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Translating Evidence-Based Depression Management Services to Community-Based Primary Care Practices
Abstract
Randomized controlled trials have demonstrated the efficacy and cost-effectiveness of using treatment models for major depression in primary care settings. Nonetheless, translating these models into enduring changes in routine primary care has proved difficult. Various health system and organizational barriers prevent the integration of these models into primary care settings. This article discusses barriers to introducing and sustaining evidence-based depression management services in community-based primary care practices and suggests organizational and financial solutions based on the Robert Wood Johnson Foundation Depression in Primary Care Program. It focuses on strategies to improve depression care in medical settings based on adaptations of the chronic care model and discusses the challenges of implementing evidence-based depression care given the structural, financial, and cultural separation between mental health and general medical care.
... However, implementation of integrated care models in real-world primary care settings is variable, may not conform to evidence-based practice, and has rarely been evaluated (14). The most vigorously studied models have been patchily implemented, owing in part to organizational, financial, and attitudinal barriers (15)(16)(17)(18). In addition, other models of integrated care have been adopted without being thoroughly tested (14,19,20). ...
... In turn, poor or incomplete implementation of integrated care contributes to poor integration of general medical and mental health care, inappropriate variation in clinical care, delayed follow-up after treatment initiation, treatment dropout, and insufficient improvement in symptoms (15)(16)(17)(18). High-profile efforts to scale up the collaborative care model have failed to demonstrate improved clinical outcomes, which is consistent with known difficulties transferring complex interventions across diverse contexts (21)(22)(23)(24)(25). Unfortunately, in these cases, important structures (that is, the conditions under which health care is provided) and care processes that may contribute to outcomes have not been consistently measured and, indeed, have not been well articulated. ...
Objective:
Although the effectiveness of integrated mental health care has been demonstrated, its implementation in real-world settings is highly variable, may not conform to evidence-based practice, and has rarely been evaluated. Quality indicators can guide improvements in integrated care implementation. However, the literature on indicators for this purpose is limited. This article reports findings from a systematic review of existing measures by which to evaluate integrated care models in primary care settings.
Methods:
Bibliographic databases and gray literature sources, including academic conference proceedings, were searched to July 2014. Measures used or proposed to evaluate integrated care implementation or outcomes were extracted and critically appraised. A qualitative synthesis was conducted to generate a panel of unique measures and to group these measures into broad domains and specific dimensions of integrated care program performance.
Results:
From 172 literature sources, 1,255 measures were extracted, which were distilled into 148 unique measures. Existing literature frequently reports integrated care program effectiveness vis-à-vis evidence-based care processes and individual clinical outcomes, as well as efficiency (cost-effectiveness) and client satisfaction. No measures of safety of care and few measures of equitability, accessibility, or timeliness of care were located, despite the known benefits of integrated care in several of these areas.
Conclusions:
To realize the potential for quality measurement to improve integrated care implementation, future measures will need to incorporate domains of quality that are presently unaddressed; microprocesses of care that influence effectiveness, sustainability, and transferability of models of care; and client and health care provider perspectives on meaningful measures of quality.
... Evidence-to-practice gaps have also been noted in other primary care settings, where organizational, financial and attitudinal barriers hinder the delivery of Collaborative Care. 23,[33][34][35][36] In turn, poor or incomplete implementation of Collaborative Care contributes to poor integration of physical and mental health care, inappropriate variation in clinical care, non-guideline-based pharmacotherapy, delayed follow up after treatment initiation, treatment drop-outs and less improvement in symptoms. [33][34][35][36] In order to meet Canada's population mental health needs, it is vital that we develop a shared understanding of the critical components of Collaborative Care that require consistency, and identify and close gaps in implementation of Collaborative Care in primary care practice. ...
... 23,[33][34][35][36] In turn, poor or incomplete implementation of Collaborative Care contributes to poor integration of physical and mental health care, inappropriate variation in clinical care, non-guideline-based pharmacotherapy, delayed follow up after treatment initiation, treatment drop-outs and less improvement in symptoms. [33][34][35][36] In order to meet Canada's population mental health needs, it is vital that we develop a shared understanding of the critical components of Collaborative Care that require consistency, and identify and close gaps in implementation of Collaborative Care in primary care practice. ...
Suggested citation: Sunderji, N., Ghavam-Rassoul, A., Ion, A., and Lin, E. " Driving improvements in the implementation of collaborative mental health care: A quality framework to guide measurement, improvement and research. " 2016. Toronto, Canada.
... 3,7 Historical protection of privacy and fears of violation of privacy have created information-sharing obstacles between primary providers and mental health specialists and confusion about responsibility for a patient's care. 7,18 Workforce shortages of professionals trained in evidence-based interventions have resulted in limited access to care. 18,19 3) Financial barriers to collaborative care implementation refer to funding and reimbursement issues. ...
... 13 In primary care, especially in the US, the lack of reimbursement for the treatment of mental health is common, especially for services such as depression screening, psychiatric consultation, and care management. 7,18,20 In spite of state-level advocacy efforts, billing restrictions for a medical and a mental health visit on the same day continue to create barriers. 7 Primary care providers are reimbursed at a lower rate for depression treatment compared to medical evaluation, and collecting fees from patients is problematic. ...
Patient-centered care and self-management of chronic disease are optimally characterized by distinct adjunct services such as education, and support for the behavioral and psychosocial elements of managing disease. The collaborative care model for the treatment of depression and anxiety in primary care includes the integration of a behavioral health specialist, in collaboration with the primary care provider, and psychiatric consultation to effectively screen and treat common mental health problems. Dissemination and sustainability of the model have encountered numerous barriers across systems of care. This article represents a discussion of the key barriers to collaborative care and offers a discussion of opportunities for dissemination and sustainability of the model.
... Despite the availability of psychosocial EBPs [1,[4][5][6][7][8] for mood disorders, they rarely get implemented and sustained in community-based practices [9][10][11]. This is primarily due to a lack of available strategies to help providers embed the EBP into routine clinical workflows, and garner support from clinical and administrative leadership on the EBP's added value to the practice [8,[12][13][14][15][16][17][18][19][20][21][22][23][24][25]. As a result, outcomes for persons with mental disorders remain suboptimal [12,26]. ...
... This is primarily due to a lack of available strategies to help providers embed the EBP into routine clinical workflows, and garner support from clinical and administrative leadership on the EBP's added value to the practice [8,[12][13][14][15][16][17][18][19][20][21][22][23][24][25]. As a result, outcomes for persons with mental disorders remain suboptimal [12,26]. New healthcare initiatives including medical home models designed to improve efficiency and value have not included specific strategies to assist local providers in implementing EBPs in routine care [27][28][29]. ...
Background
Despite the availability of psychosocial evidence-based practices (EBPs), treatment and outcomes for persons with mental disorders remain suboptimal. Replicating Effective Programs (REP), an effective implementation strategy, still resulted in less than half of sites using an EBP. The primary aim of this cluster randomized trial is to determine, among sites not initially responding to REP, the effect of adaptive implementation strategies that begin with an External Facilitator (EF) or with an External Facilitator plus an Internal Facilitator (IF) on improved EBP use and patient outcomes in 12 months.Methods/DesignThis study employs a sequential multiple assignment randomized trial (SMART) design to build an adaptive implementation strategy. The EBP to be implemented is life goals (LG) for patients with mood disorders across 80 community-based outpatient clinics (N¿=¿1,600 patients) from different U.S. regions. Sites not initially responding to REP (defined as <50% patients receiving ¿3 EBP sessions) will be randomized to receive additional support from an EF or both EF/IF. Additionally, sites randomized to EF and still not responsive will be randomized to continue with EF alone or to receive EF/IF. The EF provides technical expertise in adapting LG in routine practice, whereas the on-site IF has direct reporting relationships to site leadership to support LG use in routine practice. The primary outcome is mental health-related quality of life; secondary outcomes include receipt of LG sessions, mood symptoms, implementation costs, and organizational change.DiscussionThis study design will determine whether an off-site EF alone versus the addition of an on-site IF improves EBP uptake and patient outcomes among sites that do not respond initially to REP. It will also examine the value of delaying the provision of EF/IF for sites that continue to not respond despite EF.Trial registrationClinicalTrials.gov identifier: NCT02151331.
... Given the strong evidence base for CCMs in mental disorders, 1,[7][8][9] the key issue becomes how best to implement and sustain these models in practice. [10][11][12][13] Several specific questions arise. First, are any of the 6 elements essential for CCM effects, and are any superfluous? ...
... The first 4 elements were frequently included in clinical trials by embedding care managers (itself a form of delivery system redesign) who provide self-management support to patients, clinical information systems in the form of registry tracking, and decision support by communicating with mental health specialists. Health care organization support and leadership are crucial, however, in moving from the controlled trial environment to implementation 10,12,90,91 and sustainability 13,92 in clinical practice. ...
Prior meta-analysis indicates that collaborative chronic care models (CCMs) improve mental and physical health outcomes for individuals with mental disorders. This study aimed to investigate the stability of evidence over time and identify patient and intervention factors associated with CCM effects to facilitate implementation and sustainability of CCMs in clinical practice.
We reviewed 53 CCM trials that analyzed depression, mental quality of life (QOL), or physical QOL outcomes. Cumulative meta-analysis and metaregression were supplemented by descriptive investigations across and within trials.
Most trials targeted depression in the primary care setting, and cumulative meta-analysis indicated that effect sizes favoring CCM quickly achieved significance for depression outcomes, and more recently achieved significance for mental and physical QOL. Four of 6 CCM elements (patient self-management support, clinical information systems, system redesign, and provider decision support) were common among reviewed trials, whereas 2 elements (health care organization support and linkages to community resources) were rare. No single CCM element was statistically associated with the success of the model. Similarly, metaregression did not identify specific factors associated with CCM effectiveness. Nonetheless, results within individual trials suggest that increased illness severity predicts CCM outcomes.
Significant CCM trials have been derived primarily from 4 original CCM elements. Nonetheless, implementing and sustaining this established model will require health care organization support. Although CCMs have typically been tested as population-based interventions, evidence supports stepped care application to more severely ill individuals. Future priorities include developing implementation strategies to support adoption and sustainability of the model in clinical settings while maximizing fit of this multicomponent framework to local contextual factors.
... 6 The CCM is ideally implemented with a co-located care manager (i.e., nurse or clinical social worker) within the primary care clinic. 7,8 The care manager provides counseling to patients on self-management, monitors outcomes, and consults with a mental health specialist (i.e., psychiatrist) for more complex cases. The mental health specialist is either co-located in the primary care clinic or is located off-site, with a contractual arrangement to provide consultation. ...
... The mental health specialist is either co-located in the primary care clinic or is located off-site, with a contractual arrangement to provide consultation. 7,8 The CCM is also considered the cornerstone of healthcare reform, as an operational framework for the patient-centered medical home under accountable care organizations, which seek to reward providers on improved quality and care coordination. 5,9 However, the CCM for mental disorders has not been widely implemented in routine practice, 10,11 primarily because of the separation of physical and mental health services, and a lack of a reimbursement strategy. ...
The Chronic Care Model (CCM) has been shown to improve medical and psychiatric outcomes for persons with mental disorders in primary care settings, and has been proposed as a model to integrate mental health care in the patient-centered medical home under healthcare reform. However, the CCM has not been widely implemented in primary care settings, primarily because of a lack of a comprehensive reimbursement strategy to compensate providers for day-to-day provision of its core components, including care management and provider decision support. Drawing upon the existing literature and regulatory guidelines, we provide a critical analysis of challenges and opportunities in reimbursing CCM components under the current fee-for-service system, and describe an emerging financial model involving bundled payments to support core CCM components to integrate mental health treatment into primary care settings. Ultimately, for the CCM to be used and sustained over time to integrate physical and mental health care, effective reimbursement models will need to be negotiated across payers and providers. Such payments should provide sufficient support for primary care providers to implement practice redesigns around core CCM components, including care management, measurement-based care, and mental health specialist consultation.
... This finding appears superior to previous trials results, although there was no control group to account for regression to the mean. Regardless, these data alleviate concerns of decreases in efficacy of research-developed interventions moved into real-world settings (i.e., voltage drop) [25]. Although only a hypothesis, these clinical outcomes may reflect the autonomy given to providers to engage treatment-seeking patients as opposed to our clinical trials in which patients were randomized without any requirements for treatment seeking. ...
Evidence-based psychotherapies (EBPs) are underused in health care settings. Aligning implementation of EBPs with the needs of health care leaders (i.e., operational stakeholders) can potentially accelerate their uptake into routine practice. Operational stakeholders (such as hospital leaders, clinical directors, and national program officers) can influence development and oversight of clinical programs as well as policy directives at local, regional, and national levels. Thus, engaging these stakeholders during the implementation and dissemination of EBPs is critical when targeting wider use in health care settings. This article describes how research-operations partnerships were leveraged to increase implementation of an empirically supported psychotherapy - brief Cognitive Behavioral Therapy (brief CBT) - in Veterans Health Administration (VA) primary care settings. The partnered implementation and dissemination efforts were informed by the empirically derived World Health Organization's ExpandNet framework. A steering committee was formed and included several VA operational stakeholders who helped align the brief CBT program with the implementation needs of VA primary care settings. During the first 18 months of the project, partnerships facilitated rapid implementation of brief CBT at eight VA facilities, including training of 12 providers who saw 120 patients, in addition to expanded program elements to better support sustainability (e.g., train-the-trainer procedures).
... Facilitation, implementation strategy implementation, training, coaching, evidence-based, knowledge transfer, implementation evaluation Background Complex evidence-based clinical innovations are challenging to implement, with many settings requiring implementation assistance to increase the likelihood of innovation uptake with fidelity. These efforts often require significant stakeholder engagement, support from multiple care specialties, and changes in provider attitudes, organizational processes, and clinical practice (Bauer et al., 2015;Kilbourne et al., 2004;Lindsay et al., 2015;Ritchie et al., 2020). Top-down mandates and bottom-up approaches alone are rarely sufficient to address these barriers to innovation uptake (Ferlie & Shortell, 2001;Greenhalgh et al., 2004;Parker et al., 2007Parker et al., , 2009Ritchie et al., 2020). ...
