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Depression often coexists with other long-term health problems, presenting additional complexities. About 60 percent of depressed outpatients have at least one other chronic medical condition as well, such as a heart problem, high blood pressure, or diabetes.

The US Department of Health & Human Services, through the Agency for Healthcare Research and Quality  has funded research to track effective care of depression. 

Heart Attacks and Depression

Research results have shown that patients with a history of heart attacks have 1.8 times more depressive spells in a year and more persistent symptoms than depressed patients without a history of heart attacks.

Chronic Conditions and Depression in Older Persons

The challenge of treating depression as one of multiple chronic conditions is especially an issue in older persons. AHRQ research comparing elderly patients with and without depression in a primary care clinic found that the depressed patients had:

• Nearly $200 more in annual diagnostic test costs.
• Almost 1.5 more ambulatory care visits per year.
• Over 12 percent more annual visits to the emergency department.
• Five percent more hospitalizations each year.

To reduce the cost of care and improve outcomes for older persons with depression, coexisting psychiatric and medical illnesses must be targeted for treatment.

Best Care:  Mental Health Specialists or Medical Care Providers?

The organization of care can affect care delivery for depression. One AHRQ-sponsored study showed that shifting patients away from mental health specialists to general medical providers (as is the practice in some managed care arrangements) may lead to fewer improvements in patient functioning but costs two to three times less.

Other AHRQ-funded research on the effects of changes in health care payment and delivery found that after switching to a prepaid plan, the health status of outpatients with depression did not appear to suffer although they were 12 percent less likely to use antidepressants and made 35 to 40 percent fewer visits to their mental health care providers.

Even where there is substantial agreement about how treatment for depression can be improved, changes to everyday practice have been slow. Past efforts by managed care organizations to improve compliance with guidelines for improving diagnosis and treatment of depression have met with only modest success.

Two AHRQ studies investigating academic detailing and continuous quality improvement interventions in managed care organizations concluded that these approaches were only mildly effective in improving clinicians' adherence to the recommended guidelines for care. However, promising early results from a current study evaluating ways to increase use of antidepressants and psychotherapy in managed primary care practice suggest that depressed patients in the intervention groups were more likely to receive these interventions and exhibit better outcomes.

The National Guideline Clearinghouse™ (NGC) sponsored by AHRQ in partnership with the American Medical Association and the American Association of Health Plans, allows physicians and other Internet users to assess and compare guidelines online at http://www.guideline.gov. The NGC is being used by Georgetown University Medical Center's Mood Disorder Program in the development of clinical practice guidelines on depression for primary care physicians in managed care settings.

The vaccines that protect against 2009 H1N1 influenza (flu) are available, and more doses will be shipped in the upcoming weeks. As you are preparing to protect yourself and your family from the 2009 H1N1 flu, you may have questions about the safety of the 2009 H1N1 flu vaccines. Here are the Frequently Asked Questions about the Safety of the 2009 H1N1 Flu Vaccines.

http://www.cdc.gov/Features/H1N1Vaccine/

AHRQ is the Agency for Healthcare Research and Quality--the Nation's lead Federal agency for research on health care quality, costs, outcomes, and patient safety.

The Agency for Healthcare Research and Quality's (AHRQ) mission is to improve the quality, safety, efficiency, and effectiveness of health care for all Americans. Information from AHRQ's research helps people make more informed decisions and improve the quality of health care services. AHRQ was formerly known as the Agency for Health Care Policy and Research.

AHRQ is home to research centers that specialize in major areas of health care research:

• Quality improvement and patient safety.
• Outcomes and effectiveness of care.
• Clinical practice and technology assessment.
• Health care organization and delivery systems.
• Primary care (including preventive services).
• Health care costs and sources of payment.

Advice Columns from Dr. Carolyn Clancy
Open Enrollment: What To Consider When Choosing a Health Plan

AHRQ Director Carolyn Clancy, M.D., has prepared brief, easy-to-understand advice columns for consumers to help navigate the health care system. They will address important issues such as how to recognize high-quality health care, how to be an informed health care consumer, and how to choose a hospital, doctor, and health plan. Check back regularly for new columns.

