The magazine of the UW School of Public Health

Download full issue PDF. Spring/Summer 2017
Volume 34, Number 1

Inside this issue


What Works to Treat Depression?

UW researchers, rural clinics, and funders adapted and implemented a collaborative, evidence-based approach to mental health care. It's working—and spreading.

By Deborah Gardner

Implementing Collaborative Care in the Rural Northwest.

Depression, anxiety, and related symptoms cause more disability worldwide than any other illness. Patients and providers find effective treatment elusive. In rural areas lacking mental health specialists, successful treatment means collaborating with primary care, adapting evidence, and adjusting approaches until something works, according to UW researchers and rural health clinics.

Intersecting socioeconomic determinants, inequities, and strengths affect mental health across the rural Northwest. Geography and economic downturns contribute to social isolation. Wyoming, Montana, Idaho, and Alaska have four of the nation’s six highest suicide rates. Recruiting mental health professionals in rural areas is difficult. Health care may require driving hundreds of miles. Parking a vehicle by a psychiatrist’s office can feel stigmatizing in small communities.

Access isn’t the only problem. Depression is hard to treat. “When people understand how little evidence there is for most of what is delivered for mental health care, they’re shocked,” said Diane Powers, MA, Implementation Specialist at the UW Advancing Integrated Mental Health Solutions (AIMS) Center.

Jürgen Unützer, MD, MPH, MA, AIMS Center Director, Professor and Chair in the Department of Psychiatry and Behavioral Sciences, and Adjunct Professor in the departments of Global Health and Health Services, sought to learn what treatments work and how to make them available. That approach—researching, applying, adapting, and refining ways to carry out evidence-based interventions—is the core of implementation science.

A psychiatric clinician, Unützer adopted a population-health approach in the 1990s when studying at UW for an MPH. He later led the nation’s largest-scale depression treatment trial, finding one approach twice as effective as others: collaborative care.

The AIMS Center defines collaborative care as patient-centered, population-based, evidence-based, accountable care that measures outcomes and adjusts treatments until patients improve. To reduce stigma and reach more people, it embeds mental health care in primary care. Primary care doctors, psychiatric consultants, care managers, and patients work together. The model is adaptable, such as using telemedicine in rural areas.

To Unützer, it’s essential to use research, not just publish it. “As a researcher, that was very satisfying, but as a public health person it wasn’t very satisfying. You get more grants if you get more publications, but you’re not getting more people well.”

Implementing collaborative care is easier with coaching. Trial-and-error adaptation is difficult and time-consuming. “Translating research into real-world practice is way harder than anyone imagines until they’ve done it,” said Powers. Unützer agreed, “As a researcher, my main lesson was that we probably underestimate all those real-world things you have to navigate.”

AIMS received John A. Hartford Foundation support to help eight rural clinics with underserved populations or provider shortages to implement collaborative care. Hartford administered and matched a federal Social Innovation Fund grant, and required clinics to match funds. With the AIMS Center coaching, the clinics met annually, tracked progress each month, compared challenges and results, and adapted accordingly.

Big Horn Valley Center team

Montana’s Bighorn Valley Health Center board members.

For Montana’s Bighorn Valley Health Center, adaptability was crucial. The clinic borders the Crow reservation—60 percent of patients are tribal members—serving a frontier region with a population density of 2.5 per square mile. Residents face high poverty, depression, and anxiety, with life expectancies 12–15 years younger than statewide. “The health disparities and opportunity to do something about them are both equally great,” said Earl Sutherland, PhD, Clinic Director.

By adjusting approaches collaboratively until something works, the way in which the AIMS Center supports the clinics parallels principles of collaborative care. “It is both liberating and scary when clinics realize there is not one recipe,” said Powers. The clinic’s first approach—with two care managers—wasn’t working. AIMS staff visited and helped evaluate, role-playing the patient process until the clinic determined what worked. “It’s amazing to have that kind of absolute support and willingness to tailor resources to whatever it takes to succeed,” said Sutherland.

A new approach with a single therapist–care manager helped the clinic support people who came in—and some who didn’t. “By treating and educating one person, you’re increasing the health care of that whole family, because there are so many people in one household—a lot of different generations,” said Lacey Alexander, MSW, Clinic Care Manager. Building on a strength, the care was culturally appropriate for tribal members. “Patients are already ahead of the game because it makes sense to them that you treat the whole person,” said Alexander.

“With health care disparities, it’s hard to tell if it’s the chicken or the egg,” added Alexander. One patient faced alcoholism, diabetes, depression, anxiety, and suicidal thoughts. Addressing diabetes helped her get regular mental health care when she came for blood tests. “That’s an example of how it comes together as an integrated mental health system,” said Alexander.

Collaborative care is growing, reaching 50,000 patients in Washington State in 2016. Unützer’s testimonies have helped enable insurance coverage. The clinics share the model through primary care associations and health-center networks. These changes affirm collaborative care’s population-health focus. “Clinicians think numerators; public health thinks about denominators. When you can think about both, you can really do population-based health care,” said Unützer.

Photos by The John A. Hartford Foundation.