Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care

Impact of ongoing primary care intervention on long term outcomes in uninsured and insured patients with depression

BACKGROUND AND OBJECTIVES

To assess the differential impact of an ongoing primary care depression intervention on uninsured and insured patients' outcomes 12, 18, and 24 months following baseline.

RESEARCH DESIGN

Quasi-experimental longitudinal study of insured and uninsured patients with depression receiving treatment from 12 practices randomized to enhanced (intervention) and usual care study conditions.

SUBJECTS

In 1996 to 1997, 383 nonelderly patients with depression (290 insured, 93 uninsured) were enrolled and followed for 24 months.

MEASURES

Mental-health-related-quality-of-life (MHQOL) was assessed at each follow-up using the SF-36 Mental Component Summary scale. Presence of major depressive episode was assessed at 24-month follow-up with the Composite International Diagnostic Interview.

RESULTS

Uninsured enhanced-care patients had significantly better MHQOL outcomes at 24 months than uninsured usual care patients (40.6 vs. 32.7, respectively; P = 0.01). The intervention had no significant impact on insured patients' MHQOL outcomes at any follow-up interval. Among patients receiving usual care, the uninsured compared with the insured had significantly poorer MHQOL outcomes (32.7 vs. 40.7, respectively; P = 0.002) and significantly increased probability of experiencing a major depressive episode (40.6% vs. 19.8%, respectively; P = 0.04) at 24 months. No such disparities were observed between uninsured and insured patients receiving enhanced care.

CONCLUSIONS

The ongoing intervention significantly improved quality-of-life outcomes in uninsured patients at 24 months. If the intervention's impact on MHQOL can be confirmed and proved cost-effective in larger uninsured patient populations, clinicians serving the uninsured may want to consider implementing the study's intervention.

A three-component model for reengineering systems for the treatment of depression in primary care

Depression in primary care is a chronic disease. As with most chronic diseases, long-term adherence to treatment plans is problematic. Evidence-based systems of care address this problem, but persistence and dissemination of systems after testing is a new problem. The three-component model for the care of patients with depression is a system of widely applicable, easily transported strategies and materials to address dissemination. The three-component model provides a series of routines (processes for structured diagnostic and follow-up-care with a time line) and division of responsibility, including a role for a telephone care manager. In the three-component model, clinician and office education create a prepared practice that is predisposed to providing evidence-based depression management. Enabling elements include the telephone care managers, who are trained to promote adherence to a management plan, and a supervising psychiatrist. The key reinforcing element is care manager reports about patient response to treatment. The three-component model is bound together by a common depression diagnostic and severity measure that facilitates communication and treatment decisions.

Interventions used in disease management programmes for patients with chronic illness-which ones work? Meta-analysis of published reports

OBJECTIVE

To systematically evaluate the published evidence regarding the characteristics and effectiveness of disease management programmes.

DESIGN

Meta-analysis.

DATA SOURCES

Computerised databases for English language articles during 1987-2001.

STUDY SELECTION

102 articles evaluating 118 disease management programmes.

MAIN OUTCOME MEASURES

Pooled effect sizes calculated with a random effects model.

RESULTS

Patient education was the most commonly used intervention (92/118 programmes), followed by education of healthcare providers (47/118) and provider feedback (32/118). Most programmes (70/118) used more than one intervention. Provider education, feedback, and reminders were associated with significant improvements in provider adherence to guidelines (effect sizes (95% confidence intervals) 0.44 (0.19 to 0.68), 0.61 (0.28 to 0.93), and 0.52 (0.35 to 0.69) respectively) and with significant improvements in patient disease control (effect sizes 0.35 (0.19 to 0.51), 0.17 (0.10 to 0.25), and 0.22 (0.1 to 0.37) respectively). Patient education, reminders, and financial incentives were all associated with improvements in patient disease control (effect sizes 0.24 (0.07 to 0.40), 0.27 (0.17 to 0.36), and 0.40 (0.26 to 0.54) respectively).

CONCLUSIONS

All studied interventions were associated with improvements in provider adherence to practice guidelines and disease control. The type and number of interventions varied greatly, and future studies should directly compare different types of intervention to find the most effective.

Managing depression as a chronic disease: a randomised trial of ongoing treatment in primary care

OBJECTIVES

To evaluate the long term effect of ongoing intervention to improve treatment of depression in primary care.

