Announcer: Live, via satellite, this is psychCME TV, your interactive portal to evidence-based, clinically relevant, psychiatric continuing medical education. psychCME TV is brought to you by psychCME, a program developed at Duke University Medical Center in Durham, North Carolina, and by CME Outfitters in Bethesda, Maryland.

Your host for psychCME TV is Dr. Prakash Masand, consulting professor of psychiatry at the Duke University Medical Center's Department of Psychiatry and Behavioral Sciences.

Dr. Masand: Welcome to psychCME TV. For centuries, mental illness has been associated with stigma and shame. And, unfortunately, it continues to do so. In fact, mental health parity is a battle that we have to fight for even today. Organizations like the American Psychiatric Association, NAMI (National Alliance for the Mentally Ill), and the DBSA (Depression and Bipolar Support Alliance) have fought to combat the stigma, but we all need to do more to educate our friends, our colleagues, and the general public. And that is the focus of today's psychCME TV broadcast. Today's program is entitled, A Surgeon General's Report on the Stigma of Mental Illness: Have We Made Progress?

Let me now welcome our guests. Joining me today in the studio is Dr. Larry Culpepper, professor of family medicine and the founding chairman of the Department of Family Medicine at the Boston University School of Medicine in Boston. He is a member of the Scientific Advisory Board of both the Depression and Bipolar Support Alliance and the Anxiety Disorders Association of America. There are few people in the country that bridge both specialties, primary care and psychiatry, and we're excited to have Larry join us. Larry, welcome to the show.

Dr. Culpepper: Thanks, Prakash.

Dr. Masand: Also joining me is Dr. David Satcher. Dr. Satcher completed his four-year term as the 16th Surgeon General of the United States in February of 2002. He also served as Assistant Secretary of Health from February of 1998 to January of 2001, making him only the second person in history to have held both positions of Surgeon General and Assistant Secretary of Health simultaneously. As Surgeon General -- and I must add, I think one of the greatest Surgeon Generals this country has had -- he released 14 Surgeon General's Reports on topics that included tobacco and health; mental health, in fact, it was the first report ever by the Surgeon General on mental health; suicide prevention; oral health; sexual health; youth violence prevention; and overweight and obesity. Currently, Dr. Satcher is director of the National Center for Primary Care at the Morehouse School of Medicine. David, we're very happy to have you here. Welcome to the show.

Dr. Satcher: Thank you, Prakash.

Dr. Masand: Today's program has three learning objectives: first, to determine the role that stigma may play in the diagnosis and treatment of mental illness.

Dr. Masand: Second, to identify medical comorbidities that may be risk factors for major depressive disorder.

Dr. Masand: And finally, to utilize a multidisciplinary team approach to optimizing the management of depression.

Dr. Masand: David, as Surgeon General of the United States, you were instrumental in putting out several reports on mental illness, including your seminal report on suicide prevention. Tell us a little bit about what goes into a Surgeon General's Report. What are the pieces that contribute to that?

Dr. Satcher: Well, the Surgeon General's Report is an interesting tool, if you will, for communicating directly with the American people based on the best of available science; not politics, not religion, not personal opinion. And this goes back to 1964, when the first Surgeon General's Report was released by Dr. Luther Terry, and it was on smoking and health. And it's had a tremendous impact on the health of the American people.

Dr. Satcher: As you pointed out, we released the first ever Surgeon General's Report on mental health in December of 1999, and that had followed a very short report on suicide prevention.

Dr. Satcher: Because of the response of the American people, we followed that report with a report on treating children with mental illness and then mental health, culture, race, and ethnicity. And then later, one dealt with mental retardation.

So, these reports, I think, have helped to pave the way for looking at this field and, especially, looking at what is it going to take for people to be able to recover from mental disorders. I think this shows the kind of reports we produced, and the one standing out in front is that one dealing with treating children with mental illness.

Dr. Satcher: The major messages that were included in the first report, especially, had to do with the fact that, based on the research over the last 25 to 30 years, mental health is fundamental to overall health and well-being. This report was developed by a collection of people from academia, from associations and organizations that are shown here, federal agencies like NIH and SAMHSA, but also state and local health departments. A great team of people came together to produce this first ever Surgeon General's Report. And, I think, that's why the messages were so relevant to the needs of the American people as it relates to this topic.

Dr. Masand: David, as you so eloquently pointed out, your report said mental health is fundamental to overall health -- a message that we sometimes forget. We have mental health carve outs, and it's not integrated into the overall care of our patients. Speak a little bit about that.

Dr. Satcher: One of the most important messages is the fact that you can't be healthy without good mental health. And so, to point out how fundamental it is and that it should be treated that way in terms of our policies but also in terms of our healthcare system, it's so fundamental that it has to be integrated with the overall care and well-being. Mental disorders are real. They're not character weaknesses or spiritual weaknesses. They are brain disorders. And that's the point that we tried to make in that first report, especially.

