Cost-effectiveness of collaborative care for the treatment of major depressive disorder in primary care. A systematic review

Enhanced care for depression

PURPOSE OF REVIEW

The purpose of this study is to review recent evidence of the effects of enhanced depression care, focusing (1) on symptomatic, functional and economic outcomes and (2) across different countries, (3) ethnic groups and (4) settings.

RECENT FINDINGS

Collaborative care is currently by far the most influential and best studied method to enhance depression care. Recent trials and reviews provide firm evidence that collaborative care is more effective than care as usual (CAU), though with small effects. These effects generalized across several important health outcomes are probably more pronounced in patients with more complex or severe disorders. Cost-effectiveness and cost utility data demonstrate that collaborative care is of good value for money, and this is probably more pronounced in patients with higher a-priori levels of healthcare utilization. Collaborative care is readily exported to other healthcare systems, other regions of the world and other cultures.

SUMMARY

Given parallel development and successful testing of other cheaper and more simple interventions targeting depression (such as guided self-help and e-mental health), it may be that collaborative care will focus on the more severe, complex or recurrent forms of affective disorder in the future. Including effects of collaborative care on other outcomes, especially on work-related functioning and economic productivity, seems fruitful.

Lessons Learned From a Colocation Model Using Psychiatrists in Urban Primary Care Settings

Objectives: Comorbid psychiatric illness has been identified as a major driver of health care costs. The colocation of psychiatrists in primary care practices has been proposed as a model to improve mental health and medical care as well as a model to reduce health care costs. Methods: Financial models were developed to determine the sustainability of colocation. Results: We found that the population studied had substantial psychiatric and medical burdens, and multiple practice logistical issues were identified. Conclusion: The providers found the experience highly rewarding and colocation was financially sustainable under certain conditions. The colocation model was effective in identifying and treating psychiatric comorbidities.

Collaborative care for depression in medically ill patients

PURPOSE OF REVIEW

Depression is common in medically ill patients and associated with a negative prognosis. Recent findings indicate that single interventions have little effect on outcomes in these patients. Alternatively, complex interventions based on a collaborative care model are promising. This review summarizes recent findings regarding collaborative care in medically ill patients with comorbid depression.

RECENT FINDINGS

Recent trials provide evidence for a significantly beneficial effect on depression outcomes with moderate effect sizes regarding depressive symptoms [standardized mean differences (SMDs): -0.46 to -0.74, n = 5] and depression response [odds ratios (ORs): 1.29 to 4.75, n = 6]. Psychosocial quality of life (SMDs: 0.09 to 0.54, n = 5) and satisfaction with care (ORs: 2.55-7.43, n = 3; SMDs: 0.05 and 0.2, n = 1) were increased in intervention patients compared with usual care, whereas physical quality of life (SMDs: -0.17 to 0.06) was not. The evidence regarding medication adherence and somatic, disease-specific outcomes is sparse and conclusions cannot be drawn so far.

SUMMARY

Collaborative care interventions are efficacious in medically ill patients with depression. However, there is no data concerning their cost-effectiveness. Furthermore, as trials on collaborative care comprise a heterogeneous set of components, the most effective characteristics should be identified. Moreover, these interventions should be adapted to other healthcare systems than the United States.

Primary care management of child & adolescent depressive disorders

This article outlines the importance of primary health care in addressing the public health challenge presented by pediatric depressive disorders. The current realities of depression management in primary care are discussed. The models emerging from intervention research and the barriers to their implementation in practice are then reviewed. Drawing on this background, recent new standards for primary care management of pediatric depressive disorders are discussed, along with resources that have been developed to support their achievement.

Ten years of integrated care for mental disorders in the Netherlands

Background and problem statement

Integrated care for mental disorders aims to encompass forms of collaboration between different health care settings for the treatment of mental disorders. To this end, it requires integration at several levels, i.e. integration of psychiatry in medicine, of the psychiatric discourse in the medical discourse; of localization of mental health care and general health care facilities; and of reimbursement systems.

