From the Editor
How successful are we at treating Canadians with depression? How could Canada’s health care system serve these patients better?
This is the ‘all Canadian’ issue of the Reading of the Week.
Readings don’t necessarily follow a theme – but we do this week. The two papers are written by Canadian authors; they tackle Canadian topics; they were published in a Canadian journal, The Canadian Journal of Psychiatry.
The first paper considers depression in Canada, looking at prevalence and treatment over a decade. The second paper champions more effective care for Canadians. Both are readable and relevant.
Depression Trends: Some Good News
“Major Depression in Canada: What Has Changed over the Past 10 Years?”
Scott B. Patten et al., The Canadian Journal of Psychiatry
Major depression has been identified as a global public health priority and was ranked by the Global Burden of Disease Project as the second leading cause of disability adjusted life years in Canada. While efforts have been made to compare different countries in terms of the prevalence and correlates of major depressive episode (MDE), it has not generally been possible to make comparisons over time within countries due to modifications made to diagnostic interviews. Comparisons over time are important for discerning whether progress against this condition is being made. Improved access to treatment and more effective treatment can theoretically decrease the prevalence and impact of this condition. It is important to know whether such progress is occurring.
So opens a paper written by Scott B. Patten et al. from The Canadian Journal of Psychiatry. (Dr. Patten, you will note, is not just a frequent author for this journal, but its editor.) Drawing on two surveys, Patten and his co-authors look at depression – diagnosis, treatment, and impact over a decade. What makes this paper so interesting is that the authors attempt to answer a basic question: are we doing better with this devastating illness?
Consider: with less stigma, people are likely opting for treatment more readily. As well, there are more treatment options (especially medications). So, with these things in mind, the authors “hypothesized that such changes would have resulted in diminished burden of illness…”
This paper is relatively straightforward and draws from two mental health surveys taken a decade apart.
Here’s what Patten et al. did:
· They drew data from the Canadian Community Health Survey: Mental Health and Well-Being, done in 2002 and 2012 by Statistics Canada. In each CCHS, Stats Canada conducted a nationally representative survey of Canadian households, interviewing one representative in selected homes (age 15 or older). For the record, the 2002 sample had an overall response rate of 77% and a final sample of 36,984 respondents; the 2012 CCHS: 69% response rate and a final sample of 25,113.
· Drawing on the survey data, the authors looked at: annual and lifetime prevalence of depression, the use of services and treatment, the Kessler-6 (K-6) distress scale.
· Statistical analyses were done.
Here’s what Patten et al. found:
· “The prevalence of MDE was almost identical in the 2 surveys. The lifetime prevalence in 2012 was 11.3% (95% CI 10.7% to 11.9%), compared with 12.2% (95% CI 11.8% to 12.7%) in 2002. Annual prevalence was 4.7% (95% CI 4.3% to 5.1%) in 2012 and 4.8% (95% CI 4.5% to 5.1%) in 2002.”
· People were more likely to seek out care in 2012. For instance, people who had a depression in the past year saw family docs and psychiatrists more than those with depression back in 2002; they were also more likely to see allied health professions. See the following table.
· Medication patterns showed a shift. People with a past-year MDE used antidepressants more in 2012 over 2002 (33.9% vs. 29.9%); second generation antidepressants were also a more popular choice (7.0% vs. 1.9%). In the general population, the use of second-generation antidepressants was up (0.9% vs. 0.2%) and the use of benzodiazepines was down (1.3% vs. 2.3%). !
· The authors considered “potentially adequate treatment.” That is, whether people received therapy or medications. The surveys didn’t look at people accessing, say, CBT – that said, people who had six or more visits to social workers and psychologists could well have been getting this evidence-based therapy. Good news: “Combined with [antidepressant] use as an indicator of potentially adequate treatment, 52.2% (95% CI 47.8% to 56.6%) of people with past-year MDE were receiving potentially adequate treatment, compared with 41.3% (95% CI 37.9% to 44.7%) in 2002.”
· The mean distress rate among people with past year MDE was similar: 9.8 in 2012, and 9.1 in 2002.
The authors note:
These findings are consistent with positive changes in the direction of better treatment for depression. More people are seeking treatment and their pattern of contact with the health system is consistent with receipt of a higher standard of care. However, more specific conclusions are not possible due to limitations of the data source. For example, some proportion of people with 6 or more visits to a health professional for reasons of mental health may not have received an evidence-based treatment. Conversely, some may have achieved excellent outcomes with a smaller number of visits.
