Long-term effects of a collaborative care intervention in persistently depressed primary care patients

The interdisciplinary eHealth team: chronic care for the future

An interdisciplinary clinical team is a consistent grouping of people from relevant clinical disciplines, ideally inclusive of the patient, whose interactions are guided by specific team functions and processes to achieve team-defined favorable patient outcomes. Teamwork supported by properly designed eHealth applications could help create more effective systems of care for chronic disease. Given its synchronous and asynchronous communication capacity and information-gathering and -sharing capabilities, the Internet is a logical platform for supporting interdisciplinary clinical teamwork. Research is needed to better understand how interdisciplinary eHealth team members can work together in everyday practice and to guide the development of effective and efficient eHealth software applications to support greater clinical teamwork.

One-year clinical outcomes of depressed public sector outpatients: a benchmark for subsequent studies

BACKGROUND

The symptomatic outcomes of a cohort of public mental health sector depressed outpatients treated for 1 year are described to provide a benchmark for future long-term trials. Baseline moderators of outcome were evaluated.

METHODS

Outpatients with nonpsychotic major depressive disorder (n = 118) scoring >/=30 on the 30-item Inventory of Depressive Symptomatology-Clinician Rating (IDS-C(30)) were treated with a medication algorithm and patient/family education package. Response and remission rates were assessed every 3 months with the IDS-C(30). Logistic regression analyses evaluated several baseline features in relation to outcome.

RESULTS

While response and remission rates increased from 3 to 12 months, the 1-year last observation carried forward (LOCF) response (26.3%) and remission (11.0%) rates were not impressive (sustained response = 14.4%; sustained remission = 5.1%). Younger patients and those with full-time employment (at baseline) were more likely to respond. A shorter length of illness tended to be associated with higher response and remission rates (p <.10). Results are generalizable to public sector patients with substantial socioeconomic, general medical, and educational disadvantages who were sufficiently depressed to recommend a change in antidepressant medication.

CONCLUSIONS

Response and remission rates were modest when compared with outcomes in shorter duration efficacy trials in depressed outpatients with less chronicity, fewer concurrent general medical conditions, and less treatment resistance. Results support the need for more powerful treatments and/or the better delivery of available treatments.

Monitoring Depression Care

BACKGROUND

Linking process and outcomes is critical to accurately estimating healthcare quality and quantifying its benefits.

OBJECTIVES

The objective of this study was to explore the relationship of guideline-based depression process measures with subsequent overall and psychiatric hospitalizations.

RESEARCH DESIGN

This is a retrospective cohort study during which we used administrative and centralized pharmacy records for sample identification, derivation of guideline-based process measures (antidepressant dosage and duration adequacy), and subsequent hospitalization ascertainment. Depression care was measured from June 1, 1999, through August 31, 1999. We used multivariable regression to evaluate the link between depression care and subsequent overall and psychiatric hospitalization, adjusting for patient age, race, sex, socioeconomic status, comorbid illness, and hospitalization in the prior 12 months.

SUBJECTS

We studied a total of 12,678 patients from 14 Northeastern VHA hospitals.

RESULTS

We identified adequate antidepressant dosage in 90% and adequate duration in 45%. Those with adequate duration of antidepressants were less likely to be hospitalized in the subsequent 12 months than those with inadequate duration (odds ratio [OR],.90; 95% confidence interval [CI], .81-1.00). Those with adequate duration of antidepressants were less likely to have a psychiatric hospitalization in the subsequent 12 months than those with inadequate duration (OR, .82; 95% CI, .69-.96). We did not demonstrate a significant link between dosage adequacy and subsequent overall or psychiatric hospitalization.

CONCLUSIONS

Guideline-based depression process measures derived from centralized data sources offer an important method of depression care surveillance. Their accuracy in capturing depression care quality is supported by their link to healthcare utilization. Further work is needed to assess the effect of implementing these quality indicators on depression care.

