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October 7, 2010 Volume VII, No. 14

HIN Communications Editor Jessica Papay

Dear Healthcare Intelligence Network Client,

In honor of today's National Depression Screening Day, this week's issue highlights trends in depression — how it affects dialysis patients and how meditation can decrease depression in MS patients. This issue also provides new guidelines for depression treatment, recently released by the APA.

Your colleague in the business of healthcare,
Jessica Papay
Editor, Disease Management Update

This week's DM news:

Table of Contents

  1. Depression Affects Dialysis Patients
  2. Depression, MS & Meditation
  3. Health Coaching ROI
  4. Recognizing Depression in Clients
  5. Trends in Pharmacist Reimbursement
  6. Targeting Depression Through DM
  7. Public Health & Prevention Priorities
  8. Healthcare Trends for 2011

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Please send comments, questions and replies to jpapay@hin.com.

Melanie Matthews, mmatthews@hin.com

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Depression, Inactivity May Lead to Higher Unemployment for Dialysis Patients

Many patients with kidney failure who were actively employed one year before beginning dialysis treatments are no longer employed early in their first year of treatment, according to a study from Emory University. According to the study, depression and reduced physical activity may play a key role in dialysis patients leaving the ranks of the employed.

Among 585 end stage renal disease (ESRD) dialysis patients who had worked in the previous year, only 191 (32.6 percent) continued working after initiating dialysis. The study revealed that only 12.1 percent of patients who remained employed had possible or probable depression — compared with 32.8 percent of patients who were no longer employed. In addition, patients who scored higher on questions related to their level of physical activity were more likely to continue working.

“It is well established that depressed mood and inactivity are prevalent among patients on dialysis, but no previous studies in the U.S. have examined the associations of these variables with patients’ employment status,” says Nancy Kutner, Ph.D., professor of rehabilitation medicine and sociology at Emory University. “Controlling for receipt of disability income, we found that patients with depressed mood and those with reduced activity levels were significantly more likely to leave the labor market when they started dialysis. Both depressed mood and usual activity level are variables for which simple screening measures are available. Depressed mood and low activity can be addressed with interventions prior to, as well as after, dialysis start, and prior research shows that improvement in each of these areas is likely to also improve the other.”

When the Medicare ESRD Program was established in 1972, Congress expected that most dialysis patients would be able to continue working and contributing to society, with the remainder being able to return to work after receiving vocational rehabilitation services, according to Dr. Kutner. Employment is important for an individual’s self-esteem, and most patients say that they would like to work. About two-thirds of ESRD patients who are employed prior to dialysis leave the labor force when they start dialysis, however. Availability of Social Security disability income is a potential disincentive, although most people can earn much more by working than they would receive from disability.

To learn more about this research, please visit:

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Mindfulness Meditation May Ease Fatigue, Depression in MS

Learning mindfulness meditation may help people who have multiple sclerosis (MS) with the fatigue, depression and other life challenges that commonly accompany the disease, according to a study published in a September issue of Neurology®, the medical journal of the American Academy of Neurology. In the study, people who took an eight-week class in mindfulness meditation training reduced their fatigue and depression and improved overall quality of life compared to people with MS who received only usual medical care. The positive effects continued for at least six months.

For the study, 150 people with mild to moderate MS were randomly assigned to receive either the eight-week meditation training or only usual medical care for MS. The class focused on mental and physical exercises aimed at developing nonjudgmental awareness of the present moment or mindfulness. The training included weekly classes lasting two and a half hours, plus one all-day retreat and 40 minutes per day of homework assignments. “MS is an unpredictable disease,” said study author Paul Grossman, Ph.D., of the University of Basel Hospital in Switzerland. “People can go for months feeling great and then have an attack that may reduce their ability to work or take care of their family. Mindfulness training can help those with MS better to cope with these changes. Increased mindfulness in daily life may also contribute to a more realistic sense of control, as well as a greater appreciation of positive experiences that continue be part of life.”

Participants in the mindfulness program showed extremely good attendance rates (92 percent) and reported high levels of satisfaction with the training. Furthermore, very few (5 percent) dropped out of the course before completion. Those who went through the mindfulness program improved in nearly every measure of fatigue, depression and quality of life, while those who received usual medical care declined slightly on most of the measures. For example, those with mindfulness training reduced their depressive symptoms by over 30 percent compared to those with no training. Improvements among mindfulness participants were particularly large for those who showed significant levels of depression or fatigue at the beginning of the study. About 65 percent of participants showed evidence of serious levels of depression, anxiety or fatigue at the start of the study, and this risk group was reduced by a third at the end of training and six months later.

The other benefits of the training were also still apparent six months after the training ended, although they were sometimes reduced compared to right after finishing the training. Reductions in fatigue, however, were stable from the end of treatment to six months later. An accompanying editorial pointed out that because there was not an active control group (using a different type of intervention), it is unclear that the good results were specifically a result of mindfulness training.

