David Katzelnick, M.D.
Chair, Division of Integrated Behavioral Health, Mayo Clinic

With a world of health information literally at our fingertips, patients are more informed and engaged than ever. Research indicates that patients who are actively involved in their own healthcare receive higher quality care and achieve better health outcomes.

Yet when it comes to mental health care, there is a lag in patient involvement, often because of the stigma attached to mental illness. Patients may feel deep shame and view their illness as a character weakness, rather than a diagnosable medical condition. As a result, they may be less motivated to seek health information and less likely to question providers about why they recommend one treatment over another.

But such detachment can threaten their quality of care. If you are living with a mental health condition, or are supporting someone who has a mental disorder, you have the same opportunity to affect the quality of care delivered. Below I describe three things you can do.

1. Ask for evidence-based care.

Evidence-based practices care is backed with research to demonstrate effectiveness and plays an increasingly prominent role in delivery of health care. These practices guide treatment decisions and ensure patients receive effective, quality care. When combined with a clinician’s own expertise, evidence-based practices lead to more patient-centered care and better outcomes.

In mental health care settings, however, evidence-based practices are not yet widely adopted and research shows that many people with a mental health condition are not receiving it. In the primary care setting, use of evidence-based practices for treatment of depression, especially psychotherapy, are the exception rather than the rule.

This matters because when treating a mental health condition, not all treatments are created equal. For example, cognitive behavioral therapy is a highly effective, evidence-based treatment for people with panic disorder, while long-term supportive psychotherapy is not.Patients can increase the chance of receiving evidence-based care by asking their medical and/or behavioral health provider why they are recommending a certain treatment and the strength of the research behind the recommendation. It’s perfectly appropriate to ask which evidence-based therapies are right for a specific issue. Some people may not feel comfortable asking a provider about treatment methods and their efficacy; but if you were going in for heart surgery, you very likely would be asking those sorts of questions. Providers should be happy to answer these questions.

2. Seek a provider trained in recommended therapy.

When it comes to selecting a mental health provider, people are often constrained by coverage, cost, and location. Sometimes, it’s hard just to get an appointment; a provider’s adherence to and training in evidence-based practices may not be top of mind.

But just as not all treatments are appropriate for all conditions, not all providers are appropriate for every patient. In addition to asking about the research behind a recommended treatment, it is important to ask about a provider’s experience and training in that therapy. For example, if a provider recommends exposure therapy for post-traumatic stress syndrome, it is important to ask about the provider’s training in that therapy.

If a provider were to say, “Why are you asking me that? Of course I’m going to help you with the best thing,” or if they act defensive, that would make me nervous. People who are providing treatments they have been trained in should be happy to talk about the evidence behind the therapy and why they believe it is going to help. Taking just a few moments to ask about a provider’s experience and training in a therapy is not disrespectful, it’s responsible.

3. Better manage your care by measuring your health status.

Can you imagine your physician diagnosing and treating you for hypertension without ever taking your blood pressure? Not likely, as blood pressure monitoring is a universally-accepted measure for assessing and managing high blood pressure.

Similarly, there is an evidence-based and well-validated screening tool for depression that helps providers diagnose and manage the condition. The Patient Health Questionnaire depression scale, known as PHQ-9, is a nine-question survey that asks patients to score symptoms in terms of frequency. Each answer is then tallied for a total score from 0 to 27. It helps providers in assessing the severity of a patient’s illness and evaluating a patient’s response to treatment over time. If a score does not improve with treatment, a provider can quickly make the determination to try a different therapy.

PHQ-9 also empowers patients by providing them with a context and language for their depression. Just as a blood pressure reading of 160/100 provides an easy-to-understand measure of health, so does a PHQ-9 score. People can ask their provider how a score of 15 compares with a score of 10 or 20, and how a 15 may be treated versus a 10. Also, people can self-monitor by giving themselves the questionnaire at home.

Over the past five years, PHQ-9 use in regular practice has become more widely adopted by medical and behavioral health practices across the country. In Minnesota, all clinics and medical groups are required to report the number (and percentage) of patients completing a PHQ-9 upon diagnosis of depression, and also at six and twelve months to assess rates of remission (a score of less than 5) and response to treatment (reduction in score of 50% or more). The statewide reporting enables institutions, providers, and payers (such as the state, insurers, and employers) to evaluate providers’ and clinics’ performance and encourage improvements in care. It also allows patients to identify providers who consistently deliver better clinical outcomes. Becoming an empowered consumer is the first step in taking control of your life and recovering from depression.

Questions

• What steps are you taking to be the captain of your own mental health care?
• What kinds of changes by your (or your loved one’s) mental health provider would make a positive difference for you?

Bio

David J. Katzelnick, M.D., is the chair of the Division of Integrated Behavioral Health at the Mayo Clinic Rochester Minnesota and a member of the Executive Board of the National Network of Depression Centers (NNDC). His major clinical and research interests are in mood and anxiety disorders, psychopharmacology, diagnosis and treatment of mental disorders in primary care and medication education. He is currently Mayo Co-PI for the COMPASS Centers for Medicare and Medicaid services (CMS) grant, which has the goal of spreading a collaborative care management model to manage patients with depression and diabetes and/or cardiovascular disease.