Dr. Masand: Larry, which brings up the question... Mental health is fundamental to overall health and mental disorders are common in the United States. Tell us how common.

Dr. Culpepper: Well, what we find is in study after study, about one in five, about 21 percent of Americans each year, will suffer from a mental disorder. Now, the other thing is, we find that that's true, really, across cultural groups. Nevertheless, we also know that certain issues put patients at higher risk for mental disorders. Certainly, if you look at individuals who are in our lower income strata, they have rates of mental disease that are two or three times more common than those in higher income groups.

Dr. Masand: And David, you brought up the issue of the fact that these are disabling illnesses. Larry, and how do they compare to illnesses that most patients and clinicians acknowledge are disabling: heart disease, cancer?

Dr. Culpepper: Study after study has demonstrated that the mental disorders are as disabling as most chronic medical illnesses. So, when we look at impact on physical function and mental function and social function, across the board, the mental disorders -- major depression, major anxiety disorders, schizophrenia -- are at least as disabling as cancer or serious heart disease.

Dr. Masand: David, Larry raised the issue of differences in the likelihood of mental illnesses amongst different groups: ethnic groups, lower socioeconomic strata. Another area which I think is very under-appreciated -- and I know you did a lot of work to bring it to the forefront -- is culture, both in health-seeking behavior, in the under-diagnosis and under-treatment of psychiatric illnesses. Tell us a little bit about what you found.

Dr. Satcher: This was a supplement to the first report. It took about two years to finish this report. It was not an easy report to do, but it was very important: Mental Health: Culture, Race, and Ethnicity. And we looked at how mental disorders impacted different racial and ethnic groups in this country: African Americans, Hispanic, Native Americans, Asian Americans, and the majority of the population. And the bottom line, Dr. Prakash, we found that culture impacts on how patients manifest and describe their illnesses; how they cope with their illness or how the type of stresses that they experience (their culture determines that to a great extent); and whether they're willing to seek treatment. And a major point, here, is that stigma is a part of culture, and we see different levels of stigma toward mental disorders in different populations. Well, this became a major issue in terms of the quality treatment of all groups in this country and the challenges we face inunderstanding culture. And it's not just the patients, by the way.

Dr. Satcher: We should also point out that, as this slide shows, that it also is the providers; how healthcare professionals diagnose and treat mental disorders, determined by our own culture. And it also determines how we organize health services, especially mental health services, and how they're financed in this country. So, culture is important, and stigma is a part of culture.

Dr. Masand: So, Larry, we've seen that mental disorders are real, disabling, common. Well, which brings up the question, are we good at treating them?

Dr. Culpepper: Well, there's good news, and there's bad news. Let's look at the good news first. I think what we find is that we now have effective treatments for at least 80 to 90 percent of patients with mental illness. That's part of the good news. I think a second piece of the good news is that we actually have multiple treatment strategies that are very effective. And, I think, a third piece of good news is actually one that was, again, a key message of the culture report, and that was that our treatments work across the board, that they do work quite effectively in our minority groups as well as in mainstream America. So, that's the good news.

Dr. Culpepper: The bad news is really, if we were to give ourselves a grade, it would be a pretty low grade in terms of what we actually achieve in treating individuals with mental disorders. What we find is that we do a poor job at every point. We recognize, probably, less than half of individuals with depression, anxiety, certainly in primary care settings. And then, even if they're recognized, we move only about half of those to effective treatment, just to initiate treatment. And then we move only about two-thirds of the group that we treat to effective treatment. So, we have got a long way to go in improving the benefits the patients could receive from treatment.

Dr. Satcher: Now, and a part of this lack of recognition, of course, is so few patients who have mental disorders even seek treatment. They are children with mental disorders, and their parents, because of the stigma, are not comfortable admitting it to themselves and going out and seeking treatment. So, part of the barrier is the seeking, the health-seeking behaviors.

Dr. Culpepper: Yeah, and we have just a number of barriers. If you think about what a patient -- and a patient who may be depressed, who may have a lot of fatigue in their life already, who may not be sleeping well -- and that patient, then, is faced with problems with insurance (lack of coverage, which, as you allude, may be part of stigma), but then with a provider that may or may not be up on treatment, with family beliefs that may be decades out-of-date in terms of the benefits of treatment, the effectiveness, the side effects of treatment. We have major barriers that most of our patients have to overcome just to get in the door to present themselves for treatment. And then, I think, once they are there, we have a number of barriers that we may put up for patients to move on to effective treatment.

Dr. Masand: And in fact, Larry, you have a very nice slide outlining some of the barriers to care that you spoke about. Speak a little bit about barriers from the health policy perspective; insurance barriers, for example.

Dr. Culpepper: Right. And certainly with insurance; 150/160 million Americans are in carve out systems where, as a primary care provider, I have great difficulty providing treatment and getting adequately compensated for it. Patients from low-income groups have particularly high barriers in terms of some of our policies around reimbursement. But also what we find is that many communities have an inadequate number of skilled providers.