To learn more about this research, please visit:

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Calculating the Health Coaching ROI

According to Paul Terry, Ph.D., president and CEO of StayWell Health Management, when evaluating health coaching and population health programs, it is rare to see a return on investment in a program's first year, but generally by the second and third years, ROI begins to build. In addition to discussing ROI trends, Terry evaluates the value of self-reported data and the impact health coaching can have on an organization's productivity, presenteeism and absenteeism.

To listen to this complimentary HIN podcast, please visit:

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Recognizing Depression in Clients

Each week, healthcare professionals respond to a reader's query on an industry issue. This week's experts are Danielle Butin, former director of health services at Oxford Health Plans, a United Healthcare company, and Kerry Little, senior health coach with Duke University Medical Center.

Question: How do you help people who might be severely depressed, anxious or experiencing serious mental illness? Do you refer these participants to specialists?

Response: (Kerry Little) We refer them out. During our Strategic Health Planning study, we conducted a survey to identify participants who might be depressed. Usually, people who are severely depressed aren’t able to stick with the program and are not able to move forward. Any time in the coaching situation when someone repeatedly is not able to meet the weekly goals they’ve set for themselves, there’s a block. Something else is going on in their life. We ask them about it and look into it. I’ve made many referrals to therapists.

(Danielle Butin) We have a mini internal social service agency department called Education and Outreach. Any issues around grief, depression, psychosis or other behavioral issues are funneled from our coaches to that department, who then refers the member to the appropriate specialist. This staff is an extraordinarily kind, sensitive group who manages behavioral issues around aging.

For more information on depression management, please visit:

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Trends in Pharmacist Reimbursement

Many healthcare organizations reported a strong effort to improve medication adherence levels, with a serious focus on patient education and primary responsibility assigned to either the PCP or pharmacist. We wanted to see which medication adherence-related tasks were reimbursable for pharmacists.

Click here to view the chart.

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Targeting Depression Through DM

Nearly 6 percent of men and almost 10 percent of women worldwide will experience a depressive episode in any given year, and in America alone, approximately 18.8 million adults have depression. In an e-survey from the Healthcare Intelligence Network (HIN), 250 healthcare professionals shared how their organizations are targeting depression as part of their DM initiatives.

To download this complimentary white paper, please visit:

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APA Releases New Guidelines on Treatment of Major Depressive Disorder

The American Psychiatric Association (APA) released a new clinical practice guideline for the treatment of patients with major depressive disorder. This guideline updates a previous version published 10 years ago and includes new evidence-based recommendations on the use of antidepressant medications, depression-focused psychotherapies and somatic treatments such as electro-convulsive therapy. The guideline addresses other topics as well, including alternative and complementary treatments, the treatment of depression during pregnancy and strategies for treatment-resistant depression.

A few key changes to the guidelines include:

  • Rating scales: The guideline recommends potentially using a clinician- and/or patient-administered rating scale to assess the type, frequency and magnitude of psychiatric symptoms in order to tailor the treatment plan to match the needs of the particular patient.
  • New strategies for treatment-resistant depression: The guideline explains that electroconvulsive therapy has the strongest data supporting it as a treatment for patients who do not respond to multiple medication trials. Transcranial magnetic stimulation and vagus nerve stimulation have also been added as potential treatments for these patients. Monoamine oxidase inhibitors, known as MAOIs, are also an option.
  • Exercise and other healthy behaviors: The guideline cites randomized, controlled trials that demonstrate at least a modest improvement in mood symptoms for patients who engage in aerobic exercise or resistance training. Regular exercise may also reduce the prevalence of depressive symptoms in the general population, with specific benefit found in older adults and individuals with co-occurring medical problems.
  • Maintenance treatment recommendation strengthened: The guideline recommends that after the continuation phase, maintenance treatment should be considered, especially for patients with risk factors for recurrence. Maintenance treatment should definitely be provided for patients with more than three prior depressive episodes or chronic illness.
The work group was made up of APA members with extensive research and clinical expertise in the assessment and treatment of major depressive disorder. The group reviewed over 13,000 articles published from 1999 — when the search from the previous edition ended — to 2006. Draft versions of the guideline underwent extensive review by more than 100 stakeholders, including experts from the field of psychiatry, allied physician organizations, patient advocacy groups and members of APA. More than 1,000 comments were submitted and each comment was reviewed by the work group and APA’s steering committee on practice guidelines; substantive revisions were made in response to comments. In 2009, an independent panel of depression treatment experts without ties to industry specifically reviewed the guideline for potential bias, and the final guideline was approved by the APA board of trustees.

To learn more about this research, please visit:

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Healthcare Trends for 2011

Following this year's passage of the Patient Protection and Affordable Care Act, the real work of healthcare reform has begun. To learn how fellow healthcare companies are preparing for 2011, complete HIN's sixth annual survey on Healthcare Trends in 2011 by October 31. You'll receive a free executive summary of the compiled results, and your responses will be kept strictly confidential.

To participate in this survey and receive its results, please visit:

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