Background: Implementation scientists are identifying evidence-based implementation strategies that support the uptake of evidence-based practices and other clinical innovations. However, there is limited information regarding the development of training methods to educate implementation practitioners on the use of implementation strategies and help them sustain these competencies. Methods: To address this need, we developed, implemented, and evaluated a training program for one strategy, implementation facilitation (IF), that was designed to maximize applicability in diverse clinical settings. Trainees included implementation practitioners, clinical managers, and researchers. From May 2017 to July 2019, we sent trainees an electronic survey via email and asked them to complete the survey at three-time points: approximately 2 weeks before and 2 weeks and 6 months after each training. Participants ranked their knowledge of and confidence in applying IF skills using a 4-point Likert scale. We compared scores at baseline to post-training and at 6 months, as well as post-training to 6 months post-training (nonparametric Wilcoxon signed-rank tests). Results: Of the 102 participants (76 in-person, 26 virtual), there was an increase in perceived knowledge and confidence in applying IF skills across all learning objectives from pre- to post-training (95% response rate) and pre- to 6-month (35% response rate) follow-up. There was no significant difference in results between virtual and in-person trainees. When comparing post-training to 6 months (30% response rate), perceptions of knowledge increase remained unchanged, although participants reported reduced perceived confidence in applying IF skills for half of the learning objectives at 6 months. Conclusions: Findings indicated that we have developed a promising IF training program. Lack of differences in results between virtual and in-person participants indicated the training can be provided to a remote site without loss of knowledge/skills transfer but ongoing support may be needed to help sustain perceived confidence in applying these skills.
Plain Language Summary
While implementation scientists are documenting an increasing number of implementation strategies that support the uptake of evidence-based practices and other clinical innovations, little is known about how to transfer this knowledge to those who conduct implementation efforts in the frontline clinical practice settings. We developed, implemented, and conducted a preliminary evaluation of a training program for one strategy, implementation facilitation (IF). The training program targets facilitation practitioners, clinical managers, and researchers. This paper describes the development of the training program, the program components, and the results from an evaluation of IF knowledge and skills reported by a subset of people who participated in the training. Findings from the evaluation indicate that this training program significantly increased trainees' perceived knowledge of and confidence in applying IF skills. Further research is needed to examine whether ongoing mentoring helps trainees retain confidence in applying some IF skills over the longer term.
... Poor levels of detection, treatment, and monitoring of depression have been extensively documented. [153][154][155] Providers often feel ill prepared to meet the needs of these patients, and training for depression has been perceived as inadequate by some professionals. 156 The delivery of behavioral health services in the primary care setting thus requires a new approach to the way physicians are trained and monitored to practice across the span of their primary care careers. ...
Depression is a common and heterogeneous condition with a chronic and recurrent natural course that is frequently seen in the primary care setting. Primary care providers play a central role in managing depression and concurrent physical comorbidities, and they face challenges in diagnosing and treating the condition. In this two part series, we review the evidence available to help to guide primary care providers and practices to recognize and manage depression. The first review outlined an approach to screening and diagnosing depression in primary care. This second review presents an evidence based approach to the treatment of depression in primary care, detailing the recommended lifestyle, drug, and psychological interventions at the individual level. It also highlights strategies that are being adopted at an organizational level to manage depression more effectively in primary care.
... 10,11 This is an important issue because when the most evidence-based Collaborative Care models are not well-implemented, studies have shown this results in poor integration of physical and mental health care, inappropriate variation in clinical care, nonguideline-based pharmacotherapy, delayed follow-up, treatment drop-outs, and less improvement in symptoms. [12][13][14][15][16] As research in Collaborative Care shifts from clinical trials to real-world practice, the perceptions of individuals who use such services are vital to developing, delivering, and evaluating Collaborative Care. Patient-reported outcome and experience measures (PROMs and PREMs, respectively) are increasingly being used to assess and compare outcomes achieved by healthcare providers and organizations, and are being supported by policymakers and regulatory bodies. ...
This report summarizes the proceedings of a Knowledge-to-Action event to mobilize the findings of the research, “Meaningfully involving mental health service users in improving Collaborative Care.” The study was funded by the Canadian Institutes of Health Research (CIHR) Strategy for Patient Oriented Research (SPOR) from 2017-2019.
Collaborative Care involves mental health specialists and primary care providers working in partnership with patients and families to deliver accessible, high-quality mental health care. As we work toward more evidence-informed practice and practice-based evidence in Collaborative Care across Canada, people with lived experience (PWLE) of mental health challenges and mental health service use have a key role to play in evaluating and improving Collaborative Care programs.
We engaged 50 PWLE in Toronto and Thunder Bay to explore the challenges and successes they have encountered when trying to access and/or when receiving mental health care, as well as to develop priority areas for patient-reported outcome measures (PROMs) and patient-reported experience measures (PREMs) that can be used to evaluate quality of care. We also surveyed leaders in primary care organizations across Ontario to understand their readiness for patient engagement in quality improvement in order to inform strategies for uptake of client recommendations.
On May 31st 2018, 31 stakeholders came together to hear the research findings and develop strategies and recommendations to move forward with client-oriented quality improvement and research efforts in Collaborative Care. Meeting participants included mental health service users, primary care and mental health care providers, health services and quality improvement researchers, and healthcare policy decision-makers and influencers. This report summarizes the proceedings and recommendations from the meeting.
... Given the robust evidence base for structuring mental health care around the CCM (Badamgarav et al. 2003;Gilbody et al. 2006;Miller et al. 2013;Woltmann et al. 2012), the pivotal issue becomes how best to implement and sustain it in clinical settings (Kilbourne et al. 2004(Kilbourne et al. , 2007; Wiltsey 1 3 Stirman et al. 2012). The breadth and depth of efforts needed to implement the CCM depend, however, on the ways in which care is (or is not) already aligned with its six elements. ...
The Collaborative Care Model (CCM) is an evidence-based approach for structuring care for chronic health conditions. Attempts to implement CCM-based care in a given setting depend, however, on the extent to which care in that setting is already aligned with the specific elements of CCM-based care. We therefore interviewed staff from ten outpatient mental health teams in the US Department of Veterans Affairs to determine whether care delivery was consistent or inconsistent with CCM-based care in those settings. We discuss implications of our findings for future attempts to implement CCM-based outpatient mental health care.
... Over the last 20 years, position papers, discussion documents and research findings have identified the central role of primary care and general medical services in delivering mental health care, the need for better collaboration between mental health and primary care providers, and strategies that have been developed at national, regional and clinical service level to make this happen (Patel 2002;Kilbourne et al. 2004;WHO 2008;WHO and Wonca 2008;WHO 2010;Dua et al. 2011;Kates et al. 2011 entitled "Integrating mental health into primary care: A global perspective" (WHO and Wonca 2008) and in the development of the mental health Gap Action Program (mhGAP) (WHO 2008). This position paper builds on this work and translates the most current A c c e p t e d M a n u s c r i p t evidence into a framework that will be of value to clinicians working in any community in any country. ...
In almost any country – whether high, middle or low income - primary care providers play major roles in delivering mental health care. Indeed, the World Health Organization has recognized that in many low and middle-income countries, meeting the mental health needs of the population can only be achieved through greater integration of mental health services within primary care settings.
Other guidelines and planning documents have reached similar conclusions and made suggestions as to how to achieve this. This position paper builds upon this work and synthesizes their ideas and recommendations into a framework for enhancing mental health care delivered within primary care settings. This framework is based upon principles that can be adapted to any context, rather than specific models.
The paper identifies the key elements of successful collaboration and presents a three-step approach to improving collaboration. The first is the mental health services that any primary care provider can deliver, with or without the presence of psychiatrists or other mental health professionals. The second is practical ways in which effective collaboration can enhance and expand this care. This includes both the integration of mental health services within primary care and changes that any mental health service can make to better support local primary care providers. The third step looks at wider system changes required to support these new roles and activities, and how better collaboration can create new opportunities to respond to the challenges that all mental health systems are facing.
... Despite both documentation of the burden of depression on the primary care system and research supporting improved outcomes with integrated mental health care models that include care management, such programs are not yet widespread [22,33,34]. Research on reasons for slow implementation is currently limited. ...
Background
The collaborative care model is an evidence-based practice for treatment of depression in which designated care managers provide clinical services, often by telephone. However, the collaborative care model is infrequently adopted in the Department of Veterans Affairs (VA). Almost all VA medical centers have adopted a co-located or embedded approach to integrating mental health care for primary care patients. Some VA medical centers have also adopted a telephone-based collaborative care model where depression care managers support patient education, patient activation, and monitoring of adherence and progress over time.
This study evaluated two research questions: (1) What does a dedicated care manager offer in addition to an embedded-only model? (2) What are the barriers to implementing a dedicated depression care manager?
Methods
This study involved 15 qualitative, multi-disciplinary, key informant interviews at two VA medical centers where reimbursement options were the same— both with embedded mental health staff, but one with a depression care manager. Participant interviews were recorded and transcribed. Thematic analysis was used to identify descriptive and analytical themes.
Results
Findings suggested that some of the core functions of depression care management are provided as part of embedded-only mental health care. However, formal structural attention to care management may improve the reliability of care management functions, in particular monitoring of progress over time. Barriers to optimal implementation were identified at both sites. Themes from the care management site included finding assertive care managers to hire, cross-discipline integration and collaboration, and primary care provider burden. Themes from interviews at the embedded site included difficulty getting care management on leaders’ agendas amidst competing priorities and logistics (staffing and space).
Conclusions
Providers and administrators see depression care management as a valuable healthcare service that improves patient care. Barriers to implementation may be addressed by team-building interventions to improve cross-discipline integration and communication. Findings from this study are limited in scope to the VA healthcare system. Future investigation of whether alternative barriers exist in implementation of depression care management programs in non-VA hospital systems, where reimbursement rates may be a more prominent concern, would be valuable.
... However, poor levels of detection, treatment and monitoring of depression have been highlighted in primary care settings [14]. Research shows that only a minority of patients with a depressive or anxiety disorder are treated in a primary care setting in accordance with clinical guidelines [15,16]. ...
Background
Despite the growing interest in assessing the quality of care for depression, there is little evidence to support measurement of the quality of primary care for depression. This study identified evidence-based quality indicators for monitoring, evaluating and improving the quality of care for depression in primary care settings.
Methods
Ovid MEDLINE and Ovid PsycINFO databases, and grey literature, including relevant organizational websites, were searched from 2000 to 2015. Two reviewers independently selected studies if (1) the study methodology combined a systematic literature search with assessment of quality indicators by an expert panel and (2) quality indicators were applicable to assessment of care for adults with depression in primary care settings. Included studies were appraised using the Appraisal of Indicators through Research and Evaluation (AIRE) instrument, which contains four domains and 20 items. A narrative synthesis was used to combine the indicators within themes. Quality indicators applicable to care for adults with depression in primary care settings were extracted using a structured form. The extracted quality indicators were categorized according to Donabedian’s ‘structure-process-outcome’ framework.
Results
The search revealed 3838 studies. Four additional publications were identified through grey literature searching. Thirty-nine articles were reviewed in detail and seven met the inclusion criteria. According to the AIRE domains, all studies were clear on purpose and stakeholder involvement, while formal endorsement and usage of indicators in practice were scarcely described. A total of 53 quality indicators were identified from the included studies, many of which overlap conceptually or in content: 15 structure, 33 process and four outcome indicators. This study identified quality indicators for evaluating primary care for depression among adult patients.
Conclusions
The identified set of indicators address multiple dimensions of depression care and provide an excellent starting point for further development and use in primary care settings.
Electronic supplementary material
The online version of this article (doi:10.1186/s13643-017-0530-7) contains supplementary material, which is available to authorized users.
... Implementing a chronic care model requires substantial adaptations in daily practice regarding decision support, delivery system design, and clinical information systems. 33 When collaborative care models with depression were successfully implemented, depression symptoms improved, as did adherence to treatment, response to treatment, and quality of life/ functional status. This was reported in a 2012 meta-analysis. ...
Background:
Depression, anxiety, and emotional distress occur frequently and are usually treated in general practice. Little has been reported about the long-term course of these conditions and the long-term use of medical services.
Aim:
To follow up patients with depression, anxiety, and emotional distress in general practice for 5 years and examine the length and number of index episodes, prescribing behaviour, and the use of services in general practice.
Design and setting:
A case-control study using data from electronic medical records.
Method:
Three cohorts of patients with depression (n = 453), anxiety (n = 442), and emotional distress (n = 185) were compared against a cohort of control patients (n = 4156) during a 5-year follow-up from 2007 to 2011. The occurrence or recurrence of the index disorders, other psychological disorders or medical conditions, the numbers of prescriptions, and the number of contacts with the general practice were all examined.
Results:
Patients in the depression group had 1.1 followup episodes of depression, those in the anxiety group had 0.9 follow-up episodes of anxiety, and those in the emotional distress group had 0.5 follow-up episodes of emotional distress during the 5 years. All three groups had more consultations (for both psychological and somatic reasons) during each of the follow-up years than control patients. Furthermore, the groups with mental health disorders were given more prescriptions for psychopharmacological treatment.
Conclusion:
Five years after the index episode in 2007, patients with an episode of depression, anxiety, or emotional distress are still not comparable with control patients, in terms of the prevalence of mental health conditions, the number of prescriptions, and healthcare use.
... While the death and disability related to tobacco use is higher than any other chronic illness, tobacco addiction is a chronic condition that continues to be sub-optimally treated. Most studies of chronic illnesses have focused on improving the care of patients with diabetes, hyper-tension, congestive heart failure, asthma, and depression (e.g., Kilbourne et al., 2004;Parchman, Zeber, Romero, & Pugh, 2007;Pearson et al., 2005;Stroebel et al., 2005). But similar to these chronic conditions, there are proven treatments for tobacco use (Steinberg et al., 2008). ...
Tobacco use is a chronic, relapsing condition. While there are proven cessation medications and counselling treatments, uptake of available aids is poor and smokers often do not have access to evidence-based services.
Aims:
The Association for the Treatment of Tobacco Use and Dependence (ATTUD) is an organisation of tobacco treatment specialists (TTSs) representing a wide array of disciplines and healthcare settings. This case vignette was intended to provide a clinical example of an interdisciplinary approach to tobacco use treatment.
Methods:
ATTUD Interdisciplinary Committee members representing tobacco-cessation experts from five professions were asked to respond to the same composite case vignette detailing key areas of clinical consideration and treatment.
Results/Findings:
While there were common treatment themes across professions, each provider also offered a unique treatment perspective addressing different facets of the patient's complex care needs, including attention to other chronic illnesses, mental illnesses, and preventive services. Expert responses highlighted that different treatment approaches across a continuum of healthcare settings are complementary.
Conclusions:
Responses to this vignette support the need to address tobacco use from an interdisciplinary approach. Existing chronic care and patient-centred models should be utilised to ensure that tobacco users receive a sufficient range of cessation services.