Dr. Masand: David, unfortunately, stigma is attached to mental illness even today. And some of the implications are the public health policy implications of this stigma attached to mental illness. Tell us a little bit about, from a public health policy perspective, what does this mean?

Dr. Satcher: Yeah, it's interesting. A stigma deters treatment significantly, and starting with the individual, as we pointed out, in terms of how the individual responds to a mental disorder. But it also affects the family and the community -- how people view people with mental disorders; whether, in fact, people are willing to help get people into care. And all of that, of course, impacts upon policy. It's no accident that you can practice insurance in this country and discriminate against people with mental disorders. It's no accident that Medicare, one of the best programs ever developed in this country, requires a 20 percent co-payment for outpatient treatment, generally, but for a mental disorder it requires a 50 percent co-payment. It's no accident that we don't have comprehensive parity of access for mental health services. It all relates to attitudes toward mental disorders that, I think, we have to change as a country and, hopefully, we will change soon.

Dr. Culpepper: Trust is a part of that, isn't it?

Dr. Satcher: Trust is a critical part of the way people respond to mental disorders. It's a critical part of culture.

Dr. Satcher: African Americans, for example, in general, have a distrust of the healthcare system that dates back to experiences like the Tuskegee study. And working to try to overcome that to get more people into care, get more people involved in research studies involving mental health is really critical. Trust is very important.

Dr. Masand: David, as you pointed out, minorities (African Americans) are less likely to seek treatment because of the trust issue that Larry raised. Tell us a little bit about what are some of the other findings with the relationship to mental illness and minorities that potentially could impact the treatment that they receive, the diagnosis that they receive?

Dr. Satcher: Well, as Larry pointed out earlier, it's not that minorities have a greater prevalence ordinarily of mental disorders or more severe, but because of the difficulty accessing care and the attitude starting in the community and in the system, it makes it more difficult.

So, what we said in our report was that the burden of mental disorders tend to be much greater on minorities because of problems in accessing care in this country and, therefore, having to live with the burdens of mental disorder and the disabilities of them. And, so, minorities, also, are more likely to be misdiagnosed when they do get treatment. African Americans, for example, are likely to be diagnosed as schizophrenic when they're not and also less likely to be diagnosed as depressed when they are.

So, if somebody has a spiritual approach to mental disorders and they talk about "a devil riding with me," or if you don't understand the culture, it becomes very difficult to understand what they're saying. So, if you're going to improve the care for minorities, we have to better understand their history and culture.

Dr. Masand: Larry, another area which, I think, is beginning to get more attention, and rightly so, is the comorbidity of psychiatric illness with other medical illnesses, kind of this bi-directional comorbidity. Let's look at depression and cardiovascular disease, because I think that's a relationship that's been best studied. What lessons have you learned?

Dr. Culpepper: To look at that relationship, we really go back to the 1980s when key studies emerged, and the data has just piled on since then. And, what it has done has absolutely shattered any basis for us separating mental disease from medical disease. That duality is just fundamentally a false duality.

When we add that to what we now know in terms of brain science, about the effects of mental disease on brain anatomy and on the neurochemistry of brain function, it's clear these have to be integrated.

When we look at cardiovascular disease as a model of chronic illness -- and I think we have similar data for other chronic illnesses -- what we find is if you take a group of young adults who exactly match for all the other known risk factors for cardiovascular disease, and one group has depression and the other group doesn't, the group that lives with depression is twice as likely, to go on and develop hypertension, coronary artery disease. And with those -- those who continue depression -- are at a higher risk to then go on to have myocardial infarctions, to develop congestive heart failure.

The other thing we know is that even at that late stage, once you've had an MI, if you've got a history of depression and you're now depressed post-MI, your rate of death is something on the order of three- to five-fold increased, and that's at six months, at 12 months, at 18 months. Now, this basically shows a number of these relationships, and you can see across the board at least a two- to five-fold increase. When we look at mechanisms, this slide shows those potential mechanisms for cardiovascular disease. And it's not simple. We certainly have impact through the autonomic nervous system, through catecholamine level increases, but we also have effects on platelet aggregation, we have effects on lipids, we have effects on adherence to lifestyle recommendations.

So, depression has to be treated if we're going to effectively treat cardiovascular disease. You cannot treat a patient with cardiac disease who has depression adequately unless you treat their depression.

Dr. Masand: David, let's look at another illness which... Again, as Surgeon General, you put out a report on overweight and obesity, which kind of was a portent of things to come, which is now a public health epidemic around the world. And diabetes is also a growing public health epidemic. And the relationship between depression and diabetes is a very intimate one. Tell us a little bit about that relationship.

Dr. Satcher: Prakash, after we released that report in December of 2001, I was invited to speak at the International Conference on Diabetes a couple of years ago in Ocho Rios. And, invariably, the clinicians there complain about the difficulty they had in successfully controlling diabetes in people who were depressed. It was a uniform complaint. But I think this slide, here, shows that even beyond that, people who are depressed are more likely to become diabetic. And that's true in studies done in this country, as you'll see and in studies in Japan. And you shouldn't be surprised when you think about the fact that we've already shown that regular physical activity and nutrition can reduce the onset of diabetes by more than 50 percent. So, this two-fold increase in the onset of diabetes associated with depression, I think is associated with that lifestyle.

