Because patients are increasingly seeking care for depression from primary care providers rather than mental health professionals, primary care clinicians must be able to recognize and effectively treat the condition. A systematic review of published clinical trials recently found that primary care patients with depression had improved outcomes with multifaceted care management during the acute and continuation phases of treatment. Care management involves communication and coordination of care by the primary care provider and a mental health specialist, patient education and support, monitoring of symptoms and adherence to treatment, self-management support, and psychological treatments. This approach was chiefly responsible for, in most cases, a 50% improvement in patients' depressive symptoms over three to 12 months. The authors found that telephoning is often the primary method of care manager-patient communication and that it helps patients adhere to their treatment regimen, enhancing outcomes.
The study's lead author, John Williams, Jr., told AJN that although comprehensive care management is easier to implement in large settings such as the Veterans Affairs health system or through major national health plans, nurses can incorporate aspects of it in smaller practice settings. Effective programs, he said, use the nine-item Patient Health Questionnaire (PHQ-9), a diagnostic tool and treatment guide devised to help primary care providers identify and treat depression.
"Nurses in small practices can make this part of their routine," he said. "Without the PHQ-9, it's like treating hypertension without taking blood pressures."
In therapeutic areas such as mental health, cardiovascular disease, and diabetes, Williams said, "we need to show not only that care management works, but also that it has positive effects on practices and that there's a compelling business case for it. Eventually, there will be [great] demand for nurses trained in care management, so we need to expand education and make an organized effort."
Gary Wolfe, director of case management at the Diabetes Care Center in Salinas, California, and editor of CareManagement, agrees. "Health care has become narrowly focused," he told AJN. "But we're also supposed to be focused on patient education and continuity of care, whether there's a care management program or not. Care management has a much more holistic viewpoint that looks at the whole picture instead of specific tasks. It can start with the staff nurse on the floor."-Sibyl Shalo
Carol Potera