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January 14, 2010 Volume VI, No. 33

HIN Communications Editor Jessica Papay

Dear Healthcare Intelligence Network Client,

With the recent news that people with severe depression receive more of a benefit from antidepressant medication than people with mild or moderate depression, this week's issue examines other aspects of this particular mental illness. Discover the link between sleep and depression, the risks of depression during pregnancy and some surprising disparities in depression care.

The consequences of untreated or inadequately treated depression are significant; therefore, adherence to antidepressant medication is very important. Be sure to take this month's e-survey on medication adherence by January 31 — you'll receive a summary of compiled results and learn how your peers are improving medication adherence.

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

This week's DM news:

Table of Contents

  1. Putting Depression to Bed
  2. Depression Risks During Pregnancy
  3. Health Coaching ROI
  4. Mental Health Screening Tools
  5. Healthcare Trends: Targeting Depression Through DM
  6. Disparities in Depression Treatment
  7. Medication Adherence

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

Melanie Matthews, mmatthews@hin.com

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More Sleep May Reduce Depression in Teenagers

Researchers at Columbia University Medical Center have found new evidence that inadequate sleep can lead to depression and suicidal thoughts in adolescents. The study of nearly 16,000 teenagers in grades 7 to 12 found that adolescents with bedtimes set at midnight or later were 24 percent more likely to suffer from depression than those with bedtimes of 10 p.m. or earlier. Teenagers with later bedtimes also were 20 percent more likely to have suicidal thoughts. Depression and poor sleep often go hand in hand, but sleep difficulties are usually seen as a symptom of depression, not a cause, according to James Gangwisch, Ph.D., assistant professor in the Department of Psychiatry and lead investigator of the new study.

To see if sleep deprivation can lead to depression, researchers would have to alter teenagers’ sleep schedules and record the results. Such an experiment would be unethical, given other known detriments of sleep deprivation, and too expensive with large numbers of teenagers. Instead, Dr. Gangwisch did the next best thing. He gathered data from a “natural experiment”: what happened when teenagers had their bedtimes imposed by their parents. These data on bedtime and depression came from a previous survey, the National Longitudinal Study of Adolescent Health, conducted between 1994 and 1996. “Depression in adolescents can affect their choice of bedtime, but it’s less likely to affect their parents’ choice,” Dr. Gangwisch says, “By using data from the survey, we got some of the benefits of a large experimental study without the drawbacks. Together with smaller studies that have shown sleep deprivation alters mood in teenagers, our finding is strong evidence that inadequate sleep plays a role in causing depression.”

The reasons why sleep deprivation may lead to depression, though, are still unclear. Dr. Gangwisch says moodiness from a lack of sleep may interfere with a teenager’s ability to cope with daily stress or impair relationships with friends and family. Suicidal thoughts may increase due to the effects of insufficient sleep on judgment, aggression and impulse control. Of course, telling teenagers to go to bed at 10 p.m. does not mean they will actually go to sleep. But nearly 70 percent of the teenagers in the study reported going to bed at or before bedtimes set by their parents.

To learn more about this research, please visit:

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Pregnant Women at Risk for Depression if Stressed, Lack Social Support

A new University of Michigan (U-M) study published in the American Journal of Obstetrics and Gynecology finds that factors such as stress, mental health history, social support and whether a pregnancy was intended contribute to a woman being more at risk of experiencing depression than others. Depression, experienced by as many as 12.7 percent of pregnant women, is a serious complication that, if identified, can be treated during pregnancy.

Researchers set out to study risk factors that could help doctors evaluate a patient’s risk for depression while pregnant. The study consisted of a literature review that evaluated 159 English-language articles published between 1980 and 2008 conducted in the U.S., Europe, Canada, New Zealand and Australia. Those studies looked at risk factors such as maternal anxiety, life stress, history of depression, a lack of social support, unintended pregnancy, type of medical insurance, domestic violence, lower income, lower education, smoking, relationship status and poor relationship quality.

Because more organizations are now promoting screening women for depression during each trimester of pregnancy, researchers deemed it important to identify the risk factors. Study results showed that maternal anxiety, life stress, prior depression, lack of social support, domestic violence, unintended pregnancy, relationship factors and public insurance have a high correlation with depressive symptoms in pregnant women.

Numerous studies have been conducted regarding postpartum depression, but few have looked at risk factors for depression while a woman is pregnant. U-M researchers felt that studies that concentrate on post-partum depression are not adequate in evaluating depression risks in pregnant women because factors such as pregnancy intention and social support may vary before and after the arrival of the baby. Therefore, those factors could potentially be related to depression at one time point but not another.