Dr. Satcher: But, overall, we know that the depression can increase the symptoms of diabetes, it can decrease adherence to treatment; again, treatment plans require a lot of cooperation from patients. It can worsen glucose control; increase complications like end-stage renal disease, stroke, blindness, and other things; and decrease overall functional well-being. So, depression can be a major factor in our ability to control diabetes -- a disease which requires a lot of cooperation between provider and patient.

Dr. Culpepper: Yeah. In looking at the literature, there's now a number of meta-analyses of studies of adherence. And what study after study shows is that you get a threefold increased rate of non-adherence. And it's across the board: it's with diet, it's with exercise, it's with medication, it's with smoking cessation, lifestyle changes. So, unless you're dealing with the depression, you can't adequately deal with the medical condition.

Dr. Masand: Larry, David raised the issue that we need coordinated care if you're going to deal with depression, comorbid medical illness; overcome some of the barriers to care that we spoke about. Tell us a little bit about some of the models that we can use to provide this coordinated care?

Dr. Culpepper: Right. And we now have considerable literature on coordinated care and its benefits, and that literature has really grown over the last six or eight years.

What we found is reflected in this slide; is that when you have coordinated care, you do get much better outcomes. And the key components of coordinated care is really adopting a team approach where you've got the primary care professional able to integrate the care of depression with the other problems that beset a patient, but then you've got additional resources. You've got a case manager, who can help monitor the patient over time, can help with patient education, and you've got mental health backup.

Dr. Culpepper: I think this gives us insight into this critical dyad. As a primary care physician, I, at times, have difficult patients that if I'm going to be successful with them, I've got to have the input and the co-management that someone with mental health expertise can bring. Now, that's at the patient level.

Dr. Culpepper: I think the other thing that we find is that when we look at systems -- and it's particularly an issue in terms of our cultural groups -- that we need to also be thinking that my practice, be it a group practice or community health center, is working with other organizations in the community. This could be churches, schools, social clubs, because many times, patients present there, and it's the members of those groups that can open the door through a relationship with the healthcare sector.

Dr. Satcher: And this is again, I think... There are two major messages here that you've just related. I think the primary care provider, of course, is on the front line. This is first contact care. And if mental disorders are not detected there, they are often not going be detected. But by the same token, if you have coordinated care, you can assure not only that people are going to be diagnosed earlier, but they're also going to get the best available care because you have primary care providers partnering with mental health specialists. It's an ideal system. But, as Larry also said, this relationship with community is something that helps to deal with culture, because if you understand the culture because you have managers who understand the community, you're going to greatly improve diagnosis and treatment.

Dr. Masand: David, one of the concerns that you always hear from health policy experts, managed care companies, is cost; is the cost going to be driven up if you have mental health parity, if you integrate mental health into the care of the overall health of the individual? What are the facts?

Dr. Satcher: Well, in our report -- that report on mental health, the Surgeon General's Report -- we looked at costs in our overall system if you were to provide comprehensive paritive access to care and did not find a significant increase in cost. Now, other studies have gone further than that to show that with collaborative care versus usual care, you actually have a decrease in cost. And you would expect that the more that you can look at the impact of treating depression on productivity and on reducing other problems and help you to control something like diabetes, you would expect that in time you're going to get a decrease in cost. We really need to move to that kind of system where we implement this coordinated care. And I think we will see a positive impact, overall, on cost.

Dr. Culpepper: Yeah, I think if you look at the models we've used to date, they've been pretty simple in terms of just looking at the offset of, if I provide mental health care, do I decrease our emergency room use or visits back to the primary care provider? We haven't gone beyond that to models that really look at the long-term impact on cardiac outcomes, diabetes outcomes. And that's where the major savings may accrue.

Dr. Masand: Let's take depression as an example. What have we learned, if you make interventions for treating depression using this coordinated team approach, does it improve outcomes? Does it improve the adequacy of antidepressant trials?

Dr. Culpepper: Yeah, and if we look at one; and this I'd say is a typical study that has been done. This slide shows the CARE Study. This first slide basically shows impact on getting prescriptions filled. Obviously, if we write a prescription, it's got to be filled, but for a depressed patient, a patient with anxiety, it's not just simply that first prescription. It's moving the patient on to getting their prescriptions filled regularly and regularly taking the medication. And you can see here that the diabetes management program, the DMP group, had a marked increased rate of not only filling their first prescriptions, but filling three or more prescriptions over time compared to the usual care.

Dr. Culpepper: And if you look at this slide, what we find is that that translates at 12 months into a much higher rate of patients that responded with at least a 50 percent decrease in symptoms and, also, a higher rate of patients that moved on to full remission of their symptoms.