... Chronic disease self-management programs have been associated with healthy aging and several have been successfully adapted to meet the needs of specific populations [14][15][16][17][18][19][20][21][22]. However, data suggest the translation of strong evidencebased interventions for depression into routine practice has been disappointing and difficult [23]. Thus, in an effort to better understand these challenges and successes, especially when focusing on co-morbid chronic disease and depression, this paper presents findings from a multi-phase, communitybased study of chronic disease and depression among Latinos. ...
... However, CCMs have not been widely disseminated in community-based practices (Kilbourne et al. 2004), in part because of their multicomponent nature, limited access to specific, user-friendly tools for providers to implement CCM core components, and lack of ongoing provider support to address barriers to CCM adoption (Coleman et al. 2009;Katon 2012). Without additional implementation support, providers are unlikely to sustain the CCM in their practice. ...
This randomized controlled implementation study compared the effectiveness of a standard versus enhanced version of the replicating effective programs (REP) implementation strategy to improve the uptake of the life goals-collaborative care model (LG-CC) for bipolar disorder. Seven community-based practices (384 patient participants) were randomized to standard (manual/training) or enhanced REP (customized manual/training/facilitation) to promote LG-CC implementation. Participants from enhanced REP sites had no significant changes in primary outcomes (improved quality of life, reduced functioning or mood symptoms) by 24 months. Further research is needed to determine whether implementation strategies can lead to sustained, improved participant outcomes in addition to program uptake.
... Others have consistently noted that most mental health concerns present in primary care and are commonly unrecognized or undertreated (Kessler et al., 2005). Despite these consistent findings, widespread development of integrated care and the translation of research into routine clinical practice have advanced slowly (de-Gruy, 2006;Kilbourne et al., 2004). Simply embedding mental health providers in primary care has little effect on health care outcomes or cost effectiveness (Blount, 2003). ...
Since the early 1990s, primary care has been described as the de facto mental health care system in the United States. Most individuals with mental health concerns present in primary care, but the majority are either not identified or do not receive evidence-based services or guideline concordant care. Despite 20 years of research supporting the integration of mental health services into primary care, the translation of this evidence into real-world settings remains limited. The growing impetus to build comprehensive health care systems that provide care for a defined population has recently spurred interest in providing mental health care within primary care. The Department of Veterans Affairs (VA) began to systematically incorporate psychological and other mental health services into primary care in 2007. National evaluation and local program data reviewed here have demonstrated that the initiative has already improved the identification and treatment of mental health disorders in the primary care population, increased the likelihood of receiving guideline concordant care, and enhanced treatment engagement for patients referred into specialty mental health services. These results provide support for expectations that integrated care enhances access to high-quality mental health care. This article summarizes critical factors for success identified in the VA integrated care rollout. These factors are applicable for other health care organizations that seek to improve mental health services delivery. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
... The final two articles in this issue continue the Quarterly's focus on the relationship between research (and researchers) and policy (and policymakers) (Chalkidou et al. 2009;Exworthy et al. 2006;Greenhalgh et al. 2004;Jacobson, Butterill, and Goering 2005;Jewell and Bero 2008;Kilbourne et al. 2004;Lavis et al. 2003;Lavis et al. 2002;Lomas et al. 2003;Mitton et al. 2007;Tetroe et al. 2008;Walshe and Rundall 2001). First, in "Translating Medical Effectiveness Research into Policy," Janet Coffman, Mi-Kyung Hong, Wade Aubry, Harold Luft, and Edward Yelin summarize lessons from the California Health Benefits Review Program. ...
... Cleanliness and discipline have an important role in PS. Unclean places are the source of their discomfort and spread of diseases (Kilbourne et al., 2004). However, hygienic environment without is the source of rapid recovery and PS. ...
This paper aims at assessing the quality of patient care by analysing
the relationship between patients’ perceptions of and satisfaction with service
quality (SQ) in public-sector hospitals. The interaction effect of expected
service quality (ESQ) is also assessed. Data collected from the patients
admitted in two (for pilot study, N = 95) and five public-sector hospitals (for
main study, N = 775) were analysed using SPSS. The results reveal that
patients are satisfied with the SQ of hospitals. Moderating role of ESQ is also
confirmed. Management of hospital should take initiatives to improve the
overall service quality of patient care. Regular feed-back from patients should
be taken and rules should be made considering the expectations and
requirements of patients. This study attempted to examine the moderating role
of ESQ in determining the patients’ satisfaction. This supports the normative
decision theory, as patients are found making informed decisions before
selecting the hospitals. This can be of value to healthcare administration for
improving SQ based on patients’ feedback.
... Implementing evidence-based practices is a complex and challenging process, especially for multifaceted clinical programs that require engagement and support from multiple stakeholders (3). The Promoting Action on Research Implementation in Health Services (PARIHS) framework conceptualizes successful implementation as a function of the dynamic interaction between evidence, context, and facilitation (4). ...
This column describes a facilitation strategy that incorporates evidence-based implementation knowledge and practice-based wisdom. The authors also describe a partnership between research and clinical operations leaders in the U.S. Department of Veterans Affairs to bridge the gap between implementation knowledge and its use. The initial product of the partnership, the Implementation Facilitation Training Manual: Using External and Internal Facilitation to Improve Care in the Veterans Health Administration, is a resource that can be used by others to guide implementation efforts.
... Cleanliness and discipline have an important role in PS. Unclean places are the source of their discomfort and spread of diseases (Kilbourne et al., 2004). However, hygienic environment without is the source of rapid recovery and PS. ...
This paper aims at assessing the quality of patient care by analysing
the relationship between patients’ perceptions of and satisfaction with service
quality (SQ) in public-sector hospitals. The interaction effect of expected
service quality (ESQ) is also assessed. Data collected from the patients
admitted in two (for pilot study, N = 95) and five public-sector hospitals (for
main study, N = 775) were analysed using SPSS. The results reveal that
patients are satisfied with the SQ of hospitals. Moderating role of ESQ is also
confirmed. Management of hospital should take initiatives to improve the
overall service quality of patient care. Regular feed-back from patients should
be taken and rules should be made considering the expectations and
requirements of patients. This study attempted to examine the moderating role
of ESQ in determining the patients’ satisfaction. This supports the normative
decision theory, as patients are found making informed decisions before
selecting the hospitals. This can be of value to healthcare administration for
improving SQ based on patients’ feedback.
... Registries are vital to the effective management of patients with chronic illnesses, and registry use has positive impacts on patient outcomes [34,35]. Registries assist health care providers in identifying patients who can benefit from additional support, allow for provider feedback on the success of disease management efforts, and facilitate quality monitoring at the health system level [35][36][37]. ...
While key components of the Patient-Centered Medical Home (PCMH) have been described, improved patient outcomes and efficiencies have yet to be conclusively demonstrated. We describe the rationale, conceptual framework, and progress to date as part of the VA Ann Arbor Patient-Aligned Care Team (PACT) Demonstration Laboratory, a clinical care-research partnership designed to implement and evaluate PCMH programs. Evidence and experience underlying this initiative is presented. Key components of this innovation are: (a) a population-based registry; (b) a navigator system that matches veterans to programs; and (c) a menu of self-management support programs designed to improve between-visit support and leverage the assistance of patient-peers and informal caregivers. This approach integrates PCMH principles with novel implementation tools allowing patients, caregivers, and clinicians to improve disease management and self-care. Making changes within a complex organization and integrating programmatic and research goals represent unique opportunities and challenges for evidence-based healthcare improvements in the VA.
... It has been widely noted that perhaps the greatest obstacle to the treatment of mental health issues in integrated settings is the lack of reimbursement to providers for the essential components of evidence-based models of collaborative care, such as screening services, consultation between providers, and many of the services provided by care managers. 7,30,[55][56][57] In fact, in empirical studies of collaborative care, even those with substantial clinical outcomes, the financial burden associated with the intervention became a significant barrier to its sustainability after the study grants were removed. 58,59 To successfully translate research into practice will require the persistent commitment of local, state and national leaders to overcome barriers, especially those related to funding mechanisms, to support implementation and sustain integrated health care programs. ...
Across the USA, health care systems are recognizing the value of integrating behavioral health services and primary care. The Texas Legislature took a unique approach to integration, passing legislation creating a Workgroup to explore key issues, identify best practices, and recommend policy and practice changes. This article situates the Workgroup in a rapidly evolving policy environment, describing the passage of integrated health care legislation in Texas, the Integration of Health and Behavioral Health Services Workgroup that was created by the legislation, and the policy recommendations that emerged from the Workgroup. The article analyzes how the Workgroup process intersected with a changing policy environment in Texas and nationally, opening the door for essential collaboration and partnership. The Workgroup ultimately laid the groundwork for integration's key role in a comprehensive Medicaid transformation waiver designed to expand access, improve population health and satisfaction with treatment, while better managing costs.
... Fourth, financing describes the funding sources for aging network services generally along with sources specific to mental health services. Per the literature, understanding the financial incentives and disincentives related to the provision of mental health services is a key factor related to the eventual adoption of empirically supported depression practices (Kilbourne et al., 2004;Pincus, Pechura, Elinson, & Pettit, 2001;Unützer, Schoenbaum, Druss, & Katon, 2006). Economic incentives are both intentional and unintentional inducements of how health care should be provided by the structure and regulations of its financing (Ettner, 1997;Wagner, Austin, & Von Korff 1996). ...
Depression is a prevalent, debilitating yet treatable psychiatric disorder affecting older adults. Older adults underutilize specialty mental health care, persistently receive poor quality care in primary care settings, and have high rates of non-adherence to pharmacotherapy. Aging network services, such as adult day services, homecare services, senior centers, and supportive housing may be able to improve the quality of depression care. However, it is unknown how current models of empirically supported depression care are used within or could be adopted by aging network services. Thus, this study described the organizational factors, staff factors, and current agency practices regarding depression among aging network services to examine their potential to adopt new depression practices. Using mixed methods, data were gathered on the organizational culture, climate, and structure, current depression practices, and staff attitudes through interviews with program managers (n =20) and surveys with staff (n = 142) for 17 agencies. The judgment sample consisted of agencies that have ongoing contact with community-based older adults and was stratified by agency type (i.e., adult day services, homecare services, senior centers, supportive housing). Multilevel modeling and constant comparative analysis was completed. Although agencies did significantly vary according to agency type by organizational context (i.e., funding; the proficiency, rigidity, and resistance of organizational culture; and the engagement, functionality, and stress of organizational climate), these factors were not related to empirically supported depression practices or staff attitudes about depression care. Most barriers to implementing new depression practices were universal. These findings applied to organizational factors (i.e., lack of resources, limited funding) and staff factors (i.e., limited knowledge and interest, concern for client acceptance of depression care). As facilitators, agencies frequently offered psychoeducation, collaborated with health providers, and provided holistic services to promote socialization, independence and health. The distinctions between agency types involved their current depression practices (i.e., supportive housing staff rarely screened for depression due to privacy mandates for housing facilities, competition among homecare agencies prompted delivery of in-home psychotherapy and case management). Findings inform multilevel implementation strategies for translating research into acceptable and sustainable practices for aging network services, and they highlight the broader needs for increased funding, training, and awareness to improve the quality of depression care across agencies.
... Many patients with MDD present themselves in primary care; referral to specialized mental health care is not always an option and possibly not optimal either (Verhaak et al. 2000), which calls for treatment in the primary care setting (Van der ). However, although effective treatments for depression are known from the mental health care setting, their application to patients in need in the primary care setting can be troublesome (Kilbourne et al. 2004). Guidelines and educational measures alone have so far been insufficient to change this. ...
Objective: To describe the collaborative care model for primary care as it has been developed in the Depression Initiative in the Netherlands from 2006-2010. Method: Review of collaborative care models, and description of the collaborative care models as developed in the Depression Initiative. Results: Collaborative care is a treatment model based on the principles of the chronic care model that aims to translate evidence based treatment for depressive disorder to everyday practice in the primary care setting. It was found to be effective and cost effective, depending on willingness to pay, in the US and the UK. The Depression Initiative is a Nationwide program aimed at implementation of the multidisciplinary guideline for depression in the Netherlands, in which the collaborative care model has been elaborated for three settings: primary care, the occupational health care setting and the general hospital outpatient setting. The model is feasible and first outcomes are positive in the three settings in the Netherlands. Conclusions: Collaborative care as developed in the Depression Initiative in the Netherlands is a promising treatment model for major depression in the primary care setting. The model may be applied in the occupational health setting and the general hospital outpatient setting as well. In the future, anxiety disorder and Medically Unexplained Symptoms may be candidates for treatment with this model.
... This has been notoriously difficult to achieve, even in areas that have nurtured these models. 11 We therefore recommend a stepby-step approach to implementation. These are inherently not approaches that can be 'rolled out' in the usual way in which such initiatives are intended to be delivered by policy makers. ...
The arrival of the 'polyclinic' or 'GP-led health centre' has been signalled in the review of the National Health Service. A variety of options have been proposed for the way in which polyclinics will incorporate specialist services to work alongside primary care, and the relevance of these models to mental healthcare is considered. Polyclinics provide new opportunities but with those possibilities come potential threats and risks. Of key importance is the threat that they will re-institutionalise mental healthcare after many years of breaking down such barriers. Buildings provide shared space, but new working practices are more difficult to achieve.
... [49][50][51] In addition, although Veterans Affairs systems have begun to see early positive results, 33,40 even more comprehensive interventions have yielded limited enduring effects in real-world practices. [50][51][52][53][54] A gap remains between desired outcomes and the reality of how care is delivered. To understand this gap, we present a real-world primary care practice model of depression care. ...
Background:
Depression is prevalent in primary care (PC) practices and poses a considerable public health burden in the United States. Despite nearly four decades of efforts to improve depression care quality in PC practices, a gap remains between desired treatment outcomes and the reality of how depression care is delivered.
Objective:
This article presents a real-world PC practice model of depression care, elucidating the processes and their influencing conditions.
Design:
Grounded theory methodology was used for the data collection and analysis to develop a depression care model. Data were collected from 70 individual interviews (60 to 70 min each), three focus group interviews (n = 24, 2 h each), two surveys per clinician, and investigators' field notes on practice environments. Interviews were audiotaped and transcribed for analysis. Surveys and field notes complemented interview data.
Participants:
Seventy primary care clinicians from 52 PC offices in the Midwest: 28 general internists, 28 family physicians, and 14 nurse practitioners.