DESIGN

Randomised controlled trial.

SETTING

Twelve primary care practices across the United States.

PARTICIPANTS

211 adults beginning a new treatment episode for major depression; 94% of patients assigned to ongoing intervention participated.

INTERVENTION

Practices assigned to ongoing intervention encouraged participating patients to engage in active treatment, using practice nurses to provide care management over 24 months.

MAIN OUTCOME MEASURES

Patients' report of remission and functioning.

RESULTS

Ongoing intervention significantly improved both symptoms and functioning at 24 months, increasing remission by 33 percentage points (95% confidence interval 7% to 46%), improving emotional functioning by 24 points (11 to 38) and physical functioning by 17 points (6 to 28). By 24 months, 74% of patients in enhanced care reported remission, with emotional functioning exceeding 90% of population norms and physical functioning approaching 75% of population norms.

CONCLUSIONS

Ongoing intervention increased remission rates and improved indicators of emotional and physical functioning. Studies are needed to compare the cost effectiveness of ongoing depression management with other chronic disease treatment routinely undertaken by primary care.

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

OBJECTIVE

A previous study described the effect of a collaborative care intervention on improving adherence to antidepressant medications and depressive and functional outcomes of patients with persistent depressive symptoms 8 weeks after the primary care physician initiated treatment. This paper examined the 28-month effect of this intervention on adherence, depressive symptoms, functioning, and health care costs.

DESIGN

Randomized trial of stepped collaborative care intervention versus usual care.

SETTING

HMO in Seattle, Wash.

PATIENTS

Patients with major depression were stratified into severe and moderate depression groups prior to randomization.

INTERVENTIONS

A multifaceted intervention targeting patient, physician, and process of care, using collaborative management by a psychiatrist and a primary care physician.

MEASURES AND MAIN RESULTS

The collaborative care intervention was associated with continued improvement in depressive symptoms at 28 months in patients in the moderate-severity group (F1,87 = 8.65; P =.004), but not in patients in the high-severity group (F1,51 = 0.02; P =.88) Improvements in the intervention group in antidepressant adherence were found to occur for the first 6 months (chi2(1) = 8.23; P <.01) and second 6-month period (chi2(1) = 5.98; P <.05) after randomization in the high-severity group and for 6 months after randomization in the moderate-severity group(chi2(1) = 6.10; P <.05). There were no significant differences in total ambulatory costs between intervention and control patients over the 28-month period (F1,180 = 0.77; P =.40).

CONCLUSIONS

A collaborative care intervention was associated with sustained improvement in depressive outcomes without additional health care costs in approximately two thirds of primary care patients with persistent depressive symptoms.

Psychosocial intervention development for the prevention and treatment of depression: promoting innovation and increasing access

Great strides have been made in developing psychosocial interventions for the treatment of depression and bipolar disorder over the last three decades, but more remains to be done. The National Institute of Mental Health Psychosocial Intervention Development Workgroup recommends three priorities for future innovation: 1) development of new and more effective interventions that address both symptom change and functional capacity, 2) development of interventions that prevent onset and recurrence of clinical episodes in at-risk populations, and 3) development of user-friendly interventions and nontraditional delivery methods to increase access to evidence-based interventions. In each of these areas, the Workgroup recommends systematic study of the mediating mechanisms that drive the process of change and the moderators that influence their effects. This information will highlight the elements of psychosocial interventions that most contribute to the prevention and treatment of mood disorders across diagnostic groups, populations served, and community settings. The process of developing innovative interventions should have as its goal a mental health service delivery system that prevents the onset and recurrence of the mood disorders, furnishes increasingly effective treatment for those who seek it, and provides access to evidence-based psychosocial interventions via all feasible means.

Overcoming barriers to reducing the burden of affective disorders

Affective disorders impose a substantial individual and societal burden. Despite availability of efficacious treatments and practice guidelines, unmet need remains high. To reduce unmet need and the burden of affective disorders, information is needed on the distribution of burden across stakeholders, on barriers to reducing burden, and on interventions that effectively reduce burden at the levels of practice, community, and policy. This article provides the report of the Working Group on Overcoming Barriers to Reducing the Burden of Affective Disorders, for the National Institute of Mental Health Strategic Plan on Mood Disorders. We review the literature, identify key gaps, and recommend new research to guide national efforts to reduce the burden of affective disorders.

