WORCESTER, Mass. (Worcester Telegram and Gazette) -- A woman comes in to her primary care physician's office complaining of a headache that just won't go away.

The doctor examines her, looking for neurological clues to match her symptoms. Not immediately finding an explanation, he asks her what else is going on in her life.

Well, she answers, her mother has just moved in with her because her father died and nobody else could take her in, her husband drinks too much and her son just got picked up by the police for doing drugs. On top of everything else, she doesn't have enough money for the place where she lives, which has all kinds of rodents and insects the landlord won't pay to remove.

"You hear this horrible story and think, all she's got is a headache?" said Dr. Annette Hanson, medical director of the Massachusetts Division of Medical Assistance. What the patient in Hanson's story has may be depression.

"It sounds like a horrible life, and depression may be the least of her troubles," she said. "But that's what we can deal with, the illness. We can't do much with all the rest of the stuff, but we can do something about her health."

Finding the best way to do that -- to identify and treat patients with depression in primary care -- is the focus of a $100,000, one-year planning grant won by the University of Massachusetts Medical School and the Division of Medical Assistance. The Robert Wood Johnson Foundation is funding nine sites across the country to link clinical and systems strategies for treating depression in primary care. A two-year project to test improved screening, assessment, treatment and management of chronic depression in primary care will follow.

The UMass-DMA planning grant is different from the other eight project sites because it focuses on people who are clients of MassHealth, the state's Medicaid program providing health insurance to about 1 million people. MassHealth coverage is available to people whose incomes are 150 percent or less of the federal poverty level. For a family of four, the most recent federal poverty level is $18,100.

"This is the first time this model has been tried in Medicaid populations," said Carol Upshur, UMass Medical School professor in the department of family medicine and a clinical psychologist. She represents the medical school in the grant. "A big part is helping patients identify for themselves what's going to be helpful. That's very different in a community where there aren't a lot of resources."

Depression is an important illness to target. From 5 percent to 9 percent of all adult patients seeing their primary care doctors suffer from depression, the U.S. Preventive Services Task Force said in an article published last month in the Annals of Internal Medicine. Half of those cases go undetected and untreated, the authors found.

Depression costs $17 billion in lost workdays each year, second behind cardiovascular disease, and can make other chronic conditions such as diabetes worse, previous studies have shown.

If the widespread incidence of depression is well-known, so are some of the difficulties in isolating it from a welter of other symptoms. There can be pain moving from place to place, another chronic condition can mask or cause depression, or sleep disorders can be brought about by both.

"There is a lot of stigma associated with mental illness, and components of the illness itself often include fatigue or passivity, issues that make it difficult for a patient even to raise it with a doctor," said Dr. Linda Weinreb, vice chairman of the department of family medicine and community health at UMass Medical School and principal investigator of the Robert Wood Johnson grant, with DMA's Hanson. "You don't often have people walking through the door saying "I'm really depressed.' "

If it isn't easy for patients to bring up their concerns, it's also not simple for a primary care doctor to ferret it out, Weinreb said.

"The challenge is they have 15 things to do in 15 minutes. It's daunting to do this as well as everything that's expected," she said. "But most people who are depressed will get treated in primary care settings, so it's in our interest to figure out how to do it better."

Several years ago, the Great Brook Valley Community Health Center in Worcester was one of 20 sites measuring ways to improve care for people with depression, based on chronic-care models for medical illnesses. Depression is an important issue at the center, said Dr. Daniel E. O'Donnell, a family physician and the center's medical director.

"In underserved settings like ours the proportion of depression may be considerable," he said. "The challenge that one has with depression is recognizing it and making sure that people receive adequate treatment for an adequate period of time."

To recognize it, primary care providers can use a standard screening questionnaire that can rule depression in or out. To treat it, a patient needs more than just medication.

By its nature, depression waxes and wanes. The medications to treat it, while they have improved in recent years, still have some side effects and may take weeks before they become effective. That makes follow-up of patients critical.

"If we want to keep people in care and educate them in terms of how to manage the stresses of life and adhere to treatment, we need some method of keeping them in care," O'Donnell said.

At the GBV center, a nurse care manager meets with the patient to explain the disease and the importance and duration of treatment. Some patients may choose to pursue psychotherapy while others begin taking anti-depression medication through their primary care doctor.

Screening and follow-up have made a big difference, O'Donnell said. Before the program began, 20 percent of patients had at least 50 percent improvement in their symptoms after 12 weeks of treatment. The most recent data, from March, show that 54 percent of patients have demonstrated significant improvement over the same period.

Significant improvement is defined as feeling 50 percent better, according to a questionnaire answered by the patient.

Those figures are impressive, O'Donnell said, because they match what is typically reported as success in clinical trials of anti-depression medications. About 300 people have been through the GBV program.

"We have been able to actually mimic those results here through some of the changes we made," he said. "People in clinical trials don't tend to be quite as ethnically diverse. There has not been a lot published on ethnically diverse populations."

The Fallon Community Health Plan, which is one of the grant's five project partners, began a disease management program for depression in September, said Dr. Michael H. Kelleher, medical director for quality and disease management programs. Patients use a self-screening form if a primary care physician suspects depression.

If the diagnosis is depression, patients are asked for their written permission to be tracked by a case manager who checks to see whether they are taking their medications and keeping appointments.

"So far, we have over 130 patients who are actively engaged with our care manager," Kelleher said.

The screening tool used at the first visit begins the accurate assessment and proper treatment, he said. "Getting the right diagnosis at the front end is the critical piece."

Of Fallon's 190,000 members, about 11,000 are MassHealth clients, meaning MassHealth pays Fallon a fixed monthly amount for members, who receive medical and mental health care as well as medication.

For other MassHealth clients, who might go to group practices, coverage can be more difficult to patch together. Sharing a case manager across group practices might be a way to replicate the follow-up possible at a community health center such as GBV's or an HMO such as Fallon. For MassHealth, the goal is to make sure the quality of care is the same, regardless of where it's given or the payment mechanism, said Hanson of DMA.

"There are lots of mismatches between the systems and practice that relate to the insurance issues and different coverage," said Weinreb. "There's knowledge about effective ways to care for people struggling with depression. What's less clear is how to help change the system that insures people as well as allows providers to do what looks like might help."

There's also -- and always -- the issue of cost. Information systems and support services all have costs, Weinreb said, but on the other side of the ledger, people who are depressed tend to use medical services a lot, either in doctor's offices with aggravations of their medical conditions or in hospital visits with unexplained symptoms.

Hanson, whose budget is set by lawmakers, has strong beliefs on the way to spend health care dollars.

"If you give the right care at the right time and the diagnosis is correct and the treatment is correct and people are compliant and helped to be compliant with the treatment, they won't continue to be sick," she said. "It won't cost you any more than it would have and it might cost you less."

Copyright 2002 The Worcester Telegram and Gazette. All rights reserved.