Dr. Masand: And, Larry, I'm glad you mentioned remission because that brings up the next question. What should be the goals of antidepressant treatment? And, in your practice, for example, how do you ask for remission or monitor for remission?

Dr. Culpepper: Right. And I think what we need to look at is that, certainly, we want patients to respond to treatment. And through the '90s, that was about as much as we wanted. I think what we have come to recognize is that it's critical that we not only get patients to respond, but we get patients to a full remission so that they are, in essence, symptom-free and that they then move on to regain function and resume the roles in their family, at work, and in society that they had before the onset of the mental problem. So, that's what we want to shoot for.

Dr. Masand: David, and one of the reasons why we are concerned about achieving remission is if you do not, there are potential consequences. What are some of the consequences of not achieving remission?

Dr. Satcher: Well, I think this slide outlines some of those consequences: increased risk of relapse and resistance to treatment; continued limitations in one's ability to deal with psychosocial challenges; decreased ability to be productive -- to work and to be productive in the workplace and to have positive relationships with one's family and others; increased costs of medical treatment -- without question, I think we've shown that.

And sustained major depression may worsen mortality from other conditions. We want recovery. I want to use that word because it was used in the first commission's report back in the Carter administration. And recently, President Bush's White House Commission on Mental Health talked about the road to recovery and how that should be our goal.

Recovery doesn't always mean that you have no disability, but it means that you recover to the extent that you can be productive and you can have positive relationships with other people. We want people to have complete remission, but we also want people to function even if they still have some disability; want them to be able to lead full lives.

Dr. Culpepper: Right. In looking at this, in primary care, from a primary care perspective, there are a couple of take-home messages that I think are key.

One is, if I've got a patient with diabetes or with hypertension, when they come in, I don't say, "Well, gee, how are you feeling?" "I'm okay." "Well, gee, that's fine. Let's keep going with what you've got. Or if you're feeling a little bit low, why don't we bump your insulin up?" We'd never think of that type of qualitative management. But yet, we do that with depression every day. What we need to be thinking about as we talk about terms like response, remission, and recovery is more objectively evaluating our patients and following them. So, I do a number of things. One is, I put the cardinal symptoms that a patient appears with when I first diagnose them on my problem list and on a flow sheet so I can track whether that's resolved. The other thing is that with depression, we know it's a chronic, relapsing but episodic illness, so that the patient who has a first episode of depression, within five years, 50 percent are going to have a second episode. But if we follow it out to15 years, 85 percent will have a second episode.

So, in primary care settings, we need to set up strategies that will maintain patients at recovery by monitoring them, not just in the short-term but long-term, and we need to educate them and their families to participate in that long-term monitoring.

Dr. Masand: Larry, which brings up the question in primary care practice or, for that matter, in psychiatric practices, how does one choose between psychotherapy and pharmacotherapy? Are they equally effective?

Dr. Culpepper: They actually are. And, as this slide shows, and now, again, in a number of studies, what we find is that for any single therapy, about half of patients get to remission with that therapy.

Now, I think there are a couple of caveats. One is, we also know that if you fail an initial therapy, that failure does not predict that you're going to fail other therapies. So, the patient that doesn't respond, for instance, to one antidepressant medication, that non-response does not indicate they're at more risk of failing a second agent. The other thing we know is that patients respond best to medication or pharmacotherapy that they prefer. And when we ask patients in primary care, about 80 percent say yes, they would be interested and willing to have psychotherapy. About 70, 75 percent say that they would be interested and willing to have pharmacotherapy. The key is the majority of patients want treatment, which is what a lot of providers don't understand. A lot of providers say, "Oh, I would never bring that up because I know she would not accept treatment." Most patients will, and they do best when we work with them to get them the therapy that they prefer.

Dr. Satcher: And the message from before: a range of treatments exist. And that's important, because many patients give up on the first treatments that are tried. The medications today are much improved. They're more targeted, there are fewer side effects. And so, I think, in many cases a combination of medication and psychotherapy, behavioral therapy, especially in children, we've found to work best. So, sometimes, it's the combination of therapies that work best. There are some situations where medications work better than psychotherapy, but you have to tailor the treatment to the patient.

Dr. Culpepper: The other thing is over time, you may want to use both. I may find that a patient needs pharmacotherapy early on. And that gets them symptom relief.

But then they need psychotherapy in terms of regaining function and relearning how to live a full and productive life, particularly if a patient has been chronically affected by a mental disease. If they've had depression long-term, a major anxiety disorder, PTSD; any condition like that may lead to their life falling apart around them and they're needing not simply pharmacotherapy, but psychotherapy to regain function.

Dr. Masand: Larry, in terms of choosing between different pharmacotherapies, what's the best evidence-based approach looking both at efficacy -- and remission is an area that we've spoken of -- and then, safety and tolerability?