Diagnosis and treatment of older adults with depression in primary care

This article provides an overview of current challenges in the diagnosis and treatment of depressed older adults in primary care and considers suggestions for clinicians, researchers, and policy makers to improve care for this population. Despite the enormous toll of depression on individuals and society and the availability of effective treatments, depressed older adults remain largely untreated or undertreated. They rarely see mental health professionals, but have relatively frequent contact with primary care providers. In primary care, the chronic and recurrent nature of depression and a number of patient, provider, and policy-related barriers interfere with effective depression treatment. Recent research suggests that improving care for individuals with late life depression will require education and engagement of older adults and their primary care providers as active partners in caring for depression. It will also require additional human resources and systematic models of care dedicated to proactively managing depression as a chronic illness. Finally, it will require training of mental health professionals to effectively collaborate with their colleagues in primary care in treating depressed older adults. Further improvement in depression care would likely result from the implementation of true parity for mental health treatments for older adults.

Design and implementation of a randomized trial evaluating systematic care for bipolar disorder

OBJECTIVES

Everyday care of bipolar disorder typically falls short of evidence-based practice. This report describes the design and implementation of a randomized trial evaluating a systematic program to improve quality and continuity of care for bipolar disorder.

METHODS

Computerized records of a large health plan were used to identify all patients treated for bipolar disorder. Following a baseline diagnostic assessment, eligible and consenting patients were randomly assigned to either continued usual care or a multifaceted intervention program including: development of a collaborative treatment plan, monthly telephone monitoring by a dedicated nurse care manager, feedback of monitoring results and algorithm-based medication recommendations to treating mental health providers, as-needed outreach and care coordination, and a structured psychoeducational group program (the Life Goals Program by Bauer and McBride) delivered by the nurse care manager. Blinded assessments of clinical outcomes, functional outcomes, and treatment process were conducted every 3 months for 24 months.

RESULTS

A total of 441 patients (64% of those eligible) consented to participate and 43% of enrolled patients met criteria for current major depressive episode, manic episode, or hypomanic episode. An additional 39% reported significant subthreshold symptoms, and 18% reported minimal or no current mood symptoms. Of patients assigned to the intervention program, 94% participated in telephone monitoring and 70% attended at least one group session.

CONCLUSIONS

In a population-based sample of patients treated for bipolar disorder, approximately two-thirds agreed to participate in a randomized trial comparing alternative treatment strategies. Nearly all patients accepted regular telephone monitoring and over two-thirds joined a structured group program. Future reports will describe clinical effectiveness and cost-effectiveness of the intervention program compared with usual care.

Evidence review: efficacy and effectiveness of antidepressant treatment in primary care

This review considers evidence for the efficacy of pharmacotherapy among primary care patients with depressive disorders and reviews knowledge regarding the effectiveness of current practice. Strong evidence supports the efficacy of antidepressant pharmacotherapy for primary care patients with major depression and dysthymia with some evidence for pharmacotherapy of less severe depression. In general, available antidepressants appear equal in both efficacy and effectiveness. Treatment selection for any individual patient remains largely empirical, with few clinical characteristics predicting better or worse response to specific treatments. Strong evidence supports continuation treatment (i.e., at least six months of pharmacotherapy) for all patients and maintenance treatment (i.e., at least 24 months of pharmacotherapy) for those with chronic or recurrent depression. Unfortunately, few patients in primary care or specialty practice receive recommended levels of pharmacotherapy or recommended frequency of follow-up care. A number of recent studies have evaluated strategies to improve the quality of antidepressant treatment in primary care. Educational programs (including academic detailing and continuous quality improvement) have had little impact on patient outcomes. Key elements of effective care improvement programs include specific, evidence-based treatment protocols, organized patient education and active follow-up care.

