Better mental health treatments urged

Washington -- Diagnosing depression correctly is generally a matter of asking the right questions.

While many other diseases can be detected via blood tests or various scans, a clinical diagnosis is still the way to identify this common mental illness, said Karen L. Swartz, MD, assistant professor of psychiatry at Johns Hopkins University School of Medicine in Baltimore.

But trying to incorporate this often lengthy process is among the biggest challenges for the time-strapped primary care physician, she said. Dr. Swartz is the director of clinical programs at Johns Hopkins' new mood disorders center.

Mental health and substance abuse treatment, long the poor stepchildren of the nation's health care system, received increased attention Nov. 1 as Johns Hopkins announced it was mounting a new offensive to find effective treatments for mood disorders and as an Institute of Medicine panel released a new report urging improvements in the way mental health and substance abuse treatment is delivered.

The IOM report, "Improving the Quality of Health Care for Mental and Substance-Use Conditions," took broad aim at issues that hamper the delivery of appropriate care to the millions of Americans who require treatment for mental illness or for the inappropriate use of alcohol and drugs.

Mental health and substance abuse disorders cause more than 33 million Americans to seek care each year, the IOM report said. But the care they receive is not as good as it could be.

"America will not have a high-quality health system if equal attention is not given to mental health issues and substance abuse problems," said Mary Jane England, MD, president of Regis College in Weston, Mass., and chair of the panel that produced the report.

Among its recommendations, the panel urged physicians and other professionals to adhere to clinical practice guidelines, to use valid and reliable patient questionnaires to assess the progress and outcome of treatments and to work as a member of a team to coordinate patient care.

The panel also asked the Dept. of Health and Human Services to disseminate scientific evidence on effective treatments for mental health and substance abuse and to develop an infrastructure for measuring and improving the quality of care.

There is no question that better treatments are needed, Dr. Swartz said during a Nov. 1 panel discussion on mood disorders.

"We know that depression and bipolar disorder are extremely common," she said. "And there are not a lot of quality treatments."

Delving deep for diagnoses

The new Johns Hopkins center was founded because current treatments for mood disorders are unacceptable, said J. Raymond DePaulo Jr., MD, a co-director of the center and chair of Johns Hopkins' Dept. of Psychiatry. He compared the current state of treatment for these ills to cancer treatment 35 years ago. "While that war [against cancer] hasn't been won yet, we understand it a lot better," he said. He would like to see the same thing happen with depression and other mental illnesses.

Diagnoses for depression are made by recognizing a group of symptoms that include changes in sleep and energy levels. But sorting through those symptoms can be perplexing. For example, "only 50% of people with depression describe themselves as depressed," Dr. Swartz said.

While symptoms such as crying are likely to prompt a diagnosis of depression, a lack of emotion can also be an indicator, but it is not as likely to elicit an accurate diagnosis.

"These are the limitations of our having a clinically based diagnosis. It doesn't mean you can't do it. But it takes time," Dr. Swartz said.

Even with all of its pitfalls, the diagnosis for depression is more straightforward than is the diagnosis for bipolar disorder. While its expansive, often over-the-top energetic phase might not bring a patient to the physician's office, the depressive phase might, thus setting up the possibility that a person with bipolar disorder could be misdiagnosed with depression, she said.

Plus, even if an accurate diagnosis is made, hurdles remain before an optimal treatment is found. Whereas lab tests for illnesses such as urinary tract infections can steer a physician toward an effective antibiotic, treatments for mood disorders are much less clear.

In addition, medications could take four to six weeks to make a difference in a patient's life, while side effects can occur right away, making it difficult to persuade a patient to stick with a treatment course.

Close follow-up is needed with weekly calls, perhaps placed by a nurse, to determine the effectiveness of treatment.

Education is also key, Dr. Swartz said, and for six years she and her colleagues have been traveling to high schools throughout central Maryland, southern Pennsylvania and Washington, D.C., to teach students, teachers and parents about teenage depression and bipolar disorder.

They present a three-hour curriculum to help teens recognize depression in themselves and their friends. The good news is that the course seems to be working, and studies have shown it increases knowledge and changes students' attitudes about depression, Dr. Swartz said.