Key results:
A depression care model was developed that illustrates how real-world conditions infuse complexity into each step of the depression care process. Depression care in PC settings is mediated through clinicians' interactions with patients, practice, and the local community. A clinician's interactional familiarity ("familiarity capital") was a powerful facilitator for depression care. For the recognition of depression, three previously reported processes and three conditions were confirmed. For the management of depression, 13 processes and 11 conditions were identified. Empowering the patient was a parallel process to the management of depression.
Conclusions:
The clinician's ability to develop and utilize interactional relationships and resources needed to recognize and treat a person with depression is key to depression care in primary care settings. The interactional context of depression care makes empowering the patient central to depression care delivery.
... This research-to-practice gap can lead to millions of dollars of funded research being wasted when the treatments themselves never reach the populations in need [1]. Without a clear strategy to foster implementation and acceptance at the community provider level, a "voltage drop" is experienced when an evidence-based depression treatment developed in tightly-controlled academic settings is then introduced into real-world settings [2]. Moreover, current clinical trials populations are still highly selective (<5% of the diagnosed population) despite the movement towards "community-based research." ...
... [15][16][17][18][19] Uptake of evidence-based models for improving depression care for PC populations, however, has been slow. [20][21][22][23][24] This paper aims to improve understanding of the uptake of depression care improvement models by investigating the determinants of adoption of three alternative, Veterans Affairs (VA) systemendorsed approaches to improving routine depression care. ...
Background:
Depression management can be challenging for primary care (PC) settings. While several evidence-based models exist for depression care, little is known about the relationships between PC practice characteristics, model characteristics, and the practice's choices regarding model adoption.
Objective:
We examined three Veterans Affairs (VA)-endorsed depression care models and tested the relationships between theoretically-anchored measures of organizational readiness and implementation of the models in VA PC clinics.
Design:
1) Qualitative assessment of the three VA-endorsed depression care models, 2) Cross-sectional survey of leaders from 225 VA medium-to-large PC practices, both in 2007.
Main measures:
We assessed PC readiness factors related to resource adequacy, motivation for change, staff attributes, and organizational climate. As outcomes, we measured implementation of one of the VA-endorsed models: collocation, Translating Initiatives in Depression into Effective Solutions (TIDES), and Behavioral Health Lab (BHL). We performed bivariate and, when possible, multivariate analyses of readiness factors for each model.
Key results:
Collocation is a relatively simple arrangement with a mental health specialist physically located in PC. TIDES and BHL are more complex; they use standardized assessments and care management based on evidence-based collaborative care principles, but with different organizational requirements. By 2007, 107 (47.5 %) clinics had implemented collocation, 39 (17.3 %) TIDES, and 17 (7.6 %) BHL. Having established quality improvement processes (OR 2.30, [1.36, 3.87], p = 0.002) or a depression clinician champion (OR 2.36, [1.14, 4.88], p = 0.02) was associated with collocation. Being located in a VA regional network that endorsed TIDES (OR 8.42, [3.69, 19.26], p < 0.001) was associated with TIDES implementation. The presence of psychologists or psychiatrists on PC staff, greater financial sufficiency, or greater spatial sufficiency was associated with BHL implementation.
Conclusions:
Both readiness factors and characteristics of depression care models influence model adoption. Greater model simplicity may make collocation attractive within local quality improvement efforts. Dissemination through regional networks may be effective for more complex models such as TIDES.
... A number of barriers to adequate depression management in Germany have been discussed in the existing literature, and several of them may help explain the experiences described in this study. These include system-level barriers, such as practice organization, the fiscal separation of physical and psychiatric services by the Regional Associations of Social Health Insuranceaccredited Physicians, and the subsequent lack of additional reimbursement for the increased costs associated with the care of psychiatric patients [47]. We tried to compensate by reimbursing the additional time spent on treating psychiatric patients. ...
Background:
Approximately 25% of so-called high utilizers of medical care are estimated to suffer from depression. A large proportion of these individuals remain undiagnosed and untreated. This study aims to examine the effects of a systematic screening and collaborative treatment program on depression severity in small primary care practices of the German outpatient health care system.
Method:
High utilizers of primary care who screened positive for depressive symptoms on the Brief Psychiatric Health Questionnaire (B-PHQ) were further diagnosed using the DIA-X, a standardized diagnostic interview, performed by trained and supervised interviewers. Patients with major depression were randomized (cluster randomization by practice) to (a) a six-month treatment program of pharmacotherapy, standardized patient and provider education, and physician and patient counseling or (b) six months of usual medical care. All subjects were followed for a 12-month observation period using the 17-item Hamilton Depression Rating scale (HAMD-17) rated by the treating physicians and the B-PHQ-9 rated by the patients.
Results:
A total of 63 high utilizer patients were included in the trial (17 male, 46 female), 19 randomized to intervention, 44 to usual care. The mean age was 49.7 (SD 13.8). Most patients had one or more somatic co-morbidities. There was no significant difference in response (defined as a decrease in the HAMD-17 sum score of at least 50%) after six months of treatment (50% vs. 42%, p = 0.961, all analyses adjusted for age) and after 12 months of treatment (83% vs. 54%, p = 0.282) between groups. Using patient self-rating assessments with the B-PHQ-9 questionnaire the intervention was superior to treatment as usual at six months (83% vs. 16%, p = 0.000).There was no significant difference in HAMD-17 depression severity at six months between the groups (10.5 (SD 7.6) vs. 12.3 (SD 7.8), p = 0.718), but a trend at 12 months (4.7 (SD 8.0) vs. 11.2 (SD 7.4), p = 0.083). Again, using B-PHQ-9 sum scores depression severity was significantly lower in the intervention group than in the treatment as usual group after six months (6.4 (SD 5.2) vs. 11.5 (SD 5.8), p = 0.020), but not at 12 months (7.9 (SD 8.7) vs. 9.0 (SD 5.2), p = 0.858).
Conclusion:
A systematic collaborating treatment program for depression in high utilizers in primary care showed superiority to treatment as usual only in terms of patients' self-assessment but not according to physicians' assessment. The advance of the intervention group at 6 months was lost after 12 months of follow-up. Overall, positive results from similar trials in the US health care systems could not be confirmed in a German primary care setting.
Low-income women of color receive fewer cancer screenings and have higher rates of depression, which can interfere with cancer screening participation. This study assessed the comparative effectiveness of two interventions for improving colorectal, breast, and cervical cancer screening participation and reducing depression among underserved women in Bronx, NY, with depression. This comparative effectiveness randomized controlled trial (RCT) with assessments at study entry, 6, and 12 months utilized an intent-to-treat statistical approach. Eligible women were aged 50 to 64, screened positive for depression, and were overdue for ≥ 1 cancer screening (colorectal, breast, and/or cervical). Participants were randomized to a collaborative depression care plus cancer screening intervention (CCI + PCM) or cancer screening intervention alone (PCM). Interventions were telephone-based, available in English or Spanish, delivered over 12 months, and facilitated by a skilled care manager. Cancer screening data were extracted from electronic health records. Depression was measured with a validated self-report instrument (PHQ-9). Seven hundred fifty seven women consented and were randomized (CCI + PCM, n = 378; PCM, n = 379). Analyses revealed statistically significant increases in up-to-date status for all three cancer screenings; depression improved in both intervention groups. There were no statistically significant differences between the interventions in improving cancer screening rates or reducing depression. CCI and PCM both improved breast, cervical, and colorectal cancer screening and depression in clinical settings in underserved communities; however, neither intervention showed an advantage in outcomes. Decisions about which approach to implement may depend on the nature of the practice and alignment of the interventions with other ongoing priorities and resources.
Objectives
To describe the implementation of a collaborative care (CC) screening and treatment program for major depression in people with cancer, found to be effective in clinical trials, into routine outpatient care of a cancer center.
Method
A mixed-methods observational study guided by the RE-AIM implementation framework using quantitative and qualitative data collected over five years.
Results
Program set-up took three years and required more involvement of CC experts than anticipated. Barriers to implementation were uncertainty about whether oncology or psychiatry owned the program and the hospital's organizational complexity. Selecting and training CC team members was a major task. 90% (14,412/16,074) of patients participated in depression screening and 61% (136/224) of those offered treatment attended at least one session. Depression outcomes were similar to trial benchmarks (61%; 78/127 patients had a treatment response). After two years the program obtained long-term funding. Facilitators of implementation were strong trial evidence, effective integration into cancer care and ongoing clinical and managerial support.
Conclusion
A CC program for major depression, designed for the cancer setting, can be successfully implemented into routine care, but requires time, persistence and involvement of CC experts. Once operating it can be an effective and valued component of medical care.
Objective
To evaluate the comparative effectiveness of external facilitation (EF) vs external + internal facilitation (EF/IF), on uptake of a collaborative chronic care model (CCM) in community practices that were slower to implement under low‐level implementation support.
Study Setting
Primary data were collected from 43 community practices in Michigan and Colorado at baseline and for 12 months following randomization.
Study Design
Sites that failed to meet a pre‐established implementation benchmark after six months of low‐level implementation support were randomized to add either EF or EF/IF support for up to 12 months. Key outcomes were change in number of patients receiving the CCM and number of patients receiving a clinically significant dose of the CCM. Moderators’ analyses further examined whether comparative effectiveness was dependent on prerandomization adoption, number of providers trained or practice size. Facilitation log data were used for exploratory follow‐up analyses.
Data Collection
Sites reported monthly on number of patients that had received the CCM. Facilitation logs were completed by study EF and site IFs and shared with the study team.
Principal Findings
N = 21 sites were randomized to EF and 22 to EF/IF. Overall, EF/IF practices saw more uptake than EF sites after 12 months (ΔEF/IF‐EF = 4.4 patients, 95% CI = 1.87‐6.87). Moderators' analyses, however, revealed that it was only sites with no prerandomization uptake of the CCM (nonadopter sites) that saw significantly more benefit from EF/IF (ΔEF/IF‐EF = 9.2 patients, 95% CI: 5.72, 12.63). For sites with prerandomization uptake (adopter sites), EF/IF offered no additional benefit (ΔEF/IF‐EF = −0.9; 95% CI: −4.40, 2.60). Number of providers trained and practice size were not significant moderators.
Conclusions
Although stepping up to the more intensive EF/IF did outperform EF overall, its benefit was limited to sites that failed to deliver any CCM under the low‐level strategy. Once one or more providers were delivering the CCM, additional on‐site personnel did not appear to add value to the implementation effort.
Purpose
Mood and anxiety disorders affect 20–30 percent of school-age children, contributing to academic failure, substance abuse, and adult psychopathology, with immense social and economic impact. These disorders are treatable, but only a fraction of students in need have access to evidence-based treatment practices (EBPs). Access could be substantially increased if school professionals were trained to identify students at risk and deliver EBPs in the context of school-based support services. However, current training for school professionals is largely ineffective because it lacks follow-up supported practice, an essential element for producing lasting behavioral change. The paper aims to discuss these issues.
Design/methodology/approach
In this pilot feasibility study, the authors explored whether a coaching-based implementation strategy could be used to integrate common elements of evidence-based cognitive behavioral therapy (CBT) into schools. The strategy incorporated didactic training in CBT for school professionals followed by coaching from an expert during co-facilitation of CBT groups offered to students.
Findings
In total, 17 school professionals in nine high schools with significant cultural and socioe-conomic diversity participated, serving 105 students. School professionals were assessed for changes in confidence in CBT delivery, frequency of generalized use of CBT skills and attitudes about the utility of CBT for the school setting. Students were assessed for symptom improvement. The school professionals showed increased confidence in, utilization of, and attitudes toward CBT. Student participants showed significant reductions in depression and anxiety symptoms pre- to post-group.
Originality/value
These findings support the feasibility and potential impact of a coaching-based implementation strategy for school settings, as well as student symptom improvement associated with receipt of school-delivered CBT.
Background:
Social determinants affect health, yet there are few systematic clinical strategies in primary care that leverage electronic health record (EHR) automation to facilitate screening for social needs and resource referrals. An EHR-based social determinants of health (SDOH) screening and referral model, adapted from the WE CARE model for pediatrics, was implemented in urban adult primary care.
Objectives:
This study aimed to: (1) understand the burden of SDOH among patients at Boston Medical Center; and (2) evaluate the feasibility of implementing a systematic clinical strategy to screen new primary care patients for SDOH, use EHR technology to add these needs to the patient's chart through autogenerated ICD-10 codes, and print patient language-congruent referrals to available resources upon patient request.
Research design:
This observational study assessed the number of patients who were screened to be positive and requested resources for social needs. In addition, we evaluated the feasibility of implementing our SDOH strategy by determining the proportion of: eligible patients screened, providers signing orders for positive patient screenings, and provider orders for resource referral guides among patients requesting resource connections.
Results:
In total, 1696 of 2420 (70%) eligible patients were screened. Employment (12%), food insecurity (11%), and problems affording medications (11%) were the most prevalent concerns among respondents. In total, 367 of 445 (82%) patients with ≥1 identified needs (excluding education) had the appropriate ICD-10 codes added to their visit diagnoses. In total, 325 of 376 (86%) patients who requested resources received a relevant resource referral guide.
Conclusions:
Implementing a systematic clinical strategy in primary care using EHR workflows was successful in identifying and providing resource information to patients with SDOH needs.
Background
Implementation strategies are essential for promoting the uptake of evidence-based practices and for patients to receive optimal care. Yet strategies differ substantially in their intensity and feasibility. Lower-intensity strategies (eg, training and technical support) are commonly used but may be insufficient for all clinics. Limited research has examined the comparative effectiveness of augmentations to low-level implementation strategies for nonresponding clinics.
Objectives
To compare 2 augmentation strategies for improving uptake of an evidence-based collaborative chronic care model (CCM) on 18-month outcomes for patients with depression at community-based clinics nonresponsive to lower-level implementation support.
Research Design
Providers initially received support using a low-level implementation strategy, Replicating Effective Programs (REP). After 6 months, nonresponsive clinics were randomized to add either external facilitation (REP+EF) or external and internal facilitation (REP+EF/IF).
Measures
The primary outcome was patient 12-item short form survey (SF-12) mental health score at month 18. Secondary outcomes were patient health questionnaire (PHQ-9) depression score at month 18 and receipt of the CCM during months 6 through 18.
Results
Twenty-seven clinics were nonresponsive after 6 months of REP. Thirteen clinics (N=77 patients) were randomized to REP+EF and 14 (N=92) to REP+EF/IF. At 18 months, patients in the REP+EF/IF arm had worse SF-12 [diff, 8.38; 95% confidence interval (CI), 3.59–13.18] and PHQ-9 scores (diff, 1.82; 95% CI, –0.14 to 3.79), and lower odds of CCM receipt (odds ratio, 0.67; 95% CI, 0.30–1.49) than REP+EF patients.