Unfortunately, our conjecture that outcomes would have improved over the past 10 years was not borne out by the findings. The prevalence of past-year episodes among people with lifetime MDE was comparable in the 2 surveys, as were levels of distress among people with past-year MDE.
A few thoughts:
1. This is a great paper. It seeks to answer questions about the prevalence and treatment of depression over a decade – nice.
2. There is good news here. First and foremost: people seem to be accessing care more readily. It’s also true that they seem to be getting more appropriate care: they are either getting medications or therapy (though, of course, the dataset was somewhat limited in regards to the latter point). In fact, the percentage of Canadians getting “potentially adequate care” was way up.
3. There is bad news here, too. Patients are still ill with depression. It’s deeply disappointing that past-year episodes remain as common in 2012 as 2002, and that the mean distress rate didn’t profoundly change. And let’s go back to the good news. Yes, people are getting more “potentially adequate care;” unfortunately a full half of Canadians aren’t.
4. And so the study begs a question: what could be done to better outcomes for those with depression (and, for that matter, other mental illnesses)?
The next selection attempts to answer this weighty question.
Better Care Requires Better Practice?
“Choosing Wisely? Let’s Start with Working Wisely”
Paul Kurdyak et al., The Canadian Journal of Psychiatry, January 2016
There is an increasing emphasis on quality and, relatedly, cost-effectiveness as it relates to the delivery of health care. This is conceptualized by Berwick et al from the Institute for Healthcare Improvement as the triple aim: improving the experience of care; improving the health of populations; and reducing the per capita cost of health care. The focus on quality and cost-effectiveness intensifies at a time when health care costs are increasing and are forecast to increase further still. Consequently, in 2012 the American Board of Internal Medicine initiated Choosing Wisely, a campaign intended to change practice by promoting conversation between health care providers and patients. Choosing Wisely is intended to help patients and their care providers choose effective care that is supported by evidence, waste-free (that is, not duplicative of other tests or procedures already received), free from harm, and truly necessary. The idea behind Choosing Wisely is that, in the absence of conversation and reflection, patients could be subjected to medical tests and procedures that are not supported by evidence, and thus contribute to unnecessary costs and potential harm. Choosing Wisely also emphasizes the importance of investigation and treatment decisions that are not only evidence-informed, but also in keeping with a patient’s personal goals of care determined through a collaborative process.
So opens a paper by Kurdyak et al. from The Canadian Journal of Psychiatry that argues that big changes are needed to care delivery.
The authors begin by noting the thoughtfulness of the Choosing Wisely campaign. Yet they argue a different approach is needed for mental health:
The APA’s participation and recommendations to Choosing Wisely are laudable and grounded in good evidence. However, the most urgent problem facing psychiatry is not reducing unnecessary tests or potentially harmful treatments. The biggest challenge for psychiatry today is to address the poor access to care.
They cite several examples (and I list three):
· Post-discharge physician follow-up for people with schizophrenia is “alarmingly poor.”
· In a Canadian study involving 230 psychiatrists in Vancouver, only 6 were available to provide consultation in a timely manner when contacted by a research coordinator simulating a primary care referral.
· In an Ontario study of psychiatrist supply and practice patterns, “as the number of psychiatrists increases regionally, the average psychiatrist’s outpatient volume decreases.”
“We believe that the Choosing Wisely initiative in psychiatry should be expanded to working wisely.”
Kurdyak et al. go on to make three recommendations for care delivery.
1. They call for a better “alignment” of mental health services with need. For starters, they suggest better and centralized intake.
2. They call for the “types of treatment that provide the most cost-effective way to relieve the burden of mental illness and addiction for the entire population…” That means more evidenced-based care, and closer work with primary care clinicians.
3. Finally, they argue that we need to better measure outcomes to “properly evaluate the performance of the mental health system and to further inform the development of mental health care delivery models.” After all, “you cannot change what you cannot measure.”
Of course, we can ask: is such strong medicine needed? After all, Kurdyak and his co-authors offer a roadmap for changing the way mental health care is delivered in Canada. You can read this excellent “Perspective” paper and draw your own conclusions.
My final thought: given Patten et al.’s conclusion that half of Canadians with depression get “potentially adequate treatment,” isn’t strong medicine needed?
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.