Excerpt:

It's open enrollment season, the time when millions of workers will choose the health insurance plan they'll have next year. With premiums for health coverage offered by employers rising, it may feel more like open season on your wallet. That's all the more reason you should understand your options.

To get the best value from your health plan, you need to understand your different coverage options and how they work. Then you need to make a choice that's based on your personal situation, such as whether you are single or married or have a chronic health condition.

Many of the common health insurance plans today offer several choices for coverage, based on factors including cost, flexibility and how much of a role you want to play in managing and paying for your own health care. These include:

• Preferred provider organizations (PPOs). These plans contract with doctors, hospitals, and other providers but typically do not manage your care. PPOs allow you to see providers outside the network, but you will pay more for your care if you do. These are the most common work-based health plans.
• Health maintenance organizations (HMOs). Many of these plans focus on preventing diseases and staying healthy. If you join an HMO, you typically must receive all your care from network providers, except in medical emergencies. When you join, you pick a primary care doctor to manage your care. HMOs usually have copayments rather than deductibles or co-insurance.
• Point-of-service organizations (POS). These plans are a combination of a PPO and an HMO. POS plans have a primary care doctor who manages your care but allow you to seek care from doctors and hospitals that are not part of the plan. You pay more for seeking care out of network, however.
• Consumer-directed health plans. These newer health plans give  you more control over your own health care, both in choosing the care you receive and paying for it. They often require you to pay a substantial deductible (often $2,000 or more) before coverage starts, and are combined with a personal health savings account or another similar product that allows you to pay for care with pre-tax money.   
  

... read Dr. Clancy's complete column, and more topics covering your health care.

RESOURCE:  Agency for Healthcare Research

There is nothing more powerful than having a friend or neighbor make the pitch for change!

Additional resources for learning about options or finding help (nationally) include:

• http://www.ioaging.org/ - Institute on Aging.
• http://www.apsnetwork.org/ - National Adult Protective Services Association (NAPSA).
• http://www.ncea.aoa.gov/ncearoot/Main_Site/index.aspx - National Center on Elder Abuse-Administration on Aging.
• ACF: Administration for Children & Families; http://www.acf.hhs.gov/; The ACF, within the Department of Health and Human Services (HHS) is responsible for federal programs that promote the economic and social well-being of families, children, individuals, and communities.
• ADCRC: The Alzheimer's Day Care Resource Center program's primary purpose is to provide quality daycare for persons with dementia, while giving respite to their caregivers.
• Administration on Aging; http://www.aoa.gov; The Administration on Aging funds the largest U.S. community nutrition program for older persons, and works closely with its network of state and area agencies on aging, tribal organizations and service providers to provide adequate nutrition for the elderly. In addition to Nutrition information you will find information on Alzheimer's; Senior Medicare Patrols; the Eldercare Locator. Information that can be found on the AoA website:
• Grants; http://www.grants.gov/; Grant information.
• Statistics on Older Americans; http://www.aoa.gov/prof/Statistics/statistics.asp.
• Aging Network Resource; http://www.aoa.gov/prof/agingnet/agingnet.asp.
• About the Older Americans Act; http://www.aoa.gov/about/legbudg/oaa/legbudg_oaa.asp;
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Human beings love nature!  There's no question about it -- when you look at the amount of time we spend as a species admiring sunsets, planting gardens, exchanging flowers, and taking long leisurely walks.  But healthcare has become an indoor activity -- sequestered from nature's healing embrace.

There is a large and growing body of evidence over the past decade that demonstrate the role of the physical environment in achieving healthcare quality and safety. A recent analysis of more than 600 primarily peer-reviewed studies found associations between the physical environment and patient and staff outcomes in four areas:

• Reduced staff stress and fatigue and increased effectiveness in delivering care
• Improved patient safety
• Reduced patient stress and improved health outcomes
• Improved overall healthcare quality (Ulrich, 2004)

Hospitals are complex systems in which it is difficult to isolate the impacts of individual factors and suggest that design-based evidence parallels evidence-based medicine for improving health care.