Conclusions
Patients at sites receiving the more intensive REP+EF/IF saw less improvement in mood symptoms at 18 months than those receiving REP+EF and were no more likely to receive the CCM. For community-based clinics, EF augmentation may be more feasible than EF/IF for implementing CCMs.
Our goal in this investigation was to help shed light on the very difficult process of collaboration between family physicians and specialists working at different levels of healthcare delivery. More precisely, and grounded on Giddens’ structuration theory, our investigation aims to understand how medical collaboration emerges and develops around chronic patients. This was a longitudinal interpretive case study, the “case” being a continuum-of-care for patients suffering from diabetes, put in place in an urban health center in the Canadian province of Quebec. The study shows how the application of rules of signification and of legitimation, combined with domination resources, have supported the emergence of new forms of collaborative practices. Our analysis reveals, however, that new collaborative practices at the administrative level do not necessarily entail greater shared decision-making in patient management and the mobilization of knowledge across boundaries. The study also corroborates the mutual recursive influence of practices and structures. Our study’s most important contribution concerns the impact of knowledge dynamics, that is, individual and collective learning, on the development of medical collaboration across levels of care.
Previous chapters have outlined the evidence base concerning different models of depression care in primary care. The reviews of research have identified the relative weight of evidence for each model in terms of clinical and cost-effectiveness, and the data were summarized in Chapter 9. The next step is therefore translating that evidence into routine clinical practice. However, as highlighted by the Institute of Medicine, ‘between the health care we have and the care we could have lies not just a gap but a chasm’. The chasm between research and practice remains one of the most important limitations to evidence-based practice. Despite advances in scientific methods and the ease of accessing evidence, using evidence to change clinical practice remains a significant challenge. A classic example outside of depression is the use of streptokinase in heart attacks. Figure 10.1 shows a ‘cumulative’ meta-analysis, where the results of randomized trials are ordered by date, and the plot shows the accumulation of evidence over time, with the gradual increase in the precision of the estimate (shown by the narrowing confidence intervals around the estimate) as more studies were completed. The scientific evidence that streptokinase was effective was sufficiently strong by the early 1970s, but the treatment did not become routine until 1986. There are few clearer demonstrations of the problems of the research–practice ‘chasm’.
1.
Depression is one of the most common chronic diseases you will see in your clinic. It affects approximately 20 million Americans.
2.
The lifetime prevalence of depression in the general population is 16%.
3.
Depression is more likely to occur in patients who have chronic medical problems. Your patients with diabetes, heart failure, osteoarthritis, and stroke have 1 1/2 to 2 times the rate of depression.
4.
Depression is a challenging disease to diagnose; symptoms of depression are often overlooked. For example, it is estimated that depression is identified in fewer than 50% of cardiac and diabetes patients, and only one-half of those identified receive treatment.
5.
For many of your patients, somatic pain (e.g., headache, back pain, abdominal pain) will accompany the symptoms of depression; for 69% of patients with depression, the only complaint is pain.
6.
In most patients, major depression is a relapsing illness. After the first episode, there is a 40% recurrence rate over the next 2 years; after two episodes, the risk of recurrence is 75%.
Primary care physicians have assumed an increasingly important role in US outpatient mental health care. They are providing an increasing volume of outpatient mental health services, prescribing a growing number and variety of psychotropic medications, and treating patients with a broader array of mental health conditions. These trends, which run counter to a general trend toward specialization and subspecialization within US health care, place new strains on the clinical competencies of primary care physicians. They also underscore the importance of implementing more effective models of collaboration between primary care physicians and mental health specialists. Several elements of the Affordable Care Act provide options for financing and organizing the delivery of integrated general medical and behavioral services. Such integrated services have the potential to improve access and quality of outpatient mental health care for a range of psychiatric disorders. Because people with severe and persisting mental disorders commonly require a higher-level medical expertise than is readily available within primary care as well as a complex array of social services, separate specialized mental health will likely continue to play a vitally important role in caring for this population.
Depression is a highly prevalent condition that results in substantial functional impairment. Advocates have attempted in recent years to make the ‘business case’ for investing in quality improvement efforts in depression care, particularly in primary care settings. The business case suggests that the costs of depression treatment may be offset by gains in worker productivity and/or reductions in other healthcare spending. In this paper, we review the evidence in support of this argument for improving the quality of depression treatment.
We examined the impact of depression on two of the primary drivers of the societal burden of depression: healthcare utilisation and worker productivity. Depression leads to higher healthcare utilisation and spending, most of which is not the result of depression treatment costs. Depression is also a leading cause of absenteeism and reduced productivity at work. It is clear that the economic burden of depression is substantial; however, critical gaps in the literature remain and need to be addressed. For instance, we do not know the economic burden of untreated and/or inappropriately treated versus appropriately treated depression.
There remain considerable problems with access to and quality of depression treatment. Progress has been made in terms of access to care, but quality of care is seldom consistent with national treatment guidelines. A wide range of effective treatments and care programmes for depression are available, yet rigorously tested clinical models to improve depression care have not been widely adopted by healthcare systems. Barriers to improving depression care exist at the patient, healthcare provider, practice, plan and purchaser levels, and may be both economic and non-economic.
Studies evaluating interventions to improve the quality of depression treatment have found that the cost per QALY associated with improved depression care ranges from a low of $US2519 to a high of $US49 500. We conclude from our review of the literature that effective treatment of depression is cost effective, but that evidence of a medical or productivity cost offset for depression treatment remains equivocal, and this points to the need for further research in this area.
In Italy, the importance of integrating primary care and mental health has only recently been grasped. Several reasons may explain this delay: a) until 2005, primary care physicians worked individually instead of in group practices, without any functional network or structured contacts with colleagues; b) community mental health centers with multiprofessional teams were well structured and widespread in several regions but focused on people with severe and persistent mental disorders; and c) specific national government health policies were lacking. Only two regions have implemented explicit policies on this issue. The "G. Leggieri" program started by the Emilia-Romagna region health government in 1999 aims to coordinate unsolicited bottom-up cooperation initiatives developing since the 1980s. In Liguria, a regional work group was established in 2010 to boost the strategic role of collaborative programs between primary care and mental health services. This article describes the most innovative experiences relating to primary care psychiatry in Italy.
Objective:
The present case study examines how a collaborative care model for the treatment of depression works with a low-income, uninsured adult population in a primary care setting.
Method:
The qualitative interviews were conducted in 2010 at a primary care clinic as part of an evaluation of the Integrated Behavioral Health program, a collaborative care model of identifying and treating mild-to-moderate mental disorders in adults in a primary care setting. A single-case study design of an interdisciplinary team was used: the care manager, the primary care physician, the consulting psychiatrist, and the director of social services. Other units of analysis included clinical outcomes and reports that describe the patient demographics, services offered, staff, and other operational descriptions.
Results:
Multiple themes were identified that shed light on how one primary care practice successfully operationalized a collaborative care model, including the tools they used in novel ways, the role of team members, and perceived barriers to sustainability.
Conclusions:
The insights captured by this case study allow physicians, mental health practitioners, and administrators a view into key elements of the model as they consider implementation of a collaborative care model in their own settings. It is important to understand how the model operates on a day-to-day basis, with careful consideration of the more subtle aspects of the program such as team functioning and adapting tools to new processes of care to meet the needs of patients in unique contexts. Attention to barriers that still exist, especially regarding workforce and workload, will continue to be critical to organizations attempting integration.
The high prevalence of comorbid physical and mental illnesses among veterans is well known. Therefore, ensuring effective communication between primary care (PC) and mental health (MH) clinicians in the Veterans Affairs (VA) health care system is essential. The VA's Patient Aligned Care Teams (PACT) initiative has further raised awareness of the need for communication between PC and MH. Improving such communication, however, has proven challenging.
To qualitatively understand barriers to PC-MH communication in an academic community-based clinic by using continuous quality improvement (CQI) tools and then initiate a change strategy.
An interdisciplinary quality improvement (QI) work group composed of 11 on-site PC and MH providers, administrators, and researchers identified communication barriers and facilitators using fishbone diagrams and process flow maps. The work group then verified and provided context for the diagram and flow maps through medical record review (32 patients who received both PC and MH care), interviews (6 stakeholders), and reports from four previously completed focus groups. Based on these findings and a previous systematic review of interventions to improve interspecialty communication, the team initiated plans for improvement.
Key communication barriers included lack of effective standardized communication processes, practice style differences, and inadequate PC training in MH. Clinicians often accessed advice or formal consultation based on pre-existing across-discipline personal relationships. The work group identified collocated collaborative care, joint care planning, and joint case conferences as feasible, evidence-based interventions for improving communication.
CQI tools enabled providers to systematically assess local communication barriers and facilitators and engaged stakeholders in developing possible solutions. A locally tailored CQI process focusing on communication helped initiate change strategies and ongoing improvement efforts.
More than 20 years ago the Institute of Medicine advocated for integration of physical and behavioral health care. Today, practices are integrating care in response to recent policy initiatives. However, few studies describe how integration is accomplished in real-world practices without the financial or research support available for most randomized controlled trials.
To study how practices integrate care, we are conducting a cross-case comparative, mixed-methods study of 11 practices participating in Advancing Care Together (ACT). Using a grounded theory approach, we analyzed multiple sources of data (eg, documents, practice surveys, field notes from observation visits, semistructured interviews, online diaries) collected from each ACT innovator.
Integration requires making changes in organization and interpersonal relationships. During early integration efforts, challenges related to workflow and access, leadership and culture change, and tracking and using data to evaluate patient- and practice-level improvement emerged for ACT innovators. We describe the strategies innovators are developing to address these challenges.
Integrating care is a fundamental and difficult change for practices and health care professionals. Research identifying common challenges that manifest in early efforts can help others attempting integration and inform state, local, and federal policies aimed at achieving wide-spread implementation.
Persons with bipolar disorder experience a disproportionate burden of medical conditions, notably cardiovascular disease (CVD), leading to impaired functioning and premature mortality. We hypothesized that the Life Goals Collaborative Care (LGCC) intervention, compared to enhanced usual care, would reduce CVD risk factors and improve physical and mental health outcomes in US Department of Veterans Affairs patients with bipolar disorder.
Patients with an ICD-9 diagnosis of bipolar disorder and ≥ 1 CVD risk factor (N = 118) enrolled in the Self-Management Addressing Heart Risk Trial, conducted April 2008-May 2010, were randomized to LGCC (n = 58) or enhanced usual care (n = 60). Life Goals Collaborative Care included 4 weekly self-management sessions followed by tailored contacts combining health behavior change strategies, medical care management, registry tracking, and provider guideline support. Enhanced usual care included quarterly wellness newsletters sent during a 12-month period in addition to standard treatment. Primary outcome measures included systolic and diastolic blood pressure, nonfasting total cholesterol, and physical health-related quality of life.
Of the 180 eligible patients identified for study participation, 134 were enrolled (74%) and 118 completed outcomes assessments (mean age = 53 years, 17% female, 5% African American). Mixed effects analyses comparing changes in 24-month outcomes among patients in LGCC (n = 57) versus enhanced usual care (n = 59) groups revealed that patients receiving LGCC had reduced systolic (β = -3.1, P = .04) and diastolic blood pressure (β = -2.1, P = .04) as well as reduced manic symptoms (β = -23.9, P = .01). Life Goals Collaborative Care had no significant impact on other primary outcomes (total cholesterol and physical health-related quality of life).
Life Goals Collaborative Care, compared to enhanced usual care, may lead to reduced CVD risk factors, notably through decreased blood pressure, as well as reduced manic symptoms, in patients with bipolar disorder.
ClinicalTrials.gov identifier: NCT00499096.
Literature suggests advantages for co-locating behavioral health care in primary care. We compared the impact of location of services on attendance at behavioral health appointments when access to care was assured for externalizing behavior problems with referral as usual. Two primary care pediatric practices had an evidence-based parenting program co-located in the practice for parents of children aged 2-12 years and two practices had the program available using an enhanced-referral procedure for locations external to the practices. The program was available at the regional children's hospital (referral as usual). During an 8-month period, the rate of attendance at first appointments was significantly higher in the co-located than the enhanced referral condition (.38 and .12 % of patient visits, respectively; χ(2) = 13.32; p < .0003; OR = 3.10; 95 % CI: 1.63, 5.89). These outcomes, while low, were better than the near 0 rate of attendance to referral as usual. Availability of behavioral health services in both conditions increased rates of attended appointments. However, the low rates of attendance indicate increasing availability of services, alone, is not sufficient to decrease the unmet need of children with behavioral problems. Factors other than availability must be addressed in order to improve outcomes for children.
The core services and values of Employee Assistance Programs (EAPs) have undergone many changes throughout their sixdecade history. Originally designed as an occupational resource to address workforce performance and impairment due to alcoholism, the field has expanded into a more comprehensive range of behavioral health services. In the wake of these changes, the field finds itself in search of a true identity so that it can survive as a distinct profession. This article proposes a new quality framework for guiding the future direction of the EAP field.
We studied whether standardized treatments of major depression whose efficacy was established with psychiatric patients are equally effective when provided to primary care patients, and whether standardized treatments are more effective than a primary care physician's usual care.
A randomized controlled trial was conducted, in which primary care patients meeting DSM-III-R criteria for a current major depression were assigned to nortriptyline (n = 91) or interpersonal psychotherapy (n = 93) provided within well-structured parameters, or a physician's usual care (n = 92). The main outcome measures were degree and rate of improvement in severity of depressive symptoms and proportion of patients recovered at 8 months.
Severity of depressive symptoms was reduced more rapidly and more effectively among patients randomized to pharmacotherapy or psychotherapy than among patients assigned to a physician's usual care. Among treatment completers, approximately 70% of patients participating in the full pharmacotherapy or psychotherapy protocol but only 20% of usual care patients were judged as recovered at 8 months.
Pharmacotherapy and psychotherapy effectively treat major depression among primary care patients when provided within specific parameters and for the full acute and continuation phases. Treatment principles recommended by the Depression Guideline Panel of the Agency for Health Care Policy and Research are supported.
Care of patients with depression in managed primary care settings often fails to meet guideline standards, but the long-term impact of quality improvement (QI) programs for depression care in such settings is unknown.
To determine if QI programs in managed care practices for depressed primary care patients improve quality of care, health outcomes, and employment.
Randomized controlled trial initiated from June 1996 to March 1997.