Limitations of patient satisfaction studies in telehealthcare: a systematic review of the literature

The objective of this study is to provide a systematic review of studies on patient satisfaction with telemedicine. The review included empirical studies that investigated patient satisfaction with that telemedicine service. The search strategy involved matching at least one of 11 'telemedicine' terms with one of 5 'satisfaction' terms. The following databases were searched: Telemedicine Information Exchange (TIE) database, MEDLINE, Science Citation Index (SCI), Social Science Citation Index (SSCI), Psycinfo, and Citation Index of Nursing and Allied Health (CINAHL). A highly structured instrument was used for data extraction. The review included 93 studies. Telepsychiatry represents the largest portion of these studies (25%), followed by multispecialty care (14%), nursing (11%), and dermatology (8%). Real-time videoconferencing was used in 88% of these studies. Only 19 (20%) included an independent control group, including 9 (10%) randomized control trial (RCT) studies. One third of studies were based on samples of less than 20 patients, and only 21% had samples of over 100 patients. Aspects of patient satisfaction most commonly assessed were: professional-patient interaction, the patient's feeling about the consultation, and technical aspects of the consultation. Only 33% of the studies included a measure of preference between telemedicine and face-to-face consultation. Almost half the studies measured only 1 or 2 dimensions of satisfaction. Reported levels of satisfaction with telemedicine are consistently greater than 80%, and frequently reported at 100%. Progression of telemedicine services from "trial" status to routine health service must be supported by improved research into patients' satisfaction with telemedicine. Further investigation of factors that influence patient acceptance of telemedicine is indicated.

The changing nature of consultation-liaison in primary care: bridging the gap between research and practice

Consultation-liaison (C-L) psychiatry is hypothesized to be a model of interface between primary care and specialist mental health services with significant advantages over other models of organizing mental health care. However, there are significant complexities in the definition and evaluation of this model. As well as discussing the definition of C-L in primary care, this paper highlights the gap between models of traditional C-L that are popular in practice and the increasingly complex models (based on chronic disease management) evaluated in research studies. It is hypothesized that traditional C-L approaches and newer models use different mechanisms of change to achieve their goals. The former focus on the relationships between primary care and specialist professionals, while the latter highlight the importance of the development of effective systems of delivering care. Although the latter may be crucial in enhancing the "efficacy" and "effectiveness" of these models in terms of clinician behavior change and patient outcome, the former may be crucial in terms of "dissemination" and "implementation" of these models from research contexts to routine care settings.

Geriatric depression, antidepressant treatment, and healthcare utilization in a health maintenance organization

OBJECTIVES

To assess the separate effects of depressive symptoms and antidepressant treatment on healthcare utilization and cost.

SETTING

Social Health Maintenance Organization (HMO) at HealthPartners in Minnesota.

PARTICIPANTS

Geriatric Social HMO enrollees were screened for depressive symptoms using the 30-item Geriatric Depression Scale. A stratified sample was created, composed of geriatric enrollees with depressive symptoms, with antidepressant prescriptions, or with neither (n = 516).

DESIGN

Regression analyses were conducted with separate equations for utilization and charge outcome variables, both outpatient and inpatient (log-transformed). The Charlson Comorbidity Index, age, and gender served as covariates.

MEASUREMENT

Depressive symptoms were identified through the Diagnostic Interview Schedule. Antidepressant treatment was determined from the HMO pharmacy database.

RESULTS

Having depressive symptoms was associated with a 19 increase in the number of outpatient encounters and a 30 increase in total outpatient charges. Antidepressant treatment was associated with a 32 increase in total outpatient charges but was not significantly associated with number of outpatient encounters. Depressive symptoms and antidepressant therapy were not significantly associated with inpatient utilization or charges.

CONCLUSION

This study found that patients with depressive symptoms generated more outpatient health care and higher charges but not necessarily more inpatient care. Our findings suggest that programs targeted to geriatric patients whose depression is comorbid with other chronic medical conditions might be cost-effective and particularly appropriate for geriatric care.

Barriers to initiating depression treatment in primary care practice

OBJECTIVE AND DESIGN

This study used qualitative and quantitative methods to examine the reasons primary care physicians and nurses offered for their inability to initiate guideline-concordant acute-phase care for patients with current major depression.

PARTICIPANTS AND SETTING

Two hundred thirty-nine patients with 5 or more symptoms of depression seeing 12 physicians in 6 primary care practices were randomized to the intervention arm of a trial of the effectiveness of depression treatment. Sixty-six (27.6%) patients identified as failing to meet criteria for guideline-concordant treatment 8 weeks following the index visit were the focus of this analysis.

METHODS

The research team interviewed the 12 physicians and 6 nurse care managers to explore the major reasons depressed patients fail to receive guideline-concordant acute-phase care. This information was used to develop a checklist of barriers to depression care. The 12 physicians then completed the checklist for each of the 64 patients for whom he or she was the primary care provider. Physicians chose which barriers they felt applied to each patient and weighted the importance of the barrier by assigning a total of 100 points for each patient. Cluster analysis of barrier scores identified naturally occurring groups of patients with common barrier profiles.

