According to the Diagnostic and Statistical Manual 4th Edition, rates for depression in many chronic disease states are very high. In fact, almost every physical disease that involves case management has a high likelihood of co-morbid depression. Medical patients who are clinically depressed have higher utilization of healthcare with greater costs. Given the high co-morbidity, the fact that treating depression can reduce healthcare utilization and enhance physical functioning and overall quality of life, medical patients in case management should routinely be assessed for depression immediately upon entering the case management process.

Patients should also be reassessed anytime there is a significant change involving either a deterioration of health status or life circumstances, or an unexplained improvement in mood. Obviously, worsening health or increased life stress can cause, or increase, depression. Unfortunately, someone who has been very depressed and suddenly and unexpectedly is in a far better mood can feel this way because they have decided on suicide as a viable option to resolve their problems. Therefore, part of this screening should also include a question as to thoughts of suicide. The reader is referred to the April/May 2010 issue of Case In Point magazine for a more detailed discussion of case management and suicide assessment.

To assess depression the case manager needs to be thoroughly familiar with the symptoms. Some of the more common symptoms include the following and occur for most or all of the day, for a period of at least two weeks:

• Depressed mood (such as feelings of sadness or emptiness).
• Reduced interest in activities that used to be enjoyed.
• Sleep disturbances (either not being able to sleep well or sleeping too much).
• Loss of energy or a significant reduction in energy level.
• Difficulty concentrating, holding a conversation, paying attention, or making decisions that used to be made fairly easily.
• Appetite disturbance (either diminished appetite and weight loss or increased appetite and weight gain).
• Suicidal thoughts or intentions.

It can be confusing to determine if someone is actually depressed or experiencing sadness as an understandable and transient response to life circumstances. While everyone experiences periods of sadness, depression interferes with the person’s capacity to function on a daily basis and may last for a few months to many years if not treated. Further complicating the assessment process is the clinical fact that some symptoms of depression are the same as those found in medical conditions.

 

Step One: Face to Face Insights

To assess depression by an interview, the patient can be asked about the presence of the above symptoms in a conversational and supportive manner. In addition to the information gathered from talking to the patient, there are several reasons to use depression questionnaires to supplement interview information during the case management of medical patients. Many medical patients do not initially feel comfortable discussing depression, feeling ashamed of their depressive state and assuming they should focus only on their physical condition.Patients often try to be “good patients” and do not always volunteer their level of suffering, believing it might burden the case manager. Checking for depression with a valid screening instrument may be more comfortable to a patient while helping to quantify emotional pain. Thus, assessment tools can help diagnose depression and can also supply important information to clarify the stark difference between temporary sadness and severe depression.

There are a number of commonly used questionnaires available for assisting with screening. However, it is important to know whether the questionnaire is developed for the general population and medically healthy individuals, or developed to be used with the medically ill. While physical symptoms such as loss of energy can be highly suggestive of depression in healthy individuals, in medical patients this same symptom could be entirely due to the illness or medication and not be indicative of depression.

Fortunately, there are several tools readily available that have been demonstrated to be effective for screening depression in medical patients. One such instrument is the Two-Question Case-Finding Instrument. The case manager asks two simple questions about depressed mood and anhedonia.The patient’s answers have extremely high sensitivity for detecting depression. Sensitivity refers to an instrument’s ability to detect possible depression. The Patient Health Questionairre-2 (PHQ-2) is another example and again features two questions that have been demonstrated to have high sensitivity.

Like the shorter PHQ-2, the PHQ-9 was developed for the general medical population and has been found to have high specificity in assessing depression in medical patients. Specificity refers to the instrument’s ability to assist in more specifically indicating depression. It has seven additional questions that help determine more accurately whether the patient is depressed and also asks about thoughts of suicide. Information about suicide potential is valuable to the case manager and the healthcare provider in caring for the patient.

A positive response to any screening tool indicates the need for a more detailed assessment as to whether the patient is depressed. Depending on the licensure level of the case manager, this responsibility might be theirs or, at a minimum, it would serve as a trigger to be an advocate for the patient with healthcare providers to follow up and assure that the patient is properly diagnosed and treated.

Research demonstrates that depression can be treated effectively with psychotherapy and/or medication. Most patients undergoing treatment should expect to be feeling some relief within several weeks. Many physicians are comfortable with starting antidepressant medication and conterminously referring the patient for a psychiatric consultation if needed. Psychotherapy can typically be quickly arranged. It is important to get treatment started as soon as possible. If left untreated, depression can become life-threatening when the patient seriously considers suicide as a way to end suffering. Depression can also result in feeling hopeless and helpless and cause the patient to be unable or unwilling to follow their healthcare regimen and just “give up.”

Another valuable resource for case managers may be the patient’s insurance company. Many insurance carriers have behavioral health case managers available. As an example, New Directions Behavioral Health® provides case management for those patients with psychiatric needs as well as co-case management with the medical case managers. These services include coordinating care and communication among the patient’s healthcare and mental health providers. Additionally, they assist with coaching patients about managing their health condition, and provide medication adherence education and health literacy. This involves helping patients understand terminology and diagnosis and coaching them on what questions to ask their provider.

Fortunately, the case manager is in a position to provide support, educate patients and assist them in getting help. A troublesome symptom of depression is the lack of energy and sense of hopelessness as well as helplessness. As such, depressed patients may not advocate for themselves. Providing the legwork of contacting the healthcare provider to give a heads up and coordinate care as well as giving their own professional observations can go far in helping patients actually receive treatment for depression. Additionally, many medical patients assume that they should not feel as depressed as they do and focus more exclusively on their physical symptoms rather than their emotional ones. In fact, often they can be offended at the suggestion that they also are clinically depressed as being a sign of weakness. It is important that the case manager help educate the patient to understand that rather than a sign of weakness, it is a potential side effect of the physical condition (e.g., heart disease, diabetes) and therefore preventable and treatable.

It is important for case managers to screen for depression on the initial interview and routinely thereafter. It is especially important to again screen for depression if there has been a significant change, good or bad, in the medical patient’s health or their life circumstances. The case manager is in a unique position to have a “finger on the pulse” of these patients more frequently than many other healthcare providers. They are in an integral position to help screen, gain treatment, and monitor improvement. While depression may occur with many medical conditions, early and accurate assessment can lead to effective treatment.

 

Brent L. Halderman, Ph.D., is a psychologist with over 30 years of experience. He is in private practice and is the clinical manager for New Directions Behavioral Health Employee Assistance Program. Contact: bhalderman@ndbh.com. James R. Eyman, Ph.D., practices psychotherapy and psychological, neuropsychological and forensic evaluations at Heritage Mental Health Clinic in Topeka, Kan. He has several publications and has presented many workshops. Contact: jeyman@heritagemhc.org