Forty-six primary care clinics in 6 US managed care organizations.
Of 27332 consecutively screened patients, 1356 with current depressive symptoms and either 12-month, lifetime, or no depressive disorder were enrolled.
Matched clinics were randomized to usual care (mailing of practice guidelines) or to 1 of 2 QI programs that involved institutional commitment to QI, training local experts and nurse specialists to provide clinician and patient education, identification of a pool of potentially depressed patients, and either nurses for medication follow-up or access to trained psychotherapists.
Process of care (use of antidepressant medication, mental health specialty counseling visits, medical visits for mental health problems, any medical visits), health outcomes (probable depression and health-related quality of life [HRQOL]), and employment at baseline and at 6- and 12-month follow-up.
Patients in QI (n = 913) and control (n = 443) clinics did not differ significantly at baseline in service use, HRQOL, or employment after nonresponse weighting. At 6 months, 50.9% of QI patients and 39.7% of controls had counseling or used antidepressant medication at an appropriate dosage (P<.001), with a similar pattern at 12 months (59.2% vs 50.1%; P = .006). There were no differences in probability of having any medical visit at any point (each P > or = .21). At 6 months, 47.5% of QI patients and 36.6% of controls had a medical visit for mental health problems (P = .001), and QI patients were more likely to see a mental health specialist at 6 months (39.8% vs 27.2%; P<.001) and at 12 months (29.1% vs 22.7%; P = .03). At 6 months, 39.9% of QI patients and 49.9% of controls still met criteria for probable depressive disorder (P = .001), with a similar pattern at 12 months (41.6% vs 51.2%; P = .005). Initially employed QI patients were more likely to be working at 12 months relative to controls (P = .05).
When these managed primary care practices implemented QI programs that improve opportunities for depression treatment without mandating it, quality of care, mental health outcomes, and retention of employment of depressed patients improved over a year, while medical visits did not increase overall.
To test the effectiveness of two programmes to improve the treatment of acute depression in primary care.
Randomised trial.
Primary care clinics in Seattle.
613 patients starting antidepressant treatment.
Patients were randomly assigned to continued usual care or one of two interventions: feedback only and feedback plus care management. Feedback only comprised feedback and algorithm based recommendations to doctors on the basis of data from computerised records of pharmacy and visits. Feedback plus care management included systematic follow up by telephone, sophisticated treatment recommendations, and practice support by a care manager.
Blinded interviews by telephone 3 and 6 months after the initial prescription included a 20 item depression scale from the Hopkins symptom checklist and the structured clinical interview for the current DSM-IV depression module. Visits, antidepressant prescriptions, and overall use of health care were assessed from computerised records.
Compared with usual care, feedback only had no significant effect on treatment received or patient outcomes. Patients receiving feedback plus care management had a higher probability of both receiving at least moderate doses of antidepressants (odds ratio 1.99, 95% confidence interval 1.23 to 3.22) and a 50% improvement in depression scores on the symptom checklist (2.22, 1.31 to 3.75), lower mean depression scores on the symptom checklist at follow up, and a lower probability of major depression at follow up (0.46, 0.24 to 0.86). The incremental cost of feedback plus care management was about $80 ( pound50) per patient.
Monitoring and feedback to doctors yielded no significant benefits for patients in primary care starting antidepressant treatment. A programme of systematic follow up and care management by telephone, however, significantly improved outcomes at modest cost.
Primary care treatment of depression needs improvement.
To evaluate the efficacy of 2 augmentations to antidepressant drug treatment.
Randomized trial comparing usual care, telehealth care, and telehealth care plus peer support; assessments were conducted at baseline, 6 weeks, and 6 months.
Two managed care adult primary care clinics.
A total of 302 patients starting antidepressant drug therapy.
For telehealth care: emotional support and focused behavioral interventions in ten 6-minute calls during 4 months by primary care nurses; and for peer support: telephone and in-person supportive contacts by trained health plan members recovered from depression.
For depression: the Hamilton Depression Rating Scale and the Beck Depression Inventory; and for mental and physical functioning: the SF-12 Mental and Physical Composite Scales and treatment satisfaction.
Nurse-based telehealth patients with or without peer support more often experienced 50% improvement on the Hamilton Depression Rating Scale at 6 weeks (50% vs 37%; P =.01) and 6 months (57% vs 38%; P =.003) and on the Beck Depression Inventory at 6 months (48% vs 37%; P =. 05) and greater quantitative reduction in symptom scores on the Hamilton scale at 6 months (10.38 vs 8.12; P =.006). Telehealth care improved mental functioning at 6 weeks (47.07 vs 42.64; P =.004) and treatment satisfaction at 6 weeks (4.41 vs 4.17; P =.004) and 6 months (4.20 vs 3.94; P =.001). Adding peer support to telehealth care did not improve the primary outcomes.
Nurse telehealth care improves clinical outcomes of antidepressant drug treatment and patient satisfaction and fits well within busy primary care settings.
Inadequate treatments are reported for depressed patients cared for by primary care physicians (PCPs). Providing feedback and evidence-based treatment recommendations for depression to PCPs via electronic medical record improves the quality of interventions.
Patients presenting to an urban academically affiliated primary care practice were screened for major depression with the Primary Care Evaluation of Mental Disorders (PRIME-MD). During 20-month period, 212 patients met protocol-eligibility criteria and completed a baseline interview. They were cared for by 16 board-certified internists, who were electronically informed of their patients' diagnoses, and randomized to 1 of 3 methods of exposure to guideline-based advice for treating depression (active, passive, and usual care). Ensuing treatment patterns were assessed by medical chart review and by patient self-report at baseline and 3 months.
Median time for PCP response to the electronic message regarding the patient's depression diagnosis was 1 day (range, 1-95 days). Three days after notification, 120 (65%) of 186 PCP responses indicated agreement with the diagnosis, 24 (13%) indicated disagreement, and 42 (23%) indicated uncertainty. Primary care physicians who agreed with the diagnoses sooner were more likely to make a medical chart notation of depression, begin antidepressant medication therapy, or refer to a mental health specialist (P<.001). There were no differences in the agreement rate or treatments provided across guideline exposure conditions.
Electronic feedback of the diagnosis of major depression can affect PCP initial management of the disorder. Further study is necessary to determine whether this strategy, combined with delivery of treatment recommendations, can improve clinical outcomes in routine practice.
A key aim of the evaluation of the Fort Bragg Demonstration was to determine whether delivering services through a continuum of care lowered expenditures on mental health services. The evaluation clearly showed that expenditures were actually higher in the Demonstration. Critics of the evaluation claimed that the evaluation's perspective on costs was too narrow-in particular, that the Demonstration produced cost shifting and cost offset that were not captured by the evaluation. New data allow us to include a broader array of costs: mental health services received outside the catchment areas, general medical services for the children themselves, and mental health services used by family members. Results showed that reductions in other costs do partially offset higher expenditures on mental health services for children at the Fort Bragg Demonstration. However, even when broader costs are included, total family expenditures are still substantially higher at the Demonstration.
Depression is a leading cause of disability worldwide, but treatment rates in primary care are low.
To determine the cost-effectiveness from a societal perspective of 2 quality improvement (QI) interventions to improve treatment of depression in primary care and their effects on patient employment.
Group-level randomized controlled trial conducted June 1996 to July 1999.
Forty-six primary care clinics in 6 community-based managed care organizations.
One hundred eighty-one primary care clinicians and 1356 patients with positive screening results for current depression.
Matched practices were randomly assigned to provide usual care (n = 443 patients) or to 1 of 2 QI interventions offering training to practice leaders and nurses, enhanced educational and assessment resources, and either nurses for medication follow-up (QI-meds; n = 424 patients) or trained local psychotherapists (QI-therapy; n = 489). Practices could flexibly implement the interventions, which did not assign type of treatment.
Total health care costs, costs per quality-adjusted life-year (QALY), days with depression burden, and employment over 24 months, compared between usual care and the 2 interventions.
Relative to usual care, average health care costs increased $419 (11%) in QI-meds (P =.35) and $485 (13%) in QI-therapy (P =.28); estimated costs per QALY gained were between $15 331 and $36 467 for QI-meds and $9478 and $21 478 for QI-therapy; and patients had 25 (P =.19) and 47 (P =.01) fewer days with depression burden and were employed 17.9 (P =.07) and 20.9 (P =.03) more days during the study period.
Societal cost-effectiveness of practice-initiated QI efforts for depression is comparable with that of accepted medical interventions. The intervention effects on employment may be of particular interest to employers and other stakeholders.
The growing number of persons suffering from major chronic illnesses face many obstacles in coping with their condition, not least of which is medical care that often does not meet their needs for effective clinical management, psychological support, and information. The primary reason for this may be the mismatch between their needs and care delivery systems largely designed for acute illness. Evidence of effective system changes that improve chronic care is mounting. We have tried to summarize this evidence in the Chronic Care Model (CCM) to guide quality improvement. In this paper we describe the CCM, its use in intensive quality improvement activities with more than 100 health care organizations, and insights gained in the process.
Depressive disorders are highly prevalent in the general population, but recognition and accurate diagnosis are made difficult by the lack of a simple confirmatory test.
To review the accuracy and precision of depression questionnaires and the clinical examination for diagnosing clinical depression.
We searched the English-language literature from 1970 through July 2000 using MEDLINE, a specialized registry of depression trials, and bibliographies of selected articles.
Case-finding studies were included if they used depression questionnaires with easy to average literacy requirements, evaluated at least 100 primary care patients, and compared questionnaire results with accepted diagnostic criteria for major depression. Eleven questionnaires, ranging in length from 1 to 30 questions, were assessed in 28 published studies. Reliability studies for the clinical examination required criterion-based diagnoses made by at least 2 clinicians who interviewed the patient or reviewed a taped examination. Fourteen studies evaluated interrater reliability.
Pairs of authors independently reviewed articles. For case-finding studies, quality assessment addressed sample size and whether patients were selected consecutively or randomly, the criterion standard was administered and interpreted independently of and blind to the results of the case-finding instrument, and the proportion of persons receiving the criterion standard assessment was less than or more than 50% of those approached for criterion standard assessment. For reliability studies, quality assessment addressed whether key patient characteristics were described, the interviewers collected clinical history independently, and diagnoses were made blinded to other clinicians' evaluations.
In case-finding studies, average questionnaire administration times ranged from less than 1 minute to 5 minutes. The median likelihood ratio positive for major depression was 3.3 (range, 2.3-12.2) and the median likelihood ratio negative was 0.19 (range, 0.14-0.35). No significant differences between questionnaires were found. For mental health care professionals using a semistructured interview, agreement was substantial to almost perfect for major depression (kappa = 0.64-0.93). Nonstandardized interviews yielded somewhat lower agreement (kappa = 0.55-0.74). A single study showed that primary care clinicians using a semistructured interview have high agreement with mental health care professionals (kappa = 0.71).
Multiple, practical questionnaires with reasonable performance characteristics are available to help clinicians identify and diagnose patients with major depression. Diagnostic confirmation by mental health care professionals using a clinical interview or by primary care physicians using a semistructured interview can be made with high reliability.
Few depressed older adults receive effective treatment in primary care settings.
To determine the effectiveness of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression.
Randomized controlled trial with recruitment from July 1999 to August 2001.
Eighteen primary care clinics from 8 health care organizations in 5 states.
A total of 1801 patients aged 60 years or older with major depression (17%), dysthymic disorder (30%), or both (53%).
Patients were randomly assigned to the IMPACT intervention (n = 906) or to usual care (n = 895). Intervention patients had access for up to 12 months to a depression care manager who was supervised by a psychiatrist and a primary care expert and who offered education, care management, and support of antidepressant management by the patient's primary care physician or a brief psychotherapy for depression, Problem Solving Treatment in Primary Care.
Assessments at baseline and at 3, 6, and 12 months for depression, depression treatments, satisfaction with care, functional impairment, and quality of life.
At 12 months, 45% of intervention patients had a 50% or greater reduction in depressive symptoms from baseline compared with 19% of usual care participants (odds ratio [OR], 3.45; 95% confidence interval [CI], 2.71-4.38; P<.001). Intervention patients also experienced greater rates of depression treatment (OR, 2.98; 95% CI, 2.34-3.79; P<.001), more satisfaction with depression care (OR, 3.38; 95% CI, 2.66-4.30; P<.001), lower depression severity (range, 0-4; between-group difference, -0.4; 95% CI, -0.46 to -0.33; P<.001), less functional impairment (range, 0-10; between-group difference, -0.91; 95% CI, -1.19 to -0.64; P<.001), and greater quality of life (range, 0-10; between-group difference, 0.56; 95% CI, 0.32-0.79; P<.001) than participants assigned to the usual care group.
The IMPACT collaborative care model appears to be feasible and significantly more effective than usual care for depression in a wide range of primary care practices.
Recently the National Institutes of Health has been emphasizing research that takes findings generated by clinical research and translates them into treatments for patients who are seen in day-to-day nonresearch settings. This translational process requires a series of steps in which elements of both efficacy and effectiveness research are combined into successively more complex designs. However, there has been little discussion of exactly how to develop and operationalize these designs. This article describes an approach to the development of these hybrid designs. Their operationalization is illustrated by using the design of an ongoing effectiveness treatment study of panic disorder in primary care. Experts in both efficacy and effectiveness research collaborated to address the methodologic and data collection issues that need to be considered in designing a first-generation effectiveness study. Elements of the overall study design, setting or service delivery context, inclusion and exclusion criteria, recruitment and screening, assessment tools, and intervention modification are discussed to illustrate the thinking behind and rationale for decisions about these different design components. Although the series of decisions for this study were partly influenced by considerations specific to the diagnosis of panic disorder and the context of the primary care setting, the general stepwise approach to designing treatment interventions using an effectiveness model is relevant for the development of similar designs for other mental disorders and other settings.
Evidence consistently indicates that depression has adversely affected work productivity. Estimates of the cost impact in lost labor time in the US workforce, however, are scarce and dated.
To estimate the impact of depression on labor costs (ie, work absence and reduced performance while at work) in the US workforce.
All employed individuals who participated in the American Productivity Audit (conducted August 1, 2001-July 31, 2002) between May 20 and July 11, 2002, were eligible for the Depressive Disorders Study. Those who responded affirmatively to 2 depression-screening questions (n = 692), as well as a 1:4 stratified random sample of those responding in the negative (n = 435), were recruited for and completed a supplemental interview using the Primary Care Evaluation of Mental Disorders Mood Module for depression, the Somatic Symptom Inventory, and a medical and treatment history for depression. Excess lost productive time (LPT) costs from depression were derived as the difference in LPT among individuals with depression minus the expected LPT in the absence of depression projected to the US workforce.