Dr. Culpepper: Right. And we actually have to balance those. We certainly want patients to be on medication long-term for most conditions, and that requires it to be an acceptable medication, a medication with low side effects. But, obviously, we also have to have medications that are efficacious. If it doesn't work, there's no reason to be on it. Now, what we have -- and this slide shows it -- is a contrast between a dual mechanism of action agent, venlafaxine, and the serotonin receptor agents. And in this analysis -- this was a grouped analysis of a number of studies -- we do see a difference in obtaining remission over the first eight weeks. So, that's an indication of one set of evidence that we have. I might mention that in this study, most of the SSRI patients were treated with fluoxetine or paroxetine, so that we do need to look at the individual patient. We need to look at their comorbidities and choose treatments that fit that patient in the sense of if they havecomorbid anxiety or if they medical illnesses, making sure that we have a medication that is tailored to be appropriate for that individual.

Dr. Masand: Larry, David raised the question earlier on in terms of you want medications that are better tolerated; the newer antidepressants are better tolerated compared to the older drugs. Tell us a little a bit about the safety tolerability of the SSRIs, SSRIs versus the older tricyclics.

Dr. Culpepper: Right. And, actually, the diabetic patient is probably a good prototype.

What we know is the tricyclics, probably at this time, most professional groups that have looked at it have relegated them to be third-line treatment in the sense that not only do they have major problems in terms of overdose, but we find in diabetics that they cause higher rates of hyperglycemia, hypoglycemia and difficulties in controlling the diabetes.

In contrast to that, the SSRIs...yes, we do see in a small group of patients, short-term hypoglycemia, and that may be as they become activated, resume exercising, resume control of their diet, so that we have to adjust that, and you really have to manage both diseases at the same time. But long-term, the SSRIs don't have the problems that we have with the tricyclics. A good example of where we need to fit the medication to the patient.

Dr. Satcher: This is also an area where disparities in quality of care have been studied. And many studies show that minorities are more likely to get tricyclics than the more modern antidepressants, so it's one of the areas that's been looked at. The Institute of Medicine did that major study of disparities in the quality of care, and this is one of the areas.

Dr. Masand: That's a really interesting comment, David. Larry and David, this part of the show, one of the issues that we like to look at are some ethical dilemmas -- some ethical issues that clinicians struggle with. And I thought an ethical issue, which is very appropriate for today's broadcast is the reimbursement and coding of psychiatric illness in primary care. Many primary care physicians will code major depression with the symptoms -- decreased energy, insomnia -- because of reimbursement reasons.

And, so, let's talk a little bit about, what are the ethics of that, and then what can we do to change it?

Dr. Culpepper: Okay, let me address that more at the clinician level. But I'd emphasize, this is an ethical issue at multiple levels in terms of our care system and our society. A couple of just data points... One is, minority populations, for a lot of minority populations, the only access they really have is to primary care for their mental health treatment. And we provide about 70 percent of mental health treatment in primary care these days.

So, what I find is my patients, the majority of them do come with somatic complaints. They do come with medical symptoms that they want treatment for, and part of my treatment of their depression is to treat those symptoms. I think the other thing is, as we've already discussed, depression and anxiety are part and parcel of what we must manage if we're to provide quality care for our diabetic, our cardiac patients. You cannot take care... you cannot provide quality care of your cardiac patient if you're not paying attention to depression. So, my sense is, I do code it at the symptom level, because I am treating that and that is part of what the patient requested treatment for because otherwise, I can't provide the service. And the group I work for cannot stay open to provide the service.

Dr. Satcher: And when you think about the fact that we're still talking about the fact that such a large number of people with mental disorders are not being diagnosed, we ought to provide all the incentives that we can for people to be diagnosed as early as possible and integrate it into a system of care. So, I think it's really unethical not only to not provide the motivation for busy primary care providers to aggressively diagnose mental disorders, but also not to encourage a system of care that is integrated -- that includes primary care providers and mental health specialists.

Dr. Masand: We have lots of questions, so let's get right to them.

Dr. Masand: Larry, let me start with you, first. Dr. Samuel Linder writes, "I'm a primary care physician." And he asks, "Do you have any suggestions for quick screening tools that you use in your practice for depression and maybe for other psychiatric illnesses?"

Dr. Culpepper: Right. And actually, I do. The United States Public Health Services' Preventative Services Task Force -- and they're on the web, you can Google them and go right to them -- they have two questions that they pose for depression. And it's asking about, have you been sad with low affect for at least the past two weeks? And do you find that you're not enjoying the things that you used to? If either of those is positive, and those are... that's 30 seconds to ask those two questions. I do that routinely. If either of those are positive, I need to go on to explore the symptom criteria for depression. What I use is the PHQ-9. It was published in JAMA in 2001; MacArthur Foundation has put it on their website. If you just go, again, into Google and PHQ-9, you'll get right to it. A wonderful instrument; measures the severity of depression and can be useful not only at establishing the diagnosis, initially, but establishing the severity initially and, then, as atool to track over time. Very useful!

