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Trouble in paradise
Study shows high rates of depression on Cape Cod
(August/September
2008 Issue)
By Nan Shnitzler
The largest screening for depression and addiction ever done on
Cape Cod found that of some 15,000 patients, more than 43 percent
have depression, 25 percent have addictions and 16 percent are struggling
with both, according to a study called Community Care for Depression.
Tim Lineaweaver, LMHC, LADC, is behavioral health director at Community
Health Center of Cape Cod and directed the study. He has been immersed
in behavioral health on Cape Cod for 15 years and duly expected
depression rates to be higher than the national average that hovers
between 20 and 25 percent. Yet even he was stunned by the results.
"It's very surprising to me that the rates were that high and
stayed high over the four years of the study," Lineaweaver says.
Community Care for Depression was initiated in 2004 by the Cape
and Vineyard Community Health Center Network, a loose affiliation
of four community health centers: Community Health Center of Cape
Cod in Mashpee, Duffy Health Center in Hyannis, Mid-Upper Cape Community
Health Center in Hyannis and Outer Cape Health Services in Wellfleet.
The goal was to identify and treat adults and adolescents for depression
and addictions regardless of socioeconomic or insurance status.
Primary care patients were asked to complete the PHQ-9, a common
depression screener that reflects symptoms in the Diagnostic and
Statistical Manual of Mental Disorders. Organizers added four questions
pertaining to substance abuse. Anyone with urgent symptoms was immediately
directed to care.
"Screening allows us to take quick snapshot of mental health status
at that moment," Lineaweaver says. "In an ordinary primary care
practice, that conversation might not have happened."
As a result of consistent screening over time, people are engaged
before depression and addiction become chronic and treatment-resistant
necessitating expensive emergency room or inpatient care. Patients
are more likely to improve, and it's more cost effective in the
long run, Lineaweaver says.
The key is getting them to treatment, which is more likely if services
can be offered at the community health centers rather than via referrals
to outside agencies because people tend not to show up. The reasons
varied, Lineaweaver says, from lack of transportation issues to
institutional distrust to lack of sick time at work to apathy to
stigma.
"We realized we had to build mental health services internally.
It's revolutionary to offer both in the same place, but I think
it really works," Lineaweaver says. So far, Duffy and Community
Health Center of Cape Cod are licensed to provide mental heath services.
In fact, some of the same problems that keep people from appointments
contribute to the depression. The seasonal economy and the high
cost of living often force people to work multiple jobs, typically
service-sector jobs without benefits. The population is aging faster
than the national average. Transportation is problematic when people
can't afford cars because the Cape is not well served by regional
transit. Come winter, when the work peters out, there's not much
to do.
"That's what makes the Cape different from the mainland. In winter,
it's amazing how isolating it is. There's not a lot of social contact
and it becomes a rural outpost," says Steve Jochim, a southeastern
area site director for the Department of Mental Health (DMH).
"When I speak to donors, I tell them the working poor are the bulk
of who we're serving," says Karen Bissonnette, development director
for the Community Health Center of Cape Cod. "We take care of the
ones who make it possible for the rest of us to live here."
Jeffrey Rediger, M.D, M.Div., medical director of McLean Southeast
in Brockton is onboard with the community care model and working
to convince the home office in Belmont, which is looking to expand
services on the South Shore and Cape Cod. Rediger, who lives in
Sandwich, likes partial hospital programs as a more accessible
alternative to inpatient treatment.
"I think there's an enormous amount of work in the community we
could be doing and haven't been doing very well," Rediger says.
"We have new leadership at McLean and support for this way of thinking
that was absent a year ago."
DMH handles the more serious, chronic cases of mental illness and
would gladly partner with McLean and the community health centers
to expand psychiatric services, which are lacking on the Cape.
Jochim says he is developing a relationship with Duffy to ease
referrals back and forth. He is also working to recruit more local
physicians and psychiatrists, who would rather practice in urban
areas close to academic centers such as Boston and Providence. It's
hard to compete with the private sector, he says.
Community Care for Depression was funded by the Robert Wood Johnson
foundation and local matches, but the million dollars in funding
will run out soon. The money enabled each health center to hire
a social worker and support staff.
"The health centers have committed to continue screening and will
do what they need to do to get resources to beef up treatment,"
Lineaweaver says. "So it looks like we'll be sustained."
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