Initiative

to im prove detection and treatm ent of m ajor depression

The National Health and Nutrition Survey 2012 (ENSANUT) includes questions that permit us to detect some signs of depression. Even when these questions are relative to the week before of the interview, it helps us to identify the prevalence of this mental health problem in the Mexican adult population.

Table 1 shows the results about depression screening in that survey: As you can see, between 5 and 7 percent of the population present some symptoms of depression; that means, more than 1 million people of 20 years and older mentions than 5 days or more in a week they present depression mood, fatigue, poor concentration and loss of pleasure. Even worse, more than 2.5 million adults refer than in the same period cannot to conciliate the sleep. Table 1* Not at all In the last week.. (Less than 1 day) Did you feel like you cannot 18,088,795 overcome the sadness? (A) Did you have problems to concentrate in your activities? (B) Did you feel depress? (C) 71% 17,458,630 68% 17,470,881 68% Several days (1 - 2 days) 4,133,101 16% 4,826,447 19% 4,683,905 18% 4,608,546 18% 4,220,266 16% 1,939,305 8% 5,009,106 20% M ore than half the days 1,690,942 7% 1,942,688 8% 1,920,698 7% 2,006,360 8% 2,655,580 10% 2,702,782 11% 1,770,866 7% Nearly every day 1,708,124 7% 1,393,197 5% 1,545,477 6% 1,716,394 7% 2,652,287 10% 19,216,842 75% 1,495,150 6%

(3 - 4 days) (5 - 7 days)

Did you feel like everything 17,289,662 was and effort? (D) Did you have problems to sleep? (E) Did you enjoy the life? (F) 67% 16,092,829 63% 1,762,034 7% 17,345,841 68%

Have you been sad? (G)

Source: Own elaboration from ENSANUT 2012, we evaluated information from 46,227 adults (20 years and older), but the sampling design permit us to expand the results to the whole population, that means 25,620,962 people.

Moreover, with the idea of to use a general indicator, it was realized a principal component analysis to create the Depression Index. In that way, in Table 2 we show the correlation matrix between depression questions and the first component. Table 2 Question A B C D E F* G As you can see, 5 of 7 questions have correlation higher than 0.8 with the index; moreover the questions about sleep and enjoy the life are weaker. Also, this Index explicates 60 percent of the variance; for that reason, can assume that the depression index is a valid measure. It is important to say that we standardize it, with mean equal to 0 and standard deviation equal to one. The minimum value is -1.5 and the maximum 3.6 (Figure 1) Figure 1 Corr. 0.8552 0.8307 0.8862 0.8006 0.5887 0.5167 0.8433

* We invert the original values to homogenize the scale to the other questions.

 The next step consisted in evaluate the sector of the population with higher vulnerability. As it shows in Table 3, we found that people with chronic medical illness (diabetes, gastritis, cancer, hypertension, etc.) and in general, the persons with physical health problems are in higher risk to suffer about depression. Also, we found that women are more vulnerable than men. Regardless, we found some signs about depression in the people with less income and in the older, the results are not statistical significant. Table 3 Depression Freq. % Index (M ean) No Yes No Yes Sex Men Women 1 2 3 4 5 Age 20 - 39 40 59 60 -79 80+ 22,758,927 3,480,537 21,972,636 4,282,490 11,426,284 14,832,479 5,891,588 4,679,578 4,837,477 5,460,672 5,389,179 12,677,278 8,982,377 3,881,582 717,526 87% 13% 84% 16% 44% 57% 22% 18% 18% 21% 21% 48% 34% 15% 3% -0.05 0.33 -0.06 0.30 -0.20 0.15 0.08 0.07 0.02 -0.02 -0.14 -0.10 0.08 0.11 0.22 Standard Deviation 95% Confidence Interval

Have you been ever diagnosed with som e chronicle disease? 0.01 0.02 0.01 0.02 0.01 0.01 0.02 0.02 0.02 0.02 0.02 0.01 0.01 0.02 0.05 -0.07 0.28 -0.08 0.26 -0.22 0.13 0.04 0.04 -0.01 -0.05 -0.17 -0.12 0.05 0.07 0.11 -0.03 0.37 -0.04 0.34 -0.18 0.18 0.11 0.11 0.05 0.01 -0.11 -0.08 0.11 0.15 0.32

In the last 15 days have you going to the doctor for som e health problem ?

Quintiles of Incom e

This result reaffirms the arguments of Katon, et al (2003) who affirms that the

Patients with chronic medical illness have a high prevalence of major depressive illness.
With that precedent, I propose to implement the Modified Collaborative Care Model (Katon 2010) The model consists in the next phases: Training: Courses for nurses who accompanies the patients with chronicle disease, for: Apply the Patient Health Questionnaire (PHQ-2) and PHQ 9, with the intention to diagnoses some signs about depression. To identify the patients that requires consult to the mental health specialist. To monitor the patients treatment. To offer brief psychotherapy for depression. To evaluate the basic medical conditions of the patients. Treatm ent: After the training, the nurses must start to implement the model, and to save the records: Number of patients with chronic illness, which accept to answer the PHQ-2 and PHQ-9. Scores Number of patients attending the mental health specialist. Evolution of indicators to monitor the patients evolution (Table 4). Supervision: It is important to have meetings between nurses, psychiatrist, care physician, and psychologist to interchange experience about the patients progress and to review new cases.

 I choose this option because I think that with limited resources is essential to priorizate to the more vulnerable, with the advantage of the patients with chronic illness already have contact with the primary care medical settings and this contact makes easy to measure and to evaluate the results. Regardless it was not possible to estimated it with ENSANUT 2012 data, there is evidence about people with chronic illness and comorbidity of depression have worse complications, that means, lower quality of life and higher health care costs. (Katon 2010). In Table 4 I present indicators to evaluate the impact of this model. Before generalized the implementation is necessary to pilot it to detect weakness and to overcome it. It is important to take the base indicator to contrast the values after the implementation. With this model, we hope in the short run to improve the diagnoses of major depression illness, and in the long run to reduce the bad outcomes of the patients! whit chronic disease, and with that, to reduce the costs of the health care system. Table 4 Indicator M ental health PHQ-9 To monitor the patients treatment and the self " care activities Physical Health Blood pressure Nurses Nurses Nurses Nurses Every two week Every two week Every two week Every two week Laboratory test Laboratory test Laboratory test Interviews Nurses Every two week Nurses Every two week Scores Structured and semistructured interviews Responsible Period M ethod

Lipid in blood Glucose levels Gastrointestinal crisis*

Indicator Global Indicators General Evaluation of The Patients Mental Health General Evaluation of The Patients Physical Health Long Run Indicators

Responsible

Period

M ethod

Mental Health Specialist

At least once in every 6 months At least once in every 6 months

Personal Interview

Care physician

Personal Interview

Patients with complications in their chronic medical illness

Associated costs to the treatments for complications in patient with chronic medical illness

Health Institutions

To contrast the base line to Every two years the outcome of the model two years later

Health Institutions

To contrast the base line to Every two years the outcome of the model two years later

* The chronic medical illnesses with higher prevalence in Mexico are hypertension, gastritis, diabetes and colitis.