To learn more about this research, please visit:

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Health Coaching Evaluation — Measuring the ROI on Healthcare Utilization and Costs

The dismal economy of 2009 has been a bright spot for health coaching and other health improvement programs, notes Dr. Jim Reynolds, chief medical officer for Health Fitness Corporation. Dr. Reynolds also compares early results from a Massachusetts' smoking cessation program for Medicaid beneficiaries with outcomes in commercial populations, and describes what Year 1 of a coaching program for improved medication adherence might yield in the way of behavior change and cost impacts.

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Mental Health Screening Tools

Each week, healthcare professionals respond to a reader's query on an industry issue. This week's experts are Joe Eppling, assistant vice president of post acute and behavioral health services at East Jefferson General Hospital, Louisiana and Julie Szempruch, associate vice president and chief nursing officer for the Midtown Mental Health Center, Wishard Health Services, Indiana.

Question: What types of screening tools are used in retail and convenient care clinics that are dealing with the mentally ill population? Is every patient screened with these psychiatric tools or are you looking for certain situations?

Response: (Julie Szempruch) Screening techniques for clinics are still being developed. They are not something that we have a long history with. However, tools that screen for depression, addiction, anxiety — all of these are important in examining patients that are being seen for various needs. We know that if those mental areas are not being taken care of while patients are getting their physical needs met, they may still end up in the medical ED.

To determine which patients get a more in-depth screening, there are some triggers that we look for. In the future, we’ll look toward adding a few questions to the forms that patients fill out when they come into a doctor’s office for a first visit that are geared toward determining whether there might be mental health or addiction issues to deal with.

(Joe Eppling) We use some depression screening assessments, but we don’t have any formal screening tools. It’s more of an intake assessment from the psychiatric nurse. From that, we try to determine admission criteria based upon state regulations.

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Healthcare Trends & Studies: 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 October 2008 e-survey from the Healthcare Intelligence Network (HIN), 250 healthcare professionals shared how their organizations are targeting depression in DM initiatives.

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Too Few Americans with Major Depressive Disorder are Receiving Adequate Care

Only about half of Americans diagnosed with major depression in a given year receive treatment for it and even fewer — about one-fifth — receive treatment consistent with current practice guidelines, according to data from national surveys supported by the National Institute of Mental Health of the National Institutes of Health. Among the groups surveyed, African-Americans and Mexican-Americans had the lowest rates of depression care, and all groups reported higher use of psychotherapy versus medication treatment. Findings from this study will inform future research on adherence to various depression therapies, and the factors that shape differences in care among racial/ethnic groups.

A team of researchers from Wayne State University, the University of Michigan, the University of California, Los Angeles and Harvard University have published a paper in the January 2010 Archives of General Psychiatry that gives a detailed picture of the care received for major depression among different ethnic/racial groups and factors that contribute to disparities. The paper reports that too few Americans with recent major depressive disorders receive adequate depression care, and most receive no care at all.

African-Americans and Mexican-Americans, in particular, may be facing greater barriers to mental healthcare. "Contrary to our expectations that most Americans with depression would be using antidepressant drugs, we actually found higher psychotherapy use, especially among ethnic and racial minorities," said Hector González, professor from the Institute of Gerontology and Family Medicine and Public Health Sciences Department at Wayne State University. "We found in our study that there are really distinctive differences in mental healthcare use between Mexican-Americans and other Latino subgroups that have not been previously reported," said González. The authors provided evidence of well-defined disparities in depression care that mostly affected African-Americans and Mexican-Americans.

All groups were more likely to have received psychotherapy than pharmacotherapy. Caribbean blacks and African-Americans were particularly unlikely to receive pharmacotherapy consistent with APA guidelines; enabling factors such as education, health insurance and income did not explain the lower rates of medication use. The authors note possible reasons for this, including research indicating that perceived discrimination can shape healthcare seeking. They speculate that the non-immigrant status of Puerto Ricans — and with that, greater predominance of English language use within this group — may be factors in their relatively high rates of healthcare use.

To learn more about this research, please visit:

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Medication Adherence

Of 1.8 billion prescriptions dispensed annually in the U.S., only 50 percent are taken correctly by the patient, according to the World Health Organization. Beyond increasing risk of death, poor medication adherence is tied to as much as $290 billion annually in increased medical costs and responsible for 33 to 69 percent of all medication-related hospital admissions in the U.S., at a cost of about $100 billion per year. Please share your organization's efforts to improve medication adherence by completing HIN's Survey of the Month by January 31, 2010. You'll receive a free executive summary of the compiled results. Your responses will be kept strictly confidential.

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

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