Dr. Masand: David, another question comes to us from Mary Moser. Dr. Moser writes, "Can you comment on the recent FDA labeling regarding SSRIs and suicide in kids? And how do we monitor for suicidal ideation in our busy clinical practices?"

Dr. Satcher: Well, it's really clear that we need more research in this area. And, getting back to screening, we need more tools for screening for severe depression and risk of suicide than we have now. But once people are put on medication for depression, we need to have a better system for monitoring the side effects. And, so, I think that's the critical issue here.

But a lot of reaction and maybe even overreaction to some of these findings, but it's because we don't have the clinical trials that would be indicated to really know, going in, what side effects to expect because you've studied large populations. But also the range of symptoms; and that's why it's so important to detect, as early as possible, symptoms of depression and, in some cases... Now, of course, the American Foundation for Suicide Prevention has a model for screening on college campuses. And those students who show an indication that they may be at risk are then referred. But this is all done confidentially using the Internet. So, I think there's a lot of room here for progress, but we need better clinical trials.

Dr. Culpepper: Yeah, I recently led an expert review of what we do now post this new FDA warning. And I think there are several pieces of data that are important. One is... This concern really is two-part. One is that the antidepressants don't appear to have as strong signal of effectiveness in kids as in adults. And, so, the balance between benefit and possible adverse outcome is a finer balance. But the other is that we're in an interval in time when we don't have good data, as David points out. The entire data set (published, unpublished) from all of the pharmaceutical companies that have looked at treatments in children, that entire data set has been given to a group of investigators at Columbia University to do an objective analysis of. They're supposed to report back by the end of the summer.

And it really is still controversial of whether there is an increase in suicidality. What we do know is in the 4,000 or so patients in those studies, there was not a single completed suicide. And I think that's key. So, there's a balance. We don't want to deny seriously ill individuals that need treatment effective treatments. My take home from this is I need to closely monitor my patients. And that requires me to get back in touch with them regularly over the first weeks of treatment, make sure they're doing well, make sure they're progressing, and actively manage them so we do move them from initiating treatment to response to remission.

Dr. Satcher: But the FDA recommendations will never be any better than the databases they have to work with.

Dr. Masand: That's right, and that is really an excellent point. Let's take a call. We have Bint Nesheim from Sioux Falls in South Dakota. Welcome to the program.

Caller: Yes. I'm looking for comments on dealing with dual diagnosis, triple diagnosis -- people with mental illness and addictions, people who are convicted felons, have sexual deviation problems -- and resources for them when they get out of prison. Would you care to comment on this?

Dr. Masand: Sure. Thank you for your question. Larry and David, are there resources available for the kinds of patients that were described: the dual diagnosis, triple diagnosis, patient substance abuse, maybe sexual deviant behaviors, mental illness?

Dr. Culpepper: There are. They vary greatly between community and community, state to state. But that group of patients, in particular, is where a team approach is critical.

And what I find, because we do have a large population like this that we deal with in my practice setting, is that I really need very close engagement of a substance abuse specialist. What we have is, within our practice, a nurse practitioner who's got advanced training in dealing with substance abuse, and she brings a lot to that patient population. With dual diagnosis patients, I often find that that's where I also need the input from a psychiatrist who has particular expertise in tailoring pharmacotherapy. But that patient also needs me as a primary care professional because they have other problems, as well.

Dr. Satcher: I just want comment on the fact that there are inadequate resources. We are running one of the SAMHSA -- funded regional substance abuse technology and training centers and, I guess, the only one that's associated with a primary care center. And it's very clear that there are inadequate resources. Now, we in this society too often deal with substance abuse problems by punishing people, even when there's evidence that treatment could make a difference. So, we really need to work on getting these resources.

I forget, exactly, but I think in our report, something like 15 percent of patients with mental disorders also suffer from substance abuse addiction. So, it's a great need.

Dr. Masand: Larry, another quick question comes to us from Susan Yonkers, a nurse practitioner who writes, "Do you know of any data for combining SSRIs and cognitive behavioral therapy in order to achieve higher remission rates?"

Dr. Culpepper: Oh, sure. And there's been some controversy around that in the sense of, does one interfere with the other? I think, what I find is, again, is when you think about how you might combine these, you might have a patient who's receiving both at the same time, or you might have a patient who has started with one. I find, particularly, I'll have a patient that can start on pharmacotherapy, get significant symptom relief, and, frankly, in my community where there's a very significant waiting list to get in for mental healthcare in terms of therapy, that gets them through the first two or three months, but then they benefit greatly from cognitive behavioral therapy. And I work with the cognitive behavioral therapist in terms of, do we continue the medication, or do we taper off the medication?

The other place that we find cognitive behavioral therapy particularly of use is when we're going to taper a patient off treatment, and that we get much better long-term recovery if the patient has CBT at that point.

Dr. Masand: We have a comment from one of my colleagues here at Duke, Dr. Sue Wisner, who says, an effective user friendly way that she uses to track quality of life is the Duke Health Profile, which also takes depression and anxiety and correlates with standardized measures. And George Parkerson kind of put that together. So, thank you, to Dr. Wisner for that wonderful comment.