Green Healthcare Solutions

A green healthcare agenda that includes ecological health on multiple scales -- individual, staff, facilities, and global impact -- can incorporate environmental initiatives such as reduced resource use, and it can aim for improved patient outcomes.

A responsible green agenda does not guarantee that recycled floor surfaces or less outgassing of chemicals from products will result in better care or more rapid recovery, but reinventing hospitals and transforming their design becomes a tool to improve quality, safety, and experience.  Green touches everything...food, cleansers, buildings, and even transportation choices.

Seniors are probably the most vocal and highest financial supporters of healthcare institutions.  Seniors' own need for quality care creates some of that focus...but their concern for their communities, the desire to give back to their communities and their concern for following generations lead them to contribute time, talent, resources and a voice to healthcare policies.

Learning about green healthcare and sustinable communities can be a powerful tool to accomplish these altruistic goals.  The information is available through new green healthcare associations, the Institute for Medicine, etc.  Now, what's needed is for individuals with a seat at the table of local organizations to bring their concerns into the light of discussions. 

To help shape a more sustainable future based on solid environmental support systems, not based on the manmade, pharmaceutical and toxic approaches to healthcare that has been developed over the past fifty years, but to look at healthcare as a system of people caring for one another in healthful environments, using healthful products and services...and taking that new approach to clean air and water, non-toxic solutions and reduced impact on the environment home with us.

That's our challenge today.  Understanding how global systems affect our own immediate ability to breathe easily, keep our bodies free of pollutants, and thrive for the long term! 

The Principles of the Ethical Practice of Public Health begins with a statement that, prima facie, supports green health care:

"Public health should address principally the fundamental causes of disease and
requirements for health, aiming to prevent adverse health outcomes."

We are learning that many of today's diseases are being caused or exacerbated by environmental pollutants.  Asthma and heart disease are greatly impacted by exposure to pollutants, especially those from vehicular exhaust.  Allergies and sensitivities are increasing as the chemical soup in which we live increase.  Children tested for resident toxins are showing significant increases in toxin levels.

Public health is one of our vehicles for a more sustianable way of life.  If "green" will improve public health, it will also improve individual health levels for our children, our neighbors, our more vulnerable seniors and even our productivity level on the job.

Climate change brings another kind of health impact.  Severe heat kills.  Droughts kill.  Floods kill.  Those public health threats are environmental, and can only be solved with environmental solutions.  Our role as citizens in those solutions is first and foremost to reduce our impact on the global natural infrastructurel.  By wasting less.  By using less.  By selecting non-toxic products and solutions.  Even by driving less -- by using public transportation and walking.

We can make a difference in the pubic health arena, with our personal choices.  We CAN make a difference, every day. 

Green solutions aren't always common sense -- but frequently are.  But in the healthcare environment when our bodies' immune systems are delicate, special circumstances can exist.  We must reflect on history, however, and remember that patients were once kept in closed, stuffy, hot rooms with no ventilation and it was a visionary nurse who opened the windows and curtains and improved health care.  Those same innovative strategies are part of advancing our concept of green healthcare.

Craig Zimring of the Georgia Institute of Technology,  warns of the "fallacy of generalized goodness"; not all green decisions are all good.

For example, in green building, there's a delicate balance between space and the infrastructure: although wide hallways, large rooms, and oversize windows that provide natural
daylighting may create pleasant environments for staff and patients, they may also
increase energy demand and costs.

The presence of plants may pose challenges for infection control.

Thoughtful analysis, supported by empirical data and a culture of continuous improvement, is necessary to make green healthcare a smarter approach to healthful living and caring for one another. 

Your healthcare facility -- doctor's office, clinic, hospital...and even your own home, can benefit your health by making your environment more health affirming...and less toxic.

