Senior Policy Research and Director of Health Care Quality Measurement and Improvement Program, RAND
Dissertation Title: "Chronic Illness, Depression, and the Patient-Provider Relationship: Toward a Model of Biopsychosocial Care"
Chronic medical conditions are the leading cause of disability in the United States, account for 70 percent of all deaths, and are associated with high health care expenditures. Social and psychological correlates of chronic illness can adversely affect the course and treatment of these conditions. The biopsychosocial model of care posits that medicine must consider these psychosocial dimensions of health and disease when treating chronic illnesses. This dissertation adds to an understanding of the complex relationships between mental, physical and social health in the context of chronic illness and explores the current state of mental health care for people with these conditions.
Part One investigates the effect of having a chronic illness on the quality of depression care for people with comorbid major depressive disorder. Results showed that depressed people with a chronic illness were more likely than those without a chronic illness to have their depression recognized by a provider; this was explained by the finding that the chronically ill had stronger patient-provider relationships. Chronically ill depressed people took more antidepressant medications on average, though were no more likely to receive minimally adequate depression treatment or be satisfied with their mental health care than those without a chronic illness.
In Part Two, I examine the effects of depression treatment on medical and social outcomes for people with chronic pain and major depressive disorder. Results showed that receiving some depression treatment was associated with better mental health and less interference of pain on work. Receiving minimally adequate depression treatment was associated with improved social functioning. Addressing and treating comorbid depression should be a key feature of a biopsychosocial approach to the treatment of chronic pain.
In Part Three, I explore older adults’ experience of getting treatment for chronic pain in the context of a transition to patient-centered care, an important piece of the biopsychosocial model. Results of a grounded theory analysis of interviews with 15 older adults with chronic pain illustrated (1) the ambivalence this population feels toward being the “source of control” in their health care and (2) the importance to this population of having meaningful and continuous patient-provider relationships.