Mind Mental Health

Depression Is a Public Health Crisis. Why Don’t We Treat It Like One?

December 15, 2017
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Quick Read

Depression is disabling, not just difficult

  • Depression carries a public health burden because, while millions experience it, many don't seek help for it.
  • There are many barriers to treatment, including proximity to a therapist and the frequent need to try several medications before an effective one is found. 
  • Collaborative care—where mental health treatment is integrated with primary care—is one solution for making treatment more accessible.
  • Follow-up after a new treatment is tried is rarely done—but is incredibly important. 

There is a misconception that depression is just about feeling sad, but it can be so much more than that. Depression is actually a serious condition that usually has a number of symptoms, including things that aren’t obvious, like losing your appetite, wanting to sleep all the time or having difficulty with concentration.

An estimated 16.1 million people had a major depressive episode in 2015, according to the National Institute of Mental Health. Many of those people may not seek help, says Jesse Fann, M.D., a psychiatrist who sees patients at Seattle Cancer Care Alliance.

“Depression carries a big public health burden,” says Fann.

That’s because depression is disabling. Among mental and behavioral disorders, depression is responsible worldwide for 1.84 percent of all DALYs, or disability-adjusted life years, according to 2016 data from the Global Burden of Disease (GBD) study.

DALYs account for years of life lost to illness, disability or premature death.

To put this in context: DALYs for depression are comparable to those for chronic kidney disease, tuberculosis and falls, and higher than those for Alzheimer’s disease and many types of cancer.

Barriers to treatment

Though depression is common and treatment effective, access to care presents a problem for many people. There are several reasons for this. Psychiatrists can be hard to find especially in rural areas, and primary care doctors may not have the capacity to provide the focused care that depression requires, says Marc Avery, M.D., a psychiatrist and director of the University of Washington School of Medicine’s telepsychiatry program.

In a standard primary care visit, someone who is feeling depressed and brings it up will likely be treated in one of two ways, Avery says. They will either be prescribed an antidepressant medication on the spot or will be referred to a psychiatrist.

Those approaches may or may not work for that particular patient, Avery says, for a variety of reasons. The first or even second medication prescribed might not work. The psychiatrist might be located too far away from the patient or may not be covered by their insurance. All of these factors may seem small but are very real reasons people don’t get the care they need, Avery says.

Adding yet another layer of complexity is the fact that some depression symptoms—such as reduced self-esteem, energy levels and motivation—can prevent people from seeking care as well, as can the erroneous idea that they don’t need to.

“A lot of people still feel it’s something they should be able to cope with on their own,” Fann says.

A change in philosophy

One solution is an approach known as collaborative care, where mental health care is integrated with primary care. The idea is to meet people where they’re at and enable them to meet with a therapist at the primary care clinic they’re already going to.

That’s a good strategy, Avery says, since up to 20 percent of patients coming to primary care visits meet criteria for a depression diagnosis.

“In collaborative care, the therapist is right down the hall. They might not have time to see you that day, but they will be able to introduce themselves and talk about when they can see you,” Avery says.

Beyond practicality, collaborative care also influences a philosophical change, from viewing mental illness as an issue isolated in the brain to recognizing it as a physical condition like any other kind of illness.

“Why is it so easy to get treatment for something like high blood pressure, and so difficult to arrange for treatment for depression? People often devalue the concept of mental health as a bona fide condition and devalue treatments,” Avery says.

The necessity of follow-up

Equally important as effective treatment is effective follow-up, making sure whichever treatment method someone is using—medication, therapy or a combination—is actually helping them get better. This may seem obvious, but it hasn’t been the standard in primary care settings, Avery says.

In one study, 80 percent of psychiatrists surveyed said they did not use any kind of assessment scale—such as the proven-effective PHQ-9 survey—to measure depression in their patients.

Another study found that many therapists don’t know when their patients’ symptoms are worsening.

If people aren’t improving, they might get discouraged and stop seeking care. Since the expectation of getting adequate treatment for depression can be as low as 15 percent, good follow-up is important, says Avery. It can also involve reconnecting with patients who haven’t been seen recently.

Though collaborative care and follow-up still need to be implemented in many practices, Avery sees this as the direction the country is moving in—to the advantage of both patients and providers.

“We’re finally on the right track in terms of depression care,” says Avery.