RESULTS

The cluster analysis produced a 5-cluster solution with profiles characterized by patient resistance (19 patients, 30.6%), patient noncompliance with visits (15 patients, 24.2%), physician judgment overruled the guideline (12 patients, 19.3%), patient psychosocial burden (8 patients, 12.9%), and health care system problems (8 patients, 12.9%). The physicians assigned 4,707 (75.9%) of the 6,200 weighting points to patient-centered barriers. Physician-centered barriers accounted for 927 (15.0%) and system barriers accounted for 566 (9.1%) of weighting points. Twenty-eight percent of the patients not initiating guideline-concordant acute-stage care went on to receive additional care and met criteria for remission at 6 months, with no statistical difference across the 5 patient clusters.

CONCLUSIONS

Current interventions fail to address barriers to initiating guideline-concordant acute-stage care faced by more than a quarter of depressed primary care patients. Physicians feel that barriers arise most frequently from factors centered with the patients, their psychosocial circumstances, and their attitudes and beliefs about depression and its care. Physicians less frequently make judgments that overrule the guidelines, but do so when patients have complex illness patterns. Further descriptive and experimental studies are needed to confirm and further examine barriers to depression care. Because few untreated patients improve without acute-stage care, additional work is also needed to develop new intervention components that address these barriers.

The failure of a controlled trial to improve depression care: a qualitative study

BACKGROUND

The DIAMOND Project (Depression Is A MANageable Disorder), a nonrandomized controlled effectiveness trial, was intended to improve the long-term management of depression in primary care medical clinics. The project tested whether a quality improvement (QI) intervention could implement a systems approach-so that there would be more reliable and effective monitoring of patients with depression, leading to better outcomes. THE QUALITATIVE STUDY: A study was conducted in 1998-2000 to determine why a quality improvement intervention to improve depression care did not have a significant impact. Data consisted of detailed notes from observations of 12 project-related events (for example, team meetings and presentations) and open-ended interviews with a purposive sampling of 17 key informants. Thematic analytic methods were used to identify themes in the contextual data.

PRINCIPAL FINDINGS

Overall, the project implementation was very limited. Five themes emerged: (1) The project received only lukewarm support from clinic and medical group leadership. (2) Clinicians did not perceive an urgent need for the new care system, and therefore there was a lack of impetus to change. (3) The improvement initiative was perceived as too complex by the physicians. (4) There was an inherent disconnect between the commitment of the improvement team and the unresponsiveness of most other clinic staff. (5) The doctor focus in clinic culture created a catch-22 dilemma-the involvement and noninvolvement of physicians were both problematic.

CONCLUSION

Problems in both predisposing and enabling factors accounted for the ultimate failure of the DIAMOND quality improvement effort.

The PHQ-9: validity of a brief depression severity measure

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.

A theory of online social support

The ever-increasing accessibility of online services has hastened the development of persons seeking online health care information and support. These online settings are providing new ways to assist patients and nurses in gaining support with life, health, and professional situations. A theory of online social support (OSS) was developed to assist in the holistic conceptualization of online social support, linking cyberspace phenomena with traditional quantitative and qualitative methods of description, and provide a basis for further theory and related research. The article describes influences on the development of the theory, outlines focal concepts and definitions, and reviews components of the theory and their interrelationships.

Resolving disparities in antidepressant treatment and quality-of-life outcomes between uninsured and insured primary care patients with depression

BACKGROUND

Efforts to improve primary care depression treatment should penetrate to vulnerable uninsured populations.

OBJECTIVE

To assess a primary care intervention's impact on treatment and quality-of-life outcomes in uninsured and insured depressed patients during the acute treatment phase.

RESEARCH DESIGN

Twelve community primary care practices were randomized to 'enhanced' (intervention) and usual care conditions. Physicians, nurses and administrative staff in enhanced care practices received training to improve detection and management of depression.

SUBJECTS

In 1996 to 1997, 383 nonelderly depressed patients who were either uninsured or covered by private insurance/Medicaid were enrolled; 343 (89.6%) completed six-month follow-up.

MEASURES

Adequate pharmacotherapy (>or=3 months of antidepressants at therapeutic doses); adequate psychotherapy (>or=8 counseling visits); improvement in mental-health-related-quality-of-life (MHQOL), assessed by Mental Component Summary scale for SF-36.

