Gaps in service in the recognition and treatment of depression and suicidal ideation within a four-county area.

PURPOSE. To examine gaps in service in the treatment of depression and suicidal ideation. METHODS. A phenomenological investigation of clients" (n = 10) and service providers" (n = 40) perspectives. FINDINGS. Compartmentalized systems of care and lack of continuity between inpatient and outpatient treatment contributed to a sense of frustration in both groups. Receiving mental health care was likened to being given a broken-apart puzzle with individual pieces shuffling around in a box. Little bits of help are available, but none of them mesh. CONCLUSIONS. Comprehensive solutions are needed if the human and social implications of depression are to be addressed. Search terms: Depression, fragmentation of the mental health system, phenomenology, suicidal ideation ********** In terms of pain, suffering, healthcare dollars, lost productivity, and death, the human costs of depression and suicidal ideation are extremely high. Threefold reductions in medical costs have been associated with adequate recognition and treatment of depression and suicidal ideation (Callahan, Kesterson, & Ternary, 1997). Many factors make it difficult to recognize and treat depression and suicidal ideation. The presenting symptoms of these disorders are complex and manifest themselves differently in different age groups and individuals. Many healthcare personnel are not adequately trained to recognize depression or suicidal feelings. The social stigma related to mental health persists and interferes with people seeking help. As a consequence, depression is unrecognized in more than 50% of cases (Comino, Harris, Silove, Manicavasagar, & Harris, 2000). Untreated depression leads to clinically significant distress; impairment in family, social, and occupational functioning; increased healthcare utilization; and increased risk of death by suicide (Oakley & Kane, 1999). Untreated depression is associated with excessive use of healthcare resources, including increased medication use, emergency department visits, and greater overall healthcare costs (Lebowitz et al., 1997). Depression that is recognized can be treated successfully. The obstacle continues to be that it is often unrecognized, and numerous barriers to treatment exist. Treatment barriers include lack of linkages between physical health care, mental health, and social service systems, as well as the diversity of professionals staffing these systems. Additional problems arise from multiple systems of care with different gates to service, eligibility requirements, funding streams, and methods of payment. The "system of care currently available to depressed individuals is inadequate, fragmented, and passive" (National Institutes of Health, 1991, p. 8). Advanced practice mental health nurses play a major role in the recognition and treatment of depression. As client advocates and providers of care, nurses should be concerned with whether adequate treatment is available in outpatient as well as inpatient settings. A client's experience with the entire mental health system influences his or her level of trust when seeking care. The treatment of depression is complicated by a number of gaps in service, including restrictions on the ability of primary care physicians to refer to mental health specialists. As Lewis (2001) noted, many clients also fail to follow through on referrals. Health system factors complicating treatment include poor insurance reimbursement, inadequate collaboration among providers, and lack of case management over the entire course of the depressive illness. Other systemwide barriers to recognition and treatment of depression and suicide include difficulties in transmitting information between mental health and primary care settings; lack of access to care that is convenient in terms of waiting, geography, and hours of operation; and "financing of care under capitated systems, insufficient time to care for patients, and lack of continuity in the provider-patient relationship" (Docherty, 1997, p. …