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The World Health Organization predicts that by 2020 the leading disability in women worldwide will be depression. Women are at higher risk for both depression and suicide. At present, twice as many women as men (17%) will have a major depressive disorder in their lifetime. They have more severe symptoms, including self-criticism, guilt, worthlessness, anxiety, low energy and interpersonal sensitivity. (Carpenter)

Suicide is an escape behavior; a way to get out of seemingly unmanageable problems, including the pain of anxiety, guilt, hopelessness, loss of status, job and money, and/or relationship separation or conflict. Both disorders reflect the additional risk factors for women: intimate partner violence, eating disorders and hormonal changes. (Jordan)

Patients with multiple physical and behavioral health problems often are treated by providers, who “don’t talk to each other and make the patient way worse,” according to Jane Hayward, CEO and President of the Community Health Center Association. When chronic pain, substance abuse and chronic mental health issues are combined in one patient, the costs of treatment are 7 times higher than with just one situation. People with chronic mental illness are likely to die 25 years sooner than the average.

In many practices, including Community Health Centers, legal precedents and payor policies lag behind new integrated care solutions, and can inhibit effective patient treatment. This is a compelling issue now because of the epidemic issues around depression and prescription drug misuse, increase in illicit drug misuse and the unmet need for affordable, accessible mental health professionals.

Also of note: no one system of care is right for every setting. Effective systems of integrated care must be culturally specific. “If you’ve seen one health center, you’ve seen one health center.” (Hayward)

Good to Know

Depression is linked to multiple factors: aging, genes, hormone changes, exposure to toxins, infectious pathogens, injury and inflammation. Early childhood stress is a powerful contributor, including low socioeconomic class. Evidence of abuse and neglect is visible in brain tissue; abuse and neglect leaves a biological scar, which indicates risk of chronic inflammatory illnesses, depression and suicide.

Conditions linked to depression include diabetes, obesity, smoking, alcohol and a sedentary lifestyle. These co-existing conditions should be treated together. (Carpenter)

Bullying often precedes sexual violence and suicidal ideation. Students who are bullied at school are at higher risk of suicide. Men are exposed to more physical violence; women to more sexual abuse. (Perez)

Suicide is like having a glass already filled to the brim; just one more drop of agitation from panic, anger, helplessness—and in that moment the scale is tipped towards self-harm. It is the ultimate expression of hopelessness: “There is no answer for me and I’m giving up.” (Jordan)

Roadmap to Care

Improved care from the Community Health perspective means increasing better outcomes and decreasing costs. Many patients require a level of complex care no one person can provide. Some basic principles for integrated care include

  • Patient-aligned financial incentives that allow providers to do what they do best
  • Real-time patient information sharing
  • Multi-discipline care teams
  • Networks of care

Rapid Access RI demonstrates one approach—an urgent care center designed to divert people from expensive and excessive ER use. The Providence Center is seeing good outcomes in their intersection of primary care and behavioral health care. The challenge remains: continue to look for ways to integrate disciplines and overcome legal and policy barriers, because “We forget that we need to focus on systems of care, not systems of silos.” (Hayward)

In Your Practice

When the potential for depression or suicide appears, learn as much as possible about the patient’s history of trauma and functional impairment. Initial screening questions are listed on the Pocket Cards created for this workshop: Screening for Depression which includes the patient self-screening form (PHQ-9), and the series of suicide risk assessment questions known by the mnemonic IS PATH WARM? The SAFE-T card details Risk Factors, Protective Factors, Suicide Inquiry and recommended Interventions.

Other questions recommended at the workshop include:

  • Have you ever had a period in your life when you didn’t care whether you lived or not?
  • How will you behave differently when your depression is better? What is the end point? How will you know?

Consider how to move from silos of care to integrated systems of care, where the approaches of PCP’s and therapists come together to create:

o   Improved physical health, including nutrition (i.e. vitamin D for depression) and exercise to change sedentary lifestyle.

o   Behavioral health care including sessions to raise hope and self-esteem, internalize qualities of maternal warmth and assume more self-responsibility.

o   Social health including support groups for depression and suicide survivors, peer navigators and an on-going care team.

o   Complementary activities including massage, chiropractic treatments, acupuncture for pain and improved energy, and light therapy to relieve depression.