RESULTS

Multivariate results showed that 54.6% of uninsured enhanced care (UEC) patients received adequate pharmacotherapy, compared with 14.3% of uninsured usual care (UUC) patients (P = 0.0005); however, receipt of adequate psychotherapy was comparable between these two groups (18.2% UEC, 11.9% UUC; P = 0.42). Intervention effects on insured patients' treatment were modest to minimal. Among usual care patients, the insured had 5.4 points greater improvement in MHQOL at 6 months than the uninsured (12.4 points insured, 7.0 points uninsured; P = 0.02); however, among patients receiving the intervention, the insured and uninsured had comparable MHQOL improvement (12.3 points insured, 11.6 points uninsured; P = 0.76).

CONCLUSIONS

The intervention improved antidepressant treatment rates in uninsured patients and helped resolve quality-of-life outcome disparities observed between insured and uninsured patients receiving usual care.

The PHQ-9: validity of a brief depression severity measure

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.

The PHQ-9: validity of a brief depression severity measure

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.

The Quality Improvement for Depression collaboration: general analytic strategies for a coordinated study of quality improvement in depression care

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.

Does physician education on depression management improve treatment in primary care?

OBJECTIVE

To assess the effect of physician training on management of depression.

DESIGN

Primary care physicians were randomly assigned to a depression management intervention that included an educational program. A before-and-after design evaluated physician practices for patients not enrolled in the intervention trial.

SETTING

One hundred nine primary care physicians in 2 health maintenance organizations located in the Midwest and Northwest regions of the United States.

PATIENTS/PARTICIPANTS

Computerized pharmacy and visit data from a group of 124,893 patients who received visits or prescriptions from intervention and usual care physicians.

INTERVENTIONS

Primary care physicians received education on diagnosis and optimal management of depression over a 3-month training period. Methods of education included small group interactive discussions, expert demonstrations, role-play, and academic detailing of pharmacotherapy, criteria for urgent psychiatric referrals, and case reviews with psychiatric consultants.

MEASUREMENTS AND MAIN RESULTS

Pharmacy and visit data provided indicators of physician management of depression: rate of newly diagnosed depression, new prescription of antidepressant medication, and duration of pharmacotherapy. One year after the training period, intervention and usual care physicians did not differ significantly in the rate of new depression diagnosis (P =.95) or new prescription of antidepressant medicines (P =.10). Meanwhile, patients of intervention physicians did not differ from patients of usual care physicians in adequacy of pharmacotherapy (P =.53) as measured by 12 weeks of continuous antidepressant treatment.

CONCLUSIONS

After education on optimal management of depression, intervention physicians did not differ from their usual care colleagues in depression diagnosis or pharmacotherapy.

Improving primary care for depression in late life: the design of a multicenter randomized trial

BACKGROUND

Late life depression can be successfully treated with antidepressant medications or psychotherapy, but few depressed older adults receive effective treatment.

RESEARCH DESIGN

A randomized controlled trial of a disease management program for late life depression.

SUBJECTS

Approximately 1,750 older adults with major depression or dysthymia are recruited from seven national study sites.

INTERVENTION

Half of the subjects are randomly assigned to a collaborative care program where a depression clinical specialist supervised by a psychiatrist and a primary care expert supports the patient's regular primary care provider to treat depression. Intervention services are provided for 12 months using antidepressant medications and Problem Solving Treatment in Primary Care according to a stepped care protocol that varies intervention intensity according to clinical needs. The other half of the subjects are assigned to care as usual.

EVALUATION

Subjects are independently assessed at baseline, 3 months, 6 months, 12 months, 18 months, and 24 months. The evaluation assesses the incremental cost-effectiveness of the intervention compared with care as usual. Specific outcomes examined include care for depression, depressive symptoms, health-related quality of life, satisfaction with depression care, health care costs, patient time costs, market and nonmarket productivity, and household income.

CONCLUSIONS

The study blends methods from health services and clinical research in an effort to protect internal validity while maximizing the generalizability of results to diverse health care systems. We hope that this study will show the cost-effectiveness of a new model of care for late life depression that can be applied in a range of primary care settings.