Description of policy practice

Steps have been taken in the last decade to meet these requirements, enabling psychiatry to move on towards integrated treatment of mental disorder as such, by development of a collaborative care model that includes structural psychiatric consultation that was found to be applicable and effective in several Dutch health care settings. This collaborative care model is a feasible and effective model for integrated care in several health care settings. The Bio Psycho Social System has been developed as a feasible instrument for assessment in integrated care as well.

Discussion

The discipline of psychiatry has moved from anti-psychiatry in the last century, towards an emancipated medical discipline. This enabled big advances towards integrated care for mental disorder, in collaboration with other medical disciplines, in the last decade.

Conclusion

Now is the time to further expand this concept of care towards other mental disorders, and towards integrated care for medical and mental co-morbidity. Integrated care for mental disorder should be readily available to the patient, according to his/her preference, taking somatic co-morbidity into account, and with a focus on rehabilitation of the patient in his or her social roles.

Depression care management: can employers purchase improved outcomes?

Fourteen vendors are currently selling depression care management products to US employers after randomized trials demonstrate improved work outcomes. The research team interviewed 10 (71.4%) of these vendors to compare their products to four key components of interventions demonstrated to improve work outcomes. Five of 10 depression products incorporate all four key components, three of which are sold by health maintenance organizations (HMOs); however, HMOs did not deliver these components at the recommended intensity and/or duration. Only one product delivered by a disease management company delivered all four components of care at the recommended intensity and duration. This "voltage drop," which we anticipate will increase with product implementation, suggests that every delivery system should carefully evaluate the design of its depression product before implementation for its capacity to deliver evidence-based care, repeating these evaluations as new evidence emerges.

Norwegian GPs' participation in multidisciplinary meetings: a register-based study from 2007

Background

An increasing number of patients with chronic disorders and a more complex health service demand greater interdisciplinary collaboration in Primary Health Care. The aim of this study was therefore to identify factors related to general practitioners (GPs), their list populations and practice municipalities associated with a high rate of GP participation in multidisciplinary meetings (MDMs).

Methods

A national cross-sectional register-based study of Norwegian general practice was conducted, including data on all GPs in the Regular GP Scheme in 2007 (N = 3179). GPs were grouped into quartiles based on the annual number of MDMs per patient on their list, and the groups were compared using one-way analysis of variance. Binary logistic regression was used to analyse associations between high rates of participation and characteristics of the GP, their list population and practice municipality.

Results

On average, GPs attended 30 MDMs per year. The majority of the meetings concerned patients in the age groups 20-59 years. Psychological disorders were the motivation for 53% of the meetings. In a multivariate logistic regression model, the following characteristics predicted a high rate of MDM attendance: younger age of the GP, with an OR of 1.6 (95% CI 1.2-2.1) for GPs < 45 years, a short patient list, with an OR of 4.9 (3.2-7.5) for list sizes below 800 compared to lists ≥ 1600, higher proportion of psychological diagnosis in consultations (OR3.4 (2.6-4.4)) and a high MDM proportion with elderly patients (OR 4.1 (3.3-5.4)). Practising in municipalities with less than 10,000 inhabitants (OR 3.7 (2.8-4.9)) and a high proportion of disability pensioners (OR 1.6 (1.2-2.2)) or patients receiving social assistance (OR 2.2 (1.7-2.8)) also predicted high rates of meetings.

Conclusions

Psychological problems including substance addiction gave grounds for the majority of MDMs. GPs with a high proportion of consultations with such problems also participated more frequently in MDMs. List size was negatively associated with the rate of MDMs, while a more disadvantaged list population was positively associated. Working in smaller organisational units seemed to facilitate cooperation between different professionals. There may be a generation shift towards more frequent participation in interdisciplinary work among younger GPs.