Estimated LPT and associated labor costs (work absence and reduced performance while at work) due to depression.
Workers with depression reported significantly more total health-related LPT than those without depression (mean, 5.6 h/wk vs an expected 1.5 h/wk, respectively). Eighty-one percent of the LPT costs are explained by reduced performance while at work. Major depression accounts for 48% of the LPT among those with depression, again with a majority of the cost explained by reduced performance while at work. Self-reported use of antidepressants in the previous 12 months among those with depression was low (<33%) and the mean reported treatment effectiveness was only moderate. Extrapolation of these survey results and self-reported annual incomes to the population of US workers suggests that US workers with depression employed in the previous week cost employers an estimated 44 billion dollars per year in LPT, an excess of 31 billion dollars per year compared with peers without depression. This estimate does not include labor costs associated with short- and long-term disability.
A majority of the LPT costs that employers face from employee depression is invisible and explained by reduced performance while at work. Use of treatments for depression appears to be relatively low. The combined LPT burden among those with depression and the low level of treatment suggests that there may be cost-effective opportunities for improving depression-related outcomes in the US workforce.
The authors systematically evaluated the published evidence to assess the effectiveness of disease management programs in depression.
English-language articles on depression were identified through a MEDLINE search for the period from January 1987 to June 2001. Two reviewers evaluated 16,952 published titles, identified 24 depression disease management programs that met explicit inclusion criteria, and extracted data on study characteristics, interventions used, and outcome measures. Pooled effect sizes were calculated by using a random-effects model.
Pooled results for disease management program effects on symptoms of depression showed statistically significant improvements (effect size=0.33, N=24). Programs also had statistically significant effects on patients' satisfaction with treatment (effect size=0.51, N=6), patients' compliance with the recommended treatment regimen (effect size=0.36, N=7), and adequacy of prescribed treatment (effect size=0.44, N=11). One program with an explicit screening component showed significant improvement in the rate of detection of depression by primary care physicians (effect size=0.66); two other programs lacking a screening component showed small nonsignificant improvements in the detection rate (effect size=0.18). Disease management programs increased health care utilization (effect size=-0.10, N=8), treatment costs (effect size=-1.03, N=3), and hospitalization (effect size=-0.20, N=2).
Disease management appears to improve the detection and care of patients with depression. Further research is needed to assess the cost-effectiveness of disease management in depression, and consideration should be given to more widespread implementation of these programs.
For this study, the authors conducted case studies of four varied clinical programs to learn key factors influencing the diffusion and adoption of evidence-based innovations in health care. They found that the success and speed of the adoption/diffusion process depend on: the roles of senior management and clinical leadership; the generation of credible supportive data; an infrastructure dedicated to translating the innovation from research into practice; the extent to which changes in organizational culture are required; and the amount of coordination needed across departments or disciplines. The translation process also depends on the characteristics and resources of the adopting organization, and on the degree to which people believe that the innovation responds to immediate and significant pressures in their environment.
Background:
We studied whether standardized treatments of major depression whose efficacy was established with psychiatric patients are equally effective when provided to primary care patients, and whether standardized treatments are more effective than a primary care physician's usual care.Methods:
A randomized controlled trial was conducted, in which primary care patients meeting DSM-III-R criteria for a current major depression were assigned to nortriptyline (n=91) or interpersonal psychotherapy (n=93) provided within well-structured parameters, or a physician's usual care (n=92). The main outcome measures were degree and rate of improvement in severity of depressive symptoms and proportion of patients recovered at 8 months.Results:
Severity of depressive symptoms was reduced more rapidly and more effectively among patients randomized to pharmacotherapy or psychotherapy than among patients assigned to a physician's usual care. Among treatment completers, approximately 70% of patients participating in the full pharmacotherapy or psychotherapy protocol but only 20% of usual care patients were judged as recovered at 8 months.Conclusions:
Pharmacotherapy and psychotherapy effectively treat major depression among primary care patients when provided within specific parameters and for the full acute and continuation phases. Treatment principles recommended by the Depression Guideline Panel of the Agency for Health Care Policy and Research are supported.
Background:
This research study evaluates the effectiveness of a multifaceted intervention program to improve the management of depression in primary care.Methods:
One hundred fifty-three primary care patients with current depression were entered into a randomized controlled trial. Intervention patients received a structured depression treatment program in the primary care setting that included both behavioral treatment to increase use of adaptive coping strategies and counseling to improve medication adherence. Control patients received "usual" care by their primary care physicians. Outcome measures included adherence to antidepressant medication, satisfaction with care of depression and with antidepressant treatment, and reduction of depressive symptoms over time.Results:
At 4-month follow-up, significantly more intervention patients with major and minor depression than usual care patients adhered to antidepressant medication and rated the quality of care they received for depression as good to excellent. Intervention patients with major depression demonstrated a significantly greater decrease in depression severity over time compared with usual care patients on all 4 outcome analyses. Intervention patients with minor depression were found to have a significant decrease over time in depression severity on only 1 of 4 study outcome analyses compared with usual care patients.Conclusion:
A multifaceted primary care intervention improved adherence to antidepressant regimens and satisfaction with care in patients with major and minor depression. The intervention consistently resulted in more favorable depression outcomes among patients with major depression, while outcome effects were ambiguous among patients with minor depression.
Background
Inadequate treatments are reported for depressed patients cared for by primary care physicians (PCPs). Providing feedback and evidence-based treatment recommendations for depression to PCPs via electronic medical record improves the quality of interventions.
Methods
Patients presenting to an urban academically affiliated primary care practice were screened for major depression with the Primary Care Evaluation of Mental Disorders (PRIME-MD). During 20-month period, 212 patients met protocol-eligibility criteria and completed a baseline interview. They were cared for by 16 board-certified internists, who were electronically informed of their patients' diagnoses, and randomized to 1 of 3 methods of exposure to guideline-based advice for treating depression (active, passive, and usual care). Ensuing treatment patterns were assessed by medical chart review and by patient self-report at baseline and 3 months.
Results
Median time for PCP response to the electronic message regarding the patient's depression diagnosis was 1 day (range, 1-95 days). Three days after notification, 120 (65%) of 186 PCP responses indicated agreement with the diagnosis, 24 (13%) indicated disagreement, and 42 (23%) indicated uncertainty. Primary care physicians who agreed with the diagnoses sooner were more likely to make a medical chart notation of depression, begin antidepressant medication therapy, or refer to a mental health specialist (P<.001). There were no differences in the agreement rate or treatments provided across guideline exposure conditions.
Conclusions
Electronic feedback of the diagnosis of major depression can affect PCP initial management of the disorder. Further study is necessary to determine whether this strategy, combined with delivery of treatment recommendations, can improve clinical outcomes in routine practice.
Acknowledging that not all practices are structured similarly, the authors propose a flexible blueprint that can be customized and used as a clinical framework for sustaining depression treatment in primary care.
Objective:
While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity.
Measurements:
The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as "0" (not at all) to "3" (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients.
Results:
As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score > or =10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples.
Conclusion:
In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.
Objective: This study assessed the impact of an Internet-delivered care
management and patient self-management program, eCare for Moods, on
patients treated for recurrent or chronic depression. Methods: Patients with
recurrent or chronic depression were randomly assigned to eCare (N=51)
or usual specialty mental health care (N=52). The 12-month eCare program
integrates with ongoing depression care, links to patients’ electronic medical
records, and provides clinicians with panel management and decision
support. Participants were interviewed at baseline and six, 12, 18, and 24
months after enrollment. Telephone interviewers blind to treatment used
a timeline follow-back method to estimate depression severity on a 6-point
scale for each of the 105 study weeks (including the baseline). Differences
between groups in weekly severity over two years were examined by generalized
estimating equations. Results: Participants in eCare experienced
more reduction in depressive symptoms (estimate=–.74 on the 6-point scale
over two years; 95% confidence interval [CI]=–1.38 to –.09, p=.025) and
were less often depressed (–.24 over two years; CI=–.46 to –.03, p=.026). At
24 months, 43% of eCare and 30% of usual-care participants were depression
free; the number needed to treat to attain one additional
depression-free participant was 8. eCare participants had other favorable
outcomes: improved general mental health (p=.002), greater satisfaction
with specialty care (p=.003) and with learning new coping skills (p<.001),
and more confidence in managing depression (p=.006). Conclusions:
Internet-delivered care management can help improve outcomes of
patients treated for recurrent or chronic depression.
OBJECTIVE: While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity.
MEASUREMENTS: The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as “0” (not at all) to “3” (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients.
RESULTS: As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score ≥10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples.
CONCLUSION: In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.
To investigate the extent to which variations in treatment and referral patterns for adult patients with diagnosed symptoms of depression seen in primary care practices are explained by practitioner characteristics, such as training, years in primary practice, sex, and knowledge about depression; practice characteristics, such as size, patient volume, and payer mix; and service area characteristics, such as availability of specialty mental health services and rural location.
A 41-item telephone survey of primary care practitioners (PCPs) in Maine, including family and general practice doctors of medicine and doctors of osteopathy, general internists, nurse practitioners, and physician assistants (n = 267).
The degree to which PCPs treat patients with depression themselves, rather than refer them to a mental health specialist.
There is no significant (P = .10) urban-rural difference in the number of patients with depression seen as a percentage of total patient volume. Major barriers to referral to a mental health provider, as reported by the PCP, are long wait for an appointment, lack of available services, patients' unwillingness to use services, and reimbursement issues. Multivariate analyses indicate that PCP characteristics measuring knowledge and attitudes, as well as the lack of available services, are significantly related to treatment and referral patterns while practice characteristics and mental health provider supply are not.
The treatment of rural patients with symptoms of depression is more likely to be improved by targeting PCPs' medical education than by efforts to increase the supply of specialty mental health providers in rural areas.
The authors report on the help-seeking experiences of people referred to community settings for aftercare on discharge from a state mental hospital in western Massachusetts. They present results that bear on three questions relevant to public policy issues in the mental health field: 1) the proportion of patients who comply with referrals to aftercare agencies, 2) the social and psychological characteristics of patients who comply with these referrals, and 3) the impact of receiving aftercare on the probability of rehospitalization.
This research study evaluates the effectiveness of a multifaceted intervention program to improve the management of depression in primary care.
One hundred fifty-three primary care patients with current depression were entered into a randomized controlled trial. Intervention patients received a structured depression treatment program in the primary care setting that included both behavioral treatment to increase use of adaptive coping strategies and counseling to improve medication adherence. Control patients received "usual" care by their primary care physicians. Outcome measures included adherence to antidepressant medication, satisfaction with care of depression and with antidepressant treatment, and reduction of depressive symptoms over time.
At 4-month follow-up, significantly more intervention patients with major and minor depression than usual care patients adhered to antidepressant medication and rated the quality of care they received for depression as good to excellent. Intervention patients with major depression demonstrated a significantly greater decrease in depression severity over time compared with usual care patients on all 4 outcome analyses. Intervention patients with minor depression were found to have a significant decrease over time in depression severity on only 1 of 4 study outcome analyses compared with usual care patients.
A multifaceted primary care intervention improved adherence to antidepressant regimens and satisfaction with care in patients with major and minor depression. The intervention consistently resulted in more favorable depression outcomes among patients with major depression, while outcome effects were ambiguous among patients with minor depression.
Usual medical care often fails to meet the needs of chronically ill patients, even in managed, integrated delivery systems. The medical literature suggests strategies to improve outcomes in these patients. Effective interventions tend to fall into one of five areas: the use of evidence-based, planned care; reorganization of practice systems and provider roles; improved patient self-management support; increased access to expertise; and greater availability of clinical information. The challenge is to organize these components into an integrated system of chronic illness care. Whether this can be done most efficiently and effectively in primary care practice rather than requiring specialized systems of care remains unanswered.
This review considers evidence that depression is associated with increased use of general medical services and that more intensive treatment of depression might be expected to reduce medical expenditures. Cross-sectional studies strongly support an association between depression and medical utilization, but cannot establish a causal relationship. Available longitudinal studies lack the sample size and duration of follow-up necessary to examine how changes in depression influence utilization. Some quasi-experimental and experimental studies support a "cost-offset" effect due to mental health treatment, but no experimental data directly address the specific impact of depression treatment on medical utilization. The available data identify the potential for large cost savings through improved treatment of depression but do not clearly establish that such savings can be realized. Definitive proof of a cost-offset due to depression treatment will require a new generation of experimental studies adapted to assess economic outcomes.
To examine relationships between recent DSM-III-R psychiatric disorders and work impairment in major occupational groups in the US labour force.
Data are from the US National Comorbidity Survey (NCS), a survey of respondents ages 15-54 in the US. Employed people are the focus of the report.
There is substantial variation across occupations in the 30-day prevalences of NCS/ DSM-III-R psychiatric disorders, with an average prevalence of 18.2% (range: 11.0-29.6%) for any disorder. The average prevalences of psychiatric work loss days (6 days per month per 100 workers) and work cutback days (31 days per month per 100 workers), in comparison, do not differ significantly across occupations. Work impairment is more strongly concentrated among the 3.7% of the workforce with co-morbid psychiatric disorders (49 work loss days and 346 work cutback days per month per 100 workers) than the 14.5% with pure disorders (11 work loss days and 66 work cutback days per month per 100 workers) or the 81.8% with no disorder (2 work loss days and 11 work cutback days per month per 100 workers). The effects of psychiatric disorders on work loss are similar across all occupations, while effects on work cutback are greater among professional workers than those in other occupations.
The results reported here suggest that work impairment is one of the adverse consequences of psychiatric disorders. The current policy debate concerning insurance coverage for mental disorders needs to take these consequences into consideration.
Patients can have several illnesses concurrently, yet some of these diseases may be neglected if one problem consumes attention. We conducted a population-based analysis in Ontario, Canada - where universal health insurance is provided - to determine whether unrelated disorders are less likely to be treated in patients with chronic diseases.
We studied the 1,344,145 residents of Ontario in 1995 who were 65 or older and eligible to receive prescription medications free of charge as part of the Ontario Drug Benefit program. Patients with diabetes mellitus were identified by prescriptions for insulin, pulmonary emphysema by prescriptions for ipratropium bromide, and psychotic syndromes by prescriptions for haloperidol. For each chronic disease, we selected an unrelated treatment: estrogen-replacement therapy for patients with diabetes mellitus, lipid-lowering medications for those with pulmonary emphysema, and medical treatment of arthritis for those with psychotic syndromes.