Dr. Culpepper: Yeah, George did a great job on that instrument.

Dr. Masand: David and Larry, we usually end with some clinical pearls -- some take-home messages that we'd like to leave our viewers with. And maybe I can turn to you, David, for some clinical pearls, and then maybe we'll take a couple of questions after that. But David, let's have some clinical pearls about stigma and culture and minorities and mental illness.

Dr. Satcher: I think it's very important to leave with the audience the reminder that stigma is very common, that it impacts upon patients and providers. It impacts upon our system and our policies. The overall quality of life improves when a mental disorder is diagnosed early and treated, so, this whole issue of quality of life is important. It's one of the goals of Healthy People 2010 to improve not the years that they live, but the quality of their lives. And then a third point is also related to Healthy People 2010 and the need to tailor treatment to age, gender, race, and culture. If we do not tailor treatment to culture, especially, then we're not going to be successful, and we're not going to be successful in getting people into care or keeping them into care or successfully treating them.

Dr. Masand: Let's take another quick question. Larry, Charles Mayeux, a coordinator, writes in, "Please explain more thoroughly one of the slides that we used in the broadcast. In particular, what were the brand names and what is the placebo?"

And if you put up the slide, this is the pooled analysis, Larry, that you addressed with venlafaxine with SSRIs. And maybe you can talk a little bit about the placebo arm, the SSRI arm, and the venlafaxine arm.

Dr. Culpepper: Sure, okay. This is a pooled analysis, so this is the combination of a number of studies. These are studies that Wyeth had in their database about their agent venlafaxine. So, placebo is exactly that -- an inert, placebo tablet, visually not distinct from the other two.

SSRI in these, again, the majority of the SSRI arms were either fluoxetine or paroxetine. And, then, the final group was venlafaxine. And the data here are pooled, so that it's slightly different from a meta-analysis where you're aggregating the final result of the studies. This is actually being able to pool the individual patient data and then reanalyze it because the study designs were all very, very similar -- randomized, double blind studies, eight-weeks duration. And what you see here, over time, is the emergence of very clear separation of both the SSRI and venlafaxine from the placebo arm. So that they both pull away and treatment is effective. And what you see also, here, is a signal; venlafaxine is moving patients by the end of the eight weeks at least, more toward remission than the SSRI group.

Dr. Masand: And, Larry and David, again, I think one of the nice things that has happened -- looking at remission as the end point of treatment rather than response -- is we kind of raise the bar in terms of what we would like to achieve. And it's kind of akin to getting your blood pressure exactly where you want it to be or your blood sugar to be exactly where you want it to be, because, as David pointed out, there are potential consequences of failing to achieve remission. So, I think it's good for the field to kind of move in the direction of remission now being the end point. Five years ago it was just response. If you were better, people were happy; that was good enough.

Dr. Satcher: And I think one of the best ways to deal with the stigma associated with mental health is to convince people that mental disorders are treatable, that you can recover, that there's hope for recovery. Australia has shown that. That's a major message of the anti-stigma campaign is let people know what we can now do in terms of diagnosing and treating mental disorders and that they have the opportunity to recover from mental illness and to be productive citizens and have positive relationships in their lives.

Dr. Culpepper: Yeah, I think, as showed, when you compare the evidence base that we now have around the effectiveness of treatment with mental disorders to the evidence base for chronic medical diseases, what we find is that the evidence for effectiveness in mental health care is at least as strong as in medical conditions, if not stronger.

Dr. Satcher: To date, unfortunately, only about 30 percent of hypertensives in this country are controlled, and about the same is true for diabetics. So, we're struggling with controlling chronic diseases, and, certainly, mental health as another chronic disease is one that we're actually doing better when we can people into care.

Dr. Masand: Larry, let's leave our audience with some clinical pearls around the comorbidity of psychiatric illness and medical illness.

Dr. Culpepper: Okay. I think I would identify several. One is, recognize it. Patients come in with somatic complaints. These patients come in very often as our high utilizers. They come in two or three times more commonly than patients without mental conditions. Chronic patients... chronic medical patients have mental problems. Second is, be active in terms of the management of these patients. See them back frequently, move them, adjust their treatment as need be to get them to remission. And, then, third is, organize your practice. You've got to collaborate both with your fellow professionals and others in the community to deal effectively with mental health.

Dr. Masand: I want to thank you both, David and Larry, for a truly outstanding program. I think clinicians will find these pearls and some of our comments extremely helpful in their clinical practice.

Please be sure to check our website at psychcme.net for a complete listing of our upcoming broadcasts and, also, for a couple of live series that we'll be launching in June. The first is on treating unipolar and bipolar depression and the second is Treating Residual Symptoms in the Depressed Patient: A Clinician's Dilemma. You can look up the cities close to you on our website at psychcme.net.

I'm Dr. Masand, thanking you for joining us and hoping that evidence will be your guide to patient care.