in depression DM programmes picking up in the
Organizations. Disease-specific care certification. US. PharmacoEconomics and Outcomes News.
Available at: http://www.jcaho.org/dscc/index.htm. 2001;1(317):2.
Accessed October 24, 2002. 21. Fulop G, Kelly MA, Robinson D Jr, et al. Opportunities for
5. National Committee for Quality Assurance. NCQA disease depression disease management: a pharmacy benefit
management accreditation/certification information. manager’s experience. Depress Anxiety. 1999;10:61–67.
Available at: http://www.ncqa.org/Programs/ 22. Burton WN, Conti DJ. Disability management: corporate
Accreditation/DM/dmmain.htm. Accessed October 24, medical department management of employee health and
2002. productivity. J Occup Environ Med.
6 Final NCQA DM accreditation standards hit the street. DM 2000;42(10):1006–1012.
News. December 25, 2001;7(5):1,4,5. 23. Burton WN, Chen CY, Conti, DJ, Schultz AB, Edington
7. American Accreditation HealthCare Commission. URAC DW. The value of the periodic executive health
Accreditation Programs. Available at: http://www.urac.org. examination: experience at Bank One and summary of
Accessed May 22, 2003. the literature. J Occup Environ Med. 2002;44(8):737–744.
8. American Psychiatric Association. Practice guideline for 24. Wethington, E, Kessler RC. Employment, parental
the treatment of patients with major depression (revision). responsibility, and psychological distress: a longitudinal
Am J Psychiatry. 2000;157(4 suppl):1-45. Available at: study of married women. J Fam Issues.
http://www.psych.org/clin_res/Depression2e.book.cfm. 1989;10(4):527–546.
9. American Psychiatric Association. Diagnostic and 25. Depression Guideline Panel. Depression in Primary Care:
Statistical Manual of Mental Disorders DSM-IV-TR (Text Volume 1. Detection and Diagnosis. Clinical Practice
Revision). 4th ed. Washington, DC: American Psychiatric Guideline, Number 5. Rockville, MD. U.S. Department of
Association; 2000. Health and Human Services, Public Health Service,
10. National Institute of Mental Health. The numbers count: Agency for Health Care Policy and Research; April 1993.
mental disorders in America. Available at: AHCPR publication 93-0550.
http://www.nimh.nih.gov/publicat/numbers.cfm. 26. Greenberg PE, Stiglin LE, Finkelstein SN, Berndt ER. The
Accessed September 23, 2002. economic burden of depression in 1990. J Clin
11. National Institute of Mental Health. Depression. Available Psychiatry. 1993;54:405–418.
at: http://www.nimh.nih.gov/publicat/depression.cfm. 27. Vodoor M, Southwell YP, Grubin M, et al. The
Accessed August 29, 2002. management of depression: the implications for managed
12. Crawford MJ, Prince M, Menezes P, Mann AH. The care—roundtable discussion: part 3. Manag Care
recognition and treatment of depression in older people in Interface. 2000;suppl B:26–32.
primary care. Int J Geriatr Psychiatry. 1998;13:172–176. 28. Novartis Pharmacy Benefit Report: Facts & Figures. East
Disease Management for Depression

13. Docherty JP. Barriers to the diagnosis of depression in Hanover, NJ: Novartis Pharmaceuticals Corporation;
primary care. J Clin Psychiatry. 1997;58(suppl 1):5–10. 2002.
14. Strategies for effective management of depression in 29. Goetzel RZ, Ozminkowski RJ, Sederer LI, Mark TL. The
primary care. Based on a presentation by Michael S. business case for quality mental health services: why
Klinkman, MD. Am J Manag Care. 1999;5(13 employers should care about the mental health and well-
suppl):S783–S788. being of their employees. J Occup Environ Med.
15. Cole MG, Elie LM, McCusker J, Bellavance F, Mansour A. 2002;44:320–330.
Feasibility and effectiveness of treatments for depression 30. Birnbaum JG, Cremieux PY, Greenberg PE, Kessler RC.
in elderly medical inpatients: a systematic review. Int Management of major depression in the workplace:
Psychogeriatr. 2000;12:453–461. impact on employee work loss. Disease Management &
Health Outcomes. 2000;7:163–171.