The 30,669 patients with diabetes mellitus were less likely to receive estrogen-replacement therapy than the other subjects in the study (2.4 percent vs. 5.9 percent, P<0.001). The disease was associated with a 60 percent reduction in the odds of estrogen treatment (odds ratio, 0.40; 95 percent confidence interval, 0.37 to 0.43). Findings were similar for the 56,779 patients with pulmonary emphysema, who were less likely to receive lipid-lowering medications (odds ratio, 0.69; 95 percent confidence interval, 0.67 to 0.72; P<0.001), and the 17,336 patients with psychotic syndromes, who were less likely to receive medical treatments for arthritis (odds ratio, 0.59; 95 percent confidence interval, 0.57 to 0.62; P<0.001).
In patients 65 or older who have chronic medical diseases and who receive prescription medications free of charge, unrelated disorders are undertreated. Clinicians caring for patients with chronic diseases should remain alert to other disorders and minimize the number of missed opportunities for treating them.
This study augments a randomized controlled trial to analyze the cost-effectiveness of 2 standardized treatments for major depression relative to each other and to the "usual care" provided by primary care physicians.
A randomized controlled trial was conducted in which primary care patients meeting DSM-III-R criteria for current major depression were assigned to pharmacotherapy (where nortriptyline hydrochloride was given) or interpersonal psychotherapy provided in a standardized framework or a primary physician's usual care. Two outcome measures, depression-free days and quality-adjusted days, were developed using information on depressive symptoms over time. The costs of care were calculated. Cost-effectiveness ratios comparing the incremental outcomes with the incremental costs for the different treatments were estimated. Sensitivity analyses were performed.
In terms of both economic costs and quality-of-life outcomes, patients assigned to the pharmacotherapy group did slightly better than those assigned to interpersonal psychotherapy. Both standardized therapies provided better outcomes than primary physician's usual care, but each consumed more resources. No meaningful cost-offsets were found. The incremental direct cost per additional depression-free day for pharmacotherapy relative to usual care ranges from $12.66 to $16.87 which translates to direct cost per quality-adjusted year gained from $11270 to $19510.
Standardized treatments for depression lead to better outcomes than usual care but also lead to higher costs. However, the estimates of the cost per quality-of-life year gained for standardized pharmacotherapy are comparable with those found for other treatments provided in routine practice.
An emerging trend within managed care, "disease management" (DM), will affect consumers and providers of mental health services, clinicians, and mental health administrators. Central to DM programs is the idea that particular diseases, especially chronic illnesses (including depression), can be "carved out" and managed. Pharmaceutical benefit management (PBM) firms may specialize in managing prescription benefits for employers and other managed care organizations by using DM programs. However, given what is known from the theoretical and empirical literature on adherence to medication for chronic illnesses such as depression, it is questionable whether the techniques that are used by PBMs will be effective in managing illnesses that require a multifaceted approach to care. Because the management of antidepressants may have an impact on members of vulnerable populations (e.g., the elderly), more research is required on the approaches used by PBMs and on the cost and quality of the services provided.
Despite improvements in the accuracy of diagnosing depression and use of medications with fewer side effects, many patients treated with antidepressant medications by primary care physicians have persistent symptoms.
A group of 228 patients recognized as depressed by their primary care physicians and given antidepressant medication who had either 4 or more persistent major depressive symptoms or a score of 1.5 or more on the Hopkins Symptom Checklist depression items at 6 to 8 weeks were randomized to a collaborative care intervention (n = 114) or usual care (n = 114) by the primary care physician. Patients in the intervention group received enhanced education and increased frequency of visits by a psychiatrist working with the primary care physician to improve pharmacologic treatment. Follow-up assessments were completed at 1, 3, and 6 months by a telephone survey team blinded to randomization status.
Those in the intervention group had significantly greater adherence to adequate dosage of medication for 90 days or more and were more likely to rate the quality of care they received for depression as good to excellent compared with usual care controls. Intervention patients showed a significantly greater decrease compared with usual care controls in severity of depressive symptoms over time and were more likely to have fully recovered at 3 and 6 months.
A multifaceted program targeted to patients whose depressive symptoms persisted 6 to 8 weeks after initiation of antidepressant medication by their primary care physician was found to significantly improve adherence to antidepressants, satisfaction with care, and depressive outcomes compared with usual care.
To examine whether competing demands explain the appearance of inadequate primary care depression treatment observed at a single visit.
A cross-sectional patient survey.
Two hundred forty patients with 5 or more symptoms of depression seeing 12 physicians in 6 primary care practices, representing 77.4% of the depressed patients identified through 2-stage screening of more than 11,000 primary care attenders.
In patients with elevated depressive symptoms, discussing depression as a possible diagnosis in untreated patients, and changing depression management in treated patients.
Physicians and patients discussed depression in 46 (47.9%) of 96 untreated patients; physicians changed depression treatment recommendations in 87 (60.4%) of 144 treated patients with current symptoms. Chronic physical comorbidity decreased the odds that physicians and untreated patients discussed depression as a possible diagnosis (odds ratio = 0.66, P = .01). New problems decreased the odds that treatment recommendations would be changed in treated patients who remained depressed (odds ratio = 0.39, P = .05). Physicians and untreated patients were more likely to discuss depression as a possible diagnosis if patients reported antidepressant medication was acceptable (odds ratio = 4.57, P = .01) and less likely to discuss depression if patients reported specialty care counseling was acceptable (odds ratio = 0.33, P = .05).
The attention depression gets during a given medical visit is less associated with the severity of the patient's depressive symptoms than with the number or recency of other problems the patient has. If competing demands provide ongoing barriers to depression treatment, interventions will be needed to assure that patients with chronic physical problems receive high-quality mental health care in the primary care setting.
Complex interventions, which have been shown to improve primary care depression outcomes, are difficult to disseminate to routine practice settings. To address this problem, we developed a brief intervention to train primary care physicians and nurses employed by the practice to improve the detection and management of major depression. Before recruitment began, the research team conducted academic detailing conference calls with primary care physicians and nurses, and provided in-person training with nurses and administrative staff. Administrative staff screened over 11,000 patients before their visits to identify those with probable major depression. Primary care physicians delegated increased responsibility to office nurses, who educated over 90% of patients about effective depression treatment and systematically monitored their progress over time. Early results demonstrate that community primary care practices can rebundle traditional team roles over the short-term to provide more systematic mental health treatment without adding additional personnel. A rigorous evaluation of this effort will reduce time-consuming, expensive, and often unsuccessful efforts to "translate" research intervention findings into everyday practice.
Disease management is a holistic, patient-focused approach to the treatment of disease across the spectrum of healthcare delivery. In its current form, disease management was created in response to the societal and economic burden that chronic illness contributes. There has recently been rapid growth in the development of disease management programs and sponsors are widespread within the industry, with the largest increase in independent vendors. Although growth has been substantial, the hurdles these programs have encountered have kept them from reaching their full potential. The challenges that exist include clinical, financial, and regulatory issues, and these challenges have significant meaning to healthcare managers. In deciding whether to develop or enhance programs, executives must consider their capability of outcomes measurement, their provider relationships, and the arrangements for program implementation. Ultimately, if programs provide improved health and quality of life for participants, cost savings will follow.
Complexities in the diagnosis and treatment of late-life depression have stimulated various strategies for assisting the primary care physician to fulfil these tasks more effectively. The role of Health Specialist was developed for this purpose in a study to reduce suicidality among older depressed patients. This role includes clinical and case management tasks which aim to provide the physician with timely, patient-specific information and recommendations. Evolution of this role and its rewards/stressors during the study's first year are described.
It is difficult to evaluate the promise of primary care quality-improvement interventions for depression because published studies have evaluated diverse interventions by using different research designs in dissimilar populations. Preplanned meta-analysis provides an alternative to derive more precise and generalizable estimates of intervention effects; however, this approach requires the resolution of analytic challenges resulting from design differences that threaten internal and external validity. This paper describes the four-project Quality Improvement for Depression (QID) collaboration specifically designed for preplanned meta-analysis of intervention effects on outcomes. This paper summarizes the interventions the four projects tested, characterizes commonalities and heterogeneity in the research designs used to evaluate these interventions, and discusses the implications of this heterogeneity for preplanned meta-analysis.
Depression is a serious, often chronic disease that can be managed effectively with a chronic care model in primary care settings. Depressed persons are likely to be seen by a primary care physician, but their condition often goes unrecognized and untreated. There are effective treatment models that consist of efficacious psychotherapeutic and pharmacological interventions, use of evidence-based guidelines for primary care treatment of depression, development of explicit plans and protocols, reorganization of practice, longitudinal follow-up, patient self-management, decision-making support, access to community resources and leadership commitment. Moving these models into everyday practice requires overcoming both clinical and system barriers. Barriers consist of issues surrounding patients, providers, practices, plans, and purchasers. An understanding of these barriers at each level helps to provide a framework for the changes required to overcome them. The Robert Wood Johnson Foundation National Program on Depression in Primary Care will seek to apply simultaneously both clinical and system strategies in a new five-year initiative to overcome these barriers.
To assess the impacts of the characteristics of quality improvement (QI) teams and their environments on team success in designing and implementing high quality, enduring depression care improvement programs in primary care (PC) practices.
Two nonprofit managed care organizations sponsored five QI teams tasked with improving care for depression in large PC practices. Data on characteristics of the teams and their environments is from observer process notes, national expert ratings, administrative data, and interviews.
Comparative formative evaluation of the quality and duration of implementation of the depression improvement programs developed by Central Teams (CTs) emphasizing expert design and Local Teams (LTs) emphasizing participatory local clinician design, and of the effects of additional team and environmental factors on each type of team. Both types of teams depended upon local clinicians for implementation.
The CT intervention program designs were more evidence-based than those of LTs. Expert team leadership, support from local practice management, and support from local mental health specialists strongly influenced the development of successful team programs. The CTs and LTs were equally successful when these conditions could be met, but CTs were more successful than LTs in less supportive environments.
The LT approach to QI for depression requires high local support and expertise from primary care and mental health clinicians. The CT approach is more likely to succeed than the LT approach when local practice conditions are not optimal.
To evaluate the effects of depression treatment in primary care on patients' clinical status and employment, over six months.
Data are from a randomized controlled trial of quality improvement for depression that included 938 adults with depressive disorder in 46 managed primary care clinics in five states.
Observational analysis of the effects of evidence-based depression care over six months on health outcomes and employment. Selection into treatment is accounted for using instrumental variables techniques, with randomized assignment to the quality improvement intervention as the identifying instrument.
Patient-reported clinical status, employment, health care use, and personal characteristics; health care use and costs from claims data.
At six months, patients with appropriate care, compared to those without it, had lower rates of depressive disorder (24 percent versus 70 percent), better mental health-related quality of life, and higher rates of employment (72 percent versus 53 percent), each p<.05.
Appropriate treatment for depression provided in community-based primary care substantially improves clinical and quality of life outcomes and employment.
Deficits in the quality of treatment of depression in the primary care sector have been documented in multiple studies. Several clinical models for improving primary care treatment of depression have been shown to be cost-effective in recent years but have not proved to be sustainable over time, partly because of barriers created by common organizational and financing arrangements such as managed behavioral health care carve-outs and risk-based provider payment mechanisms. These arrangements, which often distort relative costs that primary care physicians face when making treatment decisions for patients who have depression, can steer these decisions away from evidence-based practice. Various changes, such as in contractual relationships, payment methods for primary care physicians, and performance measurement, can be made in existing institutional arrangements to better align them with emerging clinical technologies and evidence-based practice.
The authors reviewed the implications of the latest generation of health services research studies on primary care practice system changes for depression management, especially in the roles of care managers and mental health specialists.
Authors conducted a review of four large, related, multisite trials testing system changes in the delivery of care to depressed, mostly older, primary care patients.
These studies confirm that older patients are more likely to accept collaborative mental health treatment within primary care than within mental health specialty care. The study results published to date suggest that these system changes produce better outcomes than usual care for depression in a wide range of patients and healthcare organizations. Two key partners in implementing these system changes are a care manager to assist the primary care physician in patient education, treatment, and treatment monitoring, and a mental health specialist to provide care-manager consultation and collaborative care with the primary care physician for more complex cases.
Most patients with depression first seek attention for their symptoms in primary care, rather than in the mental health specialty sector. Since primary care visits are necessarily brief and pressured by competing demands to manage other medical problems, practice system changes are necessary. For mental health specialists, these studies emphasize the importance of joining and being integrated into primary care. Consultative and supervisory roles allow the specialist to indirectly but effectively serve a larger number of patients.
Both antidepressant medication and structured psychotherapy have been proven efficacious, but less than one third of people with depressive disorders receive effective levels of either treatment.
To compare usual primary care for depression with 2 intervention programs: telephone care management and telephone care management plus telephone psychotherapy.
Three-group randomized controlled trial with allocation concealment and blinded outcome assessment conducted between November 2000 and May 2002.
A total of 600 patients beginning antidepressant treatment for depression were systematically sampled from 7 group-model primary care clinics; patients already receiving psychotherapy were excluded.
Usual primary care; usual care plus a telephone care management program including at least 3 outreach calls, feedback to the treating physician, and care coordination; usual care plus care management integrated with a structured 8-session cognitive-behavioral psychotherapy program delivered by telephone.
Blinded telephone interviews at 6 weeks, 3 months, and 6 months assessed depression severity (Hopkins Symptom Checklist Depression Scale and the Patient Health Questionnaire), patient-rated improvement, and satisfaction with treatment. Computerized administrative data examined use of antidepressant medication and outpatient visits.
Treatment participation rates were 97% for telephone care management and 93% for telephone care management plus psychotherapy. Compared with usual care, the telephone psychotherapy intervention led to lower mean Hopkins Symptom Checklist Depression Scale depression scores (P =.02), a higher proportion of patients reporting that depression was "much improved" (80% vs 55%, P<.001), and a higher proportion of patients "very satisfied" with depression treatment (59% vs 29%, P<.001). The telephone care management program had smaller effects on patient-rated improvement (66% vs 55%, P =.04) and satisfaction (47% vs 29%, P =.001); effects on mean depression scores were not statistically significant.
For primary care patients beginning antidepressant treatment, a telephone program integrating care management and structured cognitive-behavioral psychotherapy can significantly improve satisfaction and clinical outcomes. These findings suggest a new public health model of psychotherapy for depression including active outreach and vigorous efforts to improve access to and motivation for treatment.