As managed care squeezes treatment access and public entitlement programs become increasingly restricted, clinical research projects may become important vectors of psychiatric outreach and treatment. This situation is a paradox, as clinical research is often criticized for selecting rarified cases, refined by numerous inclusion and exclusion criteria, that may not represent "normal" patient populations. Yet in screening potential subjects by telephone for eligibility for chronic depression protocols, we have found that research can offer both casefinding and treatment to marginalized individuals in the community.
We have advertised for subjects in New York City neighborhood newspapers and on radio, with overwhelming response. Most people who call us appear to suffer from psychiatric disorders and to lack insurance. Ten to 20 minutes of semistructured telephone screening usually determines whether they are eligible for our depression treatment studies.
To date, more than 40 percent of those screened have met our criteria and received treatment, which they often knew they needed but could not afford. Those who do not meet study criteria are alerted to their presumptive diagnoses (with appropriate cautions about the limits of telephone interviewing); to potential entitlement programs, including free medication for indigent patients from pharmaceutical companies; and to low-cost care available at nearby hospitals. Those screened invariably sound grateful for these brief calls. Their stories are heart-rending, and they frequently are not receiving appropriate care.
Chronically depressed patients may be more receptive than those with other diagnoses to such outreach, as dysthymic patients often feel hopeless and indecisive and may need prompting to seek help for what they believe is a personality defect. Many eligible subjects are alone at home when we call at midday. It would not be surprising, however, to find patients with other severe mood disorders, agoraphobia, or schizophrenia at home by the phone as well. Already stigmatized, people with significant psychiatric disorders have shrinking access to mental health care and thus may be increasingly receptive to research protocols.
The clinical research scheme benefits everyone. Patients receiving inadequate or no care learn of potential treatments. Misinformation is corrected. A significant minority are offered free treatment, and the rest are referred elsewhere. Those who are screened sound pleased and even remoralized by the contact. The researchers are gratified not only by the recruitment of subjects but by the chance to do some clinical good through outreach. The shame is that it falls to research projects to do such work because much of the larger health care system has abdicated responsibility.— John C. Markowitz, M.D., associate professor of clinical psychiatry at Cornell University Medical College in New York City