Opportunities  for greening and enhancing environmental performance abound and are growing quickly as research and practical solutions are being innovated in the following domains:

• Site selection of facilities so they maximize use of natural light and air flow
• Water conservation and water quality protection by reducing toxins and enhancing nature's filtration through wetlands and plant processes
  
• energy efficiency in lighting, heating and air conditioning, manual operations, etc
  
• Recycled and renewable materials in paper, furnishings and even building materials that mine our landfills and waste
  
• Low-emitting materials that reduce greenhouse gases and volatile organic chemicals, etc.
  
• Alternative transportation such as walking, bicycling, renewable energy use, and public transportation
  
• Daylighting that uses natural light in indoor and even outdoor spaces to reduce electric lighting and energy waste and costs
• Reduced waste generation -- who can argue with reducing waste as a smart move?
  
• Local and organic food use supports local jobs and reduces dependence on petroleum for transportation fuel, fertilizers, and agricultural chemicals.
  
• Green cleaning materials reduce contamination of water supplies, promote better health of maintenance workers and improve air quality for everyone in the buildings.
  

Green strategies center on protecting our natural environment -- which supports life, our lives. We need clean air, fresh clean water, healthy soil to grow healthful foods, and a sustainable way of life that supports good health. That's what all the fuss about "green" is about.

Future historians of the late 20th and early 21st centuries may well mark the growth of environmentalism as one of the epochal transformations of the time. Governments, industries, and the public have come to understand the importance of sustainability and of environmental protection, and the necessary science, tech- nology, and policy have evolved rapidly. The healthcare sector, which accounts for one-sixth of the U.S. economy, has come relatively late to environmental thinking, but the rise of "green health care" signals a major step forward.

The US Institutes of Medicine have been exploring the challenge and find that green health care--the incorporation of environmentally friendly practices into healthcare delivery--appeals to health professionals and institutions for many reasons.

• Green health care offers the potential to safeguard the environment, an increasingly compelling challenge.
  
• Green health care allows healthcare institutions to demonstrate leadership in their communities.
  
• Green health care can be a platform for educating students and members of the public.
  
• IGreen health care can save money. 

Practical implementation of green solutions include strategies such as:

• Green construction and operation to protect patients, workers, and visitors from toxins, poor ventilation, etc.
• Choosing safe cleaning agents or limiting the use of pesticides can reduce the potential for toxicity among patients, workers and visitors.
• Reducing the ecological footprint of a hospital reduces environmental haz- ards and protects natural resources.
• Linking a hospital to its community with pedestrian infrastructure and mass transit can reduce vehicle traffic and help achieve clean air.
• Reducing packaging in the hospital cafeteria can reduce waste in landfills as well as use of trees in far away forests that clean our global air supply.
• Using biodegradable cutlery and plates can reduce the volume of waste sent to landfills and use of those same wood fibers.
• Purchasing food and supplies from local sources reduces the need for long-distance transport of goods, thereby reducing the associated greenhouse gas emissions that contribute to climate change.
• Installing flooring made from sustainably harvested wood helps slow deforestation, which in turn preserves biodiversity and habitat for the entire web of life and the livelihoods of rural populations.

Green practices conserve and steward scarce resources and reduce environmental degradation. They also protect our health locally, regionally and globally. We live in a "closed system" in which we all breathe the same air, reuse the same water, and ship goods around the world. What we do locally can have a tremendous impact for good or ill for ourselves and other life.

Because we have such a large healthcare infrastructure, greening your local doctors' offices, your local hospitals and clinics can make a far reaching impact on a better future for all of us.

You can get involved. Ask for green solutions to be adopted by the building managers and boards of these institutions that you patronize or are members of. Your voice, armed with practical suggestions can make a difference.

You might share this report with the appropriate decision makers:   

You can download a PDF file of it free at the National Academies Press, haviing been authored by the National Academies of Sciences, National Academy of Medicine and the National Research Council.