Effectiveness of electroconvulsive therapy in community settings

BACKGROUND

Clinical trials indicate that electroconvulsive therapy (ECT) is the most effective treatment for major depression, but its effectiveness in community settings has not been examined.

METHODS

In a prospective, naturalistic study involving 347 patients at seven hospitals, clinical outcomes immediately after ECT and over a 24-week follow-up period were examined in relation to patient characteristics and treatment variables.

RESULTS

The sites differed markedly in patient features and ECT administration but did not differ in clinical outcomes. In contrast to the 70%-90% remission rates expected with ECT, remission rates, depending on criteria, were 30.3%-46.7%. Longer episode duration, comorbid personality disorder, and schizoaffective disorder were associated with poorer outcome. Among remitters, the relapse rate during follow-up was 64.3%. Relapse was more frequent in patients with psychotic depression or comorbid Axis I or Axis II disorders. Only 23.4% of ECT nonremitters had sustained remission during follow-up.

CONCLUSIONS

The remission rate with ECT in community settings is substantially less than that in clinical trials. Providers frequently end the ECT course with the view that patients have benefited fully, yet formal assessment shows significant residual symptoms. Patients who do not remit with ECT have a poor prognosis; this underscores the need to achieve maximal improvement with this modality.

Effectiveness of screening and treatment for depression in ambulatory indigent patients

OBJECTIVE

To determine the effectiveness of screening and treatment for depression among ambulatory indigent patients visiting resident physicians.

DESIGN

Two-group randomized trial (N = 33 intervention, N = 28 usual care) with baseline, 6-month, and 12-month outcome measurements.

SETTING

Internal Medicine Residency Clinic.

PATIENTS

Clinic patients over 18 years of age who screened positive for depression on the PRIME-MD during a visit to their resident physician. Patients were not receiving treatment nor seeking care for any emotional problems. All patients were either enrolled in Medicaid or had income below the poverty line.

INTERVENTION

Resident physicians were educated to follow AHCPR (AHRQ; Agency for Healthcare Research and Quality) guidelines for diagnosis and treatment of depression in a primary care setting. For the intervention group patients, a screening nurse advised residents regarding the positive screen, handed them a standardized protocol outline, and attempted to arrange behavioral care. The patients in the usual care group were provided the results of the screen by the screening nurse before their visit with the resident, and advised to seek care for their symptoms.

MAIN RESULTS

Results for the primary outcome of depression symptoms measured with the Beck Depression Inventory (BDI) demonstrated that intervention was successful in reducing symptoms relative to usual care (difference = -4.9 BDI points, P =.05, 95% confidence interval [CI], -9.8 to -0.005 effect size = -0.41). During the 12-month follow-up, 70% of intervention patients were treated for depression (of these, 91% with antidepressants), while 15% of usual care patients were treated with antidepressants for depression. Another 18% of the usual care group had depression noted, but no treatment was identified. BDI differences between intervention and control groups were similar at the 6- and 12-month measures. Quality of life and costs were also measured, but differences between the groups were not significant in this regard.

CONCLUSION

Screening and treatment for depression by resident physicians was successful in reducing symptoms relative to usual care in an indigent population. Almost twice as many intervention patients as usual care controls demonstrated a substantial reduction (10 BDI points) in symptoms related to depression.

Achieving long-term optimal outcomes in geriatric depression and anxiety

Depression and anxiety disorders are very common in the elderly. Data accumulated over the past 2 decades have shown that most older patients can tolerate and respond to acute treatment with serotonergic antidepressants, other psychotropic agents, or manual-based psychotherapy. However, outcomes under usual-care conditions remain poor. This review proposes that clinicians may significantly improve the long-term outcomes of their older patients with depression and anxiety by focusing on four key factors: (1) identification and treatment of comorbid conditions; (2) full remission of acute symptoms; (3) education of patients, families, and professional colleagues about the need for long-term treatment; and (4) prevention and management of medication side-effects.

