A recent study in the United States has revealed that many patients suffering from depression who are high utilisers of medical services, will respond well to treatment afforded by physicians who consult closely with psychiatrists. This enhanced method of providing treatment results in considerable financial savings to both the patient and health insurance provider, and presents a way of dealing with the many problems in this regard currently experienced in South Africa.
According to Dr David Katzelnick of the University of Wisconsin, closer working relationships between doctors and psychiatrists can bring about effective treatment programmes and enhance treatment compliance among patients. “The driving concept should be that doctors hold psychiatrists other mental health professionals with the same regard as they do specialists in other fields”. In South Africa, the lack of recognition of Psychiatrists as professionals in the treatment of depression and anxiety disorders makes this considerably difficult. According to Dr I.J. Eidelman, a local Psychiatrist in private practice, “Psychiatrists in South Africa encounter particular discrimination from Health Management Companies, who often downplay the abilities of Psychiatrists, viewing them on a par with Psychologists and Social Workers”.
In a pilot research study conducted at two primary care clinics in the United States, the financial benefits of closer liaison between medical professionals have been highlighted, both for patients and medical aid companies. It was found that primary care doctors who sought increased levels of psychiatric support (depending on patient response), were able to effectively halve the utilisation of medical services by depression patients with a history of high medical service use.
Of a screening sample of 100,000 patients, 10,461 were defined as high utilisers of medical services (averaging seven to eight visits to medical service providers each year). Of the high-utilisers, 14% suffered from major depression. The research study involved randomly assigning patients into a depression management programme or merely informing them of their diagnosis. The depression management programme made use of primary care doctors to diagnose and treat patients with antidepressants for 10 weeks. After 10 weeks, if there were no signs of improvement, the doctor consulted with a psychiatrist – if improvement continued to be unsatisfactory, patients were referred to psychiatrists for further treatment. The program also included a co-ordinator who ensured that patients filled prescriptions and attended follow-up visits, and also made use of extensive educational material in the way of books and videos. After six months of follow-up, the proportion of patients treated in the management programme who remained in remission was significantly higher than those not treated in the programme.
In another study, it was discovered that elderly patients with chronic medical problems make greater use of health care resources and services if they suffer from depression, according to Dr Jurgen Unutzer of Seattle University in the USA.
Based on a four-year survey of 2558 elderly patients in a large health maintenance organization, results indicate that costs in all areas of medical care are higher for depressed patients, regardless of the severity of their physical illnesses. At the start of the study, the overall health-care costs of patients with significant depression symptoms averaged almost R90,000 compared to the R60,000 incurred by patients without depressive symptoms. The depressed group utilised more services in all categories of medical care, including outpatient visits, prescriptions and laboratory tests. Specialty mental health care accounted for only 1% of costs. Investigators have speculated that depression amplifies patient’s physical symptoms – including pain and medication side-effects – and often leads to inadequate nutrition, all of which substantially increase both the use and cost of medical services.
In spite of the obvious benefits of early diagnosis and treatment, health maintenance organizations continue to harbor discrimination against mental illnesses, the anxiety disorders in particular. Anxiety disorders, and depression to a lesser extent, are still not viewed as “real” illnesses by several organizations. Dr Eidelman and numerous other influential psychiatrists believe that health maintenance organizations are currently making tremendous profits through denying treatment to needy patients. Although close co-operation between patients, health-care providers and health management organizations (HMOs) is imperative, attempts at providing suitable treatment options are being hampered by issues of confidentiality and the use by HMOs of unsuitably qualified professionals. The recording of telephone conversations between doctors and health case managers remains a contentious issue, impinging on the rights of patients to confidentiality and protection.