Affective disorders in children and adolescents: addressing unmet need in primary care settings

Affective disorders are common among children and adolescents but may often remain untreated. Primary care providers could help fill this gap because most children have primary care. Yet rates of detection and treatment for mental disorders generally are low in general health settings, owing to multiple child and family, clinician, practice, and healthcare system factors. Potential solutions may involve 1) more systematic implementation of programs that offer coverage for uninsured children; 2) tougher parity laws that offer equity in defined benefits and application of managed care strategies across physical and mental disorders; and 3) widespread implementation of quality improvement programs within primary care settings that enhance specialty/primary care collaboration, support use of care managers to coordinate care, and provide clinician training in clinically and developmentally appropriate principles of care for affective disorders. Research is needed to support development of these solutions and evaluation of their impacts.

Rethinking practitioner roles in chronic illness: the specialist, primary care physician, and the practice nurse

In this article, we describe an evidence-based stepped care approach to improving the care of chronic illness in organized health care systems. We review the common principles that have been found to improve the management and outcomes of patients with major depression, asthma, diabetes, and congestive heart failure. These population-based methods to improve care of chronic illness require reorganizing the roles of specialists, primary care physicians, and nurses.

Improving depression outcomes in community primary care practice: a randomized trial of the quEST intervention. Quality Enhancement by Strategic Teaming

OBJECTIVE

To determine whether redefining primary care team roles would improve outcomes for patients beginning a new treatment episode for major depression.

DESIGN

Following stratification, 6 of 12 practices were randomly assigned to the intervention condition. Intervention effectiveness was evaluated by patient reports of 6-month change in 100-point depression symptom and functional status scales.

SETTING

Twelve community primary care practices across the country employing no onsite mental health professional.

PATIENTS

Using two-stage screening, practices enrolled 479 depressed adult patients (73.4% of those eligible); 90.2% completed six-month follow-up.

INTERVENTION

Two primary care physicians, one nurse, and one administrative staff member in each intervention practice received brief training to improve the detection and management of major depression.

MAIN RESULTS

In patients beginning a new treatment episode, the intervention improved depression symptoms by 8.2 points (95% confidence interval [CI], 0.2 to 16.1; P =.04). Within this group, the intervention improved depression symptoms by 16.2 points (95% CI, 4.5 to 27.9; P =.007), physical role functioning by 14.1 points (95% CI, 1.1 to 29.2; P =.07), and satisfaction with care (P =.02) for patients who reported antidepressant medication was an acceptable treatment at baseline. Patients already in treatment at enrollment did not benefit from the intervention.

CONCLUSIONS

In practices without onsite mental health professionals, brief interventions training primary care teams to assume redefined roles can significantly improve depression outcomes in patients beginning a new treatment episode. Such interventions should target patients who report that antidepressant medication is an acceptable treatment for their condition. More research is needed to determine how primary care teams can best sustain these redefined roles over time.

Predictors of outcome in a primary care depression trial

OBJECTIVE

Previous treatment trials have found that approximately one third of depressed patients have persistent symptoms. We examined whether depression severity, comorbid psychiatric illness, and personality factors might play a role in this lack of response.

DESIGN

Randomized trial of a stepped collaborative care intervention versus usual care.

SETTING

HMO in Seattle, Wash.

PATIENTS

Patients with major depression were stratified into severe (N = 149) and mild to moderate depression (N = 79) groups prior to randomization.

INTERVENTIONS

A multifaceted intervention targeting patient, physician, and process of care, using collaborative management by a psychiatrist and primary care physician.

MEASUREMENTS AND MAIN RESULTS

Patients with more severe depression had a higher risk for panic disorder (odds ratio [OR], 5.8), loneliness (OR, 2.6), and childhood emotional abuse (OR, 2.1). Among those with less severe depression, intervention patients showed significantly improved depression outcomes over time compared with those in usual care (z = -3.06, P<.002); however, this difference was not present in the more severely depressed groups (z = 0.61, NS). Although the group with severe depression showed differences between the intervention and control groups from baseline to 3 months that were similar to the group with less severe depression (during the acute phase of the intervention), these differences disappeared by 6 months.

CONCLUSIONS

Initial depression severity, comorbid panic disorder, and other psychosocial vulnerabilities were associated with a decreased response to the collaborative care intervention. Although the intervention was appropriate for patients with moderate depression, individuals with higher levels of depression may require a longer continuation phase of therapy in order to achieve optimal depression outcomes.