Public health context of women's mental health research

As more attention is directed to the mental health care of women, sex and gender differences in research design and in regulatory policies have interfaced with clinical care and public policy. An emphasis on women's mental health issues in the provision of treatment and care as well as the design of large-scale screening strategies to identify and treat women with mental disorders promises to be effective public health approaches to reducing the burden of mental illness in women. The past decade has seen increased emphasis on women's mental health and sex/gender differences in the federal sector and in the research community. Federal regulations (summarized in the NIH Outreach Notebook) call for the inclusion of women and minorities in NIH-funded clinical research. The regulations also place emphasis on gender analysis of the results of clinical trials, in particular phase III trials, the findings of which are likely to influence practice. There has been substantial progress toward the goal of including women in research, but more remains to be done. A 2000 GAO report titled "Women's Health: NIH Has Increased Its Efforts to Include Women in Research" commended NIH for tracking the number of women in clinical research but the report also noted that relatively few NIH-funded studies, including major clinical trials, had reported findings by gender of study participants. This was seen as an impediment to progress in developing gender-based effective treatments. In the past decade, the women's health field has moved beyond an exclusive emphasis on women's reproductive function to one that defines health as a scientific enterprise to identify clinically important sex and gender differences in prevalence, etiology, course, and treatment of illnesses affecting men and women in the population as well as conditions specific to women. Nonetheless, for mental disorders, women's reproductive function and its impact on mental health conditions is still understudied. Based on the epidemiology of mental disorders, the course of mental disorders in women in relation to reproductive transitions remains an important issue for the mental health field because the burden of mental disorders, such as depression and anxiety, fall disproportionately on women of childbearing and childrearing age. The public health emphasis on women's mental health does not lessen the basic scientific opportunities to be had by a focus on gender and sex differences. A 2001 report of the Institute of Medicine titled "Exploring the Biological Contributions to Health: Does Sex Matter?" underscores the benefit to health care of looking for sex differences at the biological level. Basic and clinical neuroscience research is rapidly accruing a knowledge base that will provide information at the level of genes and cells of the influences of biological sex on mental health outcomes in both women and men. A focus on women's mental health and gender/sex differences research promises to yield improvement in treatments and services and thereby to improve the public health as well as to increase fundamental knowledge about the etiology and neurophysiology of mental disorders.

Measuring adherence to depression treatment guidelines in a VA primary care clinic

The primary objectives of this pilot study were to develop a measure of adherence for depression practice guidelines and to assess the degree to which providers and patients adhere to guidelines in a VA primary care setting. The Depression Guideline Measure (DGM) is based on three national guidelines. The DGM was used to review medical records of 111 patients with Patient Health Questionnaire (PHQ) scores >or=10. Interrater reliability for 15 of 19 DGM checklist items was excellent (kappa > 0.75). There was a broad range of adherence to guideline criteria: only 13.5% of patients were contacted for follow-up within 2 weeks, while 100% of providers documented follow-up plans. Forty percent of patients saw mental health providers, and 63% were prescribed antidepressants. A secondary objective of the study was to explore the relationship between guideline adherence and changes in PHQ scores. Among 51 patients who completed follow-up PHQs, no associations were detected. The results suggest that the DGM shows promise as a reliable measure of guideline adherence and that guideline criteria are frequently not met in busy primary care clinics. More research is needed to determine the validity of the DGM and the impact of guideline adherence on depression outcomes.

The Institute of Medicine "Chasm" report: implications for depression collaborative care models

The Institute of Medicine report "Crossing the Quality Chasm: A New Health Care System for the 21st Century" describes the barriers in the American health care system to improving quality of care and outcomes of chronic illness. This article describes how depression collaborative care models as well as newer research aimed at organizational and economic issues have addressed these barriers in order to improve outcomes for patients with depression in primary care systems.