[16]
31. Berndt ER, Finkelstein SN, Greenberg PE, et al. 44. Katon W, Von Korff M, Lin E, et al. Collaborative
Workplace performance effects from chronic depression management to achieve treatment guidelines. Impact on
and its treatment. J Health Econ. 1998;17:511–535. depression in primary care. JAMA. 1995;273:1026–1031.
32. Depression Guideline Panel. Depression in Primary Care: 45. Katon W, Robinson P, Von Korff M, et al. A multifaceted
Volume 2. Treatment of Major Depression. Clinical intervention to improve treatment of depression in primary
Practice Guideline, Number 5. Rockville, MD. U.S. care. Arch Gen Psychiatry. 1996;53:924–932.
Department of Health and Human Services, Public Health 46. Von Korff M, Katon W, Bush T, et al. Treatment costs,
Service, Agency for Health Care Policy and Research; cost offset, and cost-effectiveness of collaborative
April 1993. AHCPR publication 93-0551. management of depression. Psychosom Med.
33. Kupfer DJ. Long-term treatment of depression. J Clin 1998;60:143–149.
Psychiatry. 1991;52:28–34. 47. Berger BA, Hudmon KS. Readiness for change:
34. Mynors-Wallis L, Gath D. Predictors of treatment outcome implications for patient care. J Am Pharm Assoc.
for major depression in primary care. Psychol Med. 1997;NS37:321–329.
1997;27:731–736. 48. Tutty S, Simon G, Ludman E. Telephone counseling as an
35. Delgado PL. Depression: the case for a monoamine adjunct to antidepressant treatment in the primary care
deficiency. J Clin Psychiatry. 2000;61(suppl 6):7–11. system. A pilot study. Eff Clin Pract. 2000;3:170–178.
36. Leonard BE. Evidence for a biochemical lesion in 49. Simon GE, VonKorff M, Rutter C, Wagner E. Randomised
depression. J Clin Psychiatry. 2000;(61 suppl 6):12–17. trial of monitoring, feedback, and management of care by
37. Townsend E, Hawton K, Altman DG, et al. The efficacy of telephone to improve treatment of depression in primary
problem-solving treatments after deliberate self-harm: care. BMJ. 2000;320:550–554.
meta-analysis of randomized controlled trials with respect 50. Katon W, Rutter C, Ludman EJ, et al. A randomized trial
to depression, hopelessness and improvement in of relapse prevention of depression in primary care. Arch
problems. Psychol Med. 2001;31:979–988. Gen Psychiatry. 2001;58:241–247.
38. DeRubeis RJ, Gelfand LA, Tang TZ, Simons AD. 51. Burns BJ, Ryan Wagner H, Gaynes BN, Wells KB,
Medications versus cognitive behavior therapy for severely Schulberg HC. General medical and specialty mental
depressed outpatients: mega-analysis of four randomized health service use for major depression. Int J Psychiatry
comparisons. Am J Psychiatry. 1999;156:1007–1013. Med. 2000;30:127–143.
39. Barkham M, Hardy GE. Counselling and interpersonal 52. Rost K, Nutting P, Smith J, Coyne JC, Cooper-Patrick L,
therapies for depression: towards securing an evidence- Rubenstein L. The role of competing demands in the
base. Br Med Bull. 2001;57:115–132. treatment provided primary care patients with major
40. Gerson S, Belin TR, Kaufman A, Mintz J, Jarvik L. depression. Arch Fam Med. 2000;9:150–154.
Pharmacological and psychological treatments for 53. Von Korff M, Katon W, Unutzer J, Wells K, Wagner EH.
depressed older patients: a meta-analysis and overview Improving depression care: barriers, solutions, and
of recent findings. Harv Rev Psychiatry. 1999;7:1–28. research needs. J Fam Pract. 2001;50:528.
41. Paykel ES. Continuation and maintenance therapy in 54. Lewis L. The role of mental health patient organizations in
depression. Br Med Bull. 2001;57:145–159. disease management: focus on the US National
42. Researchers hot on the trail of modest interventions to Depressive and Manic-Depressive Association. Disease
boost depression care. Dis Manag Advis. July Management & Health Outcomes. 2001;9:607–617.
2001;7(7):107–110. 55. Pignone MP, Gaynes BN, Rushton JL, et al. Screening for
43. National Committee for Quality Assurance. HEDIS‚ 2002 depression in adults: a summary of the evidence for the
summary table of measures, product lines and changes. U.S. Preventive Services Task Force. Ann Intern Med.
Available at: 2002;136:765–776.
http://www.ncqa.org/Programs/HEDIS/02measures.pdf. 56. Ustun TB, Kessler RC. Global burden of depressive
Accessed September 23, 2002. disorders: the issue of duration. Br J Psychiatry.
2002;181:181–183.
Disease Management for Depression

[17]
The National Pharmaceutical Council
1894 Preston White Drive
Reston, VA 20191-5433

Phone: 703-620-6390
Fax: 703-476-0904
www.npcnow.org
www.dmnow.org

1DXM0110603

You might also like