Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis

Teaching Collaborative Care in Primary Care Settings for Psychiatry Residents

BACKGROUND

Job descriptions for psychiatrists will change significantly over the next decade, as psychiatrists will be called on to work as caseload consultants to the primary care team.

OBJECTIVE

The purpose of this pilot study was to examine the effects of an American Association of Directors of Psychiatric Residency Training-approved collaborative care curriculum on caseload consulting skills among psychiatry residents.

METHODS

In 2014, 46 psychiatry residents (5 postgraduate year 1s, 10 postgraduate year 2s, 22 postgraduate year 3s, and 9 postgraduate year 4s) from 5 academic psychiatry residency programs in the New England area were given the 2-hour pilot collaborative care curriculum. Participants were asked to complete an anonymous survey at both the beginning and the end of the workshop to rate their comfort level in aspects of collaborative care psychiatry (7 items from SBP4 psychiatry milestones) based on a Likert scale (1-not at all, 2-slightly, 3-moderately, and 4-extremely). Paired t-test was used to examine the difference between pretest and posttest results of residents participating in the workshop.

RESULTS

The pretest mean score for the group was 2.9 (standard deviation = 0.44), whereas the posttest mean was 3.51 (standard deviation = 0.42), p < 0.0001. Only 15% (n = 7) of residents reported having some form of primary care or ambulatory specialty care consultation experience while in training.

CONCLUSION

This brief collaborative care curriculum significantly improved resident confidence in milestone criteria related to population health and case-based consultations.

Population-Level Quality Measures for Behavioral Screening and Intervention

Delivered routinely in general health care settings, smoking, alcohol, depression, and obesity screening and intervention (behavioral screening and intervention [BSI]) could substantially improve population health and reduce health care costs. Yet BSI is seldom delivered in an evidence-based manner. This article assesses the adequacy of quality measures for BSI. Online searches of the National Quality Forum's Quality Positioning System and the National Clearinghouse for Quality Measures databases were conducted using the keywords smoking, tobacco, alcohol, depression, and obesity The types and focuses of each measure were classified, and differences between the metrics and evidence-based practice were identified. Most measures indicate whether BSI components are delivered, not how well. Clinicians can perform well on most metrics without delivering evidence-based services. More rigorous quality measures are needed. A new kind of measure is proposed, whereby separate terms representing the reach and effectiveness of key BSI components are multiplied to produce a single indicator of population-level impact for each behavioral topic.

Diagnoses, intervention strategies, and rates of functional improvement in integrated behavioral health care patients

OBJECTIVE

Compared with more traditional mental health care, integrated behavioral health care (IBHC) offers greater access to services and earlier identification and intervention of behavioral and mental health difficulties. The current study examined demographic, diagnostic, and intervention factors that predict positive changes for IBHC patients.

METHOD

Participants were 1,150 consecutive patients (mean age = 30.10 years, 66.6% female, 60.1% Hispanic, 47.9% uninsured) seen for IBHC services at 2 primary care clinics over a 34-month period. Patients presented with depressive (23.2%), anxiety (18.6%), adjustment (11.3%), and childhood externalizing (7.6%) disorders, with 25.7% of patients receiving no diagnosis.

RESULTS

The most commonly delivered interventions included behavioral activation (26.1%), behavioral medicine-specific consultation (14.6%), relaxation training (10.3%), and parent-management training (8.5%). There was high concordance between diagnoses and evidence-based intervention selection. We used latent growth curve modeling to explore predictors of baseline global assessment of functioning (GAF) and improvements in GAF across sessions, utilizing data from a subset of 117 patients who attended at least 3 behavioral health visits. Hispanic ethnicity and being insured predicted higher baseline GAF, while patients with an anxiety disorder had lower baseline GAF than patients with other diagnoses. Controlling for primary diagnosis, patients receiving behavioral activation or exposure therapy improved at faster rates than patients receiving other interventions. Demographic variables did not relate to rates of improvement.

CONCLUSION

Results suggest even brief IBHC interventions can be focused, targeting specific patient concerns with evidence-based treatment components. (PsycINFO Database Record

Managing depression in people with multimorbidity: a qualitative evaluation of an integrated collaborative care model

BACKGROUND

Patients with comorbid depression and physical health problems have poorer outcomes compared with those with single long term conditions (LTCs), or multiple LTCs without depression. Primary care has traditionally struggled to provide integrated care for this group. Collaborative care can reduce depression in people with LTCs but evidence is largely based on trials conducted in the United States that adopted separate treat to target protocols for physical and mental health. Little is known about whether collaborative care that integrates depression care within the management of LTCs is implementable in UK primary care, and acceptable to patients and health care professionals.

METHODS

Nested interview study within the COINCIDE trial of collaborative care for patients with depression and diabetes/CHD (ISRCTN80309252). The study was conducted in primary care practices in North West England. Professionals delivering the interventions (nurses, GPs and psychological well-being practitioners) and patients in the intervention arm were invited to participate in semi-structured qualitative interviews.

RESULTS

Based on combined thematic analysis of 59 transcripts, we identified two major themes: 1) Integration: patients and professionals valued collaborative ways of working because it enhanced co-ordination of mental and physical health care and provided a sense that patients' health was being more holistically managed. 2) Division: patients and professionals articulated a preference for therapeutic and spatial separation between mental and physical health. Patients especially valued a separate space outside of their LTC clinic to discuss their emotional health problems.

CONCLUSION

The COINCIDE care model, that sought to integrate depression care within the context of LTC management, achieved service level integration but not therapeutic integration. Patients preferred a protected space to discuss mental health issues, and professionals maintained barriers around physical and mental health expertise. Findings therefore suggest that in the context of mental-physical multimorbidity, collaborative care can facilitate access to depression care in ways that overcome stigma and enhance the confidence of multidisciplinary health teams to work together. However, such care models need to be flexible and patient centred to accommodate the needs of patients for whom their depression may be independent of their LTC.

Screening for depression in the primary care population

Despite strong efforts, the diagnosis and treatment of depression bring many challenges in the primary care setting. Screening for depression has been shown to be effective only if reliable systems of care are in place to ensure appropriate treatment by clinicians and adherence by patients. New evidence-based models of care for depression exist, but spread has been slow because of inadequate funding structures and conflicts within current clinical culture. The Affordable Care Act introduces potential opportunities to reorganize funding structures, conceivably leading to increased adoption of these collaborative care models. Suicide screening remains controversial.

Reduction of patient-reported antidepressant side effects, by type of collaborative care

OBJECTIVE

Antidepressants are effective for treating depression, and collaborative care increases initiation of and adherence to antidepressants. Side effects of antidepressants are common and can adversely affect quality of life. Care managers address antidepressant side effects directly, but the impact of collaborative care on adverse effects is unknown. This secondary data analysis tested the hypothesis that patient-reported antidepressant side effects were lower for depressed patients receiving high-intensity, telemedicine-based collaborative care (TBCC) than for patients receiving low-intensity, practice-based collaborative care (PBCC).

METHODS

This analysis used data from 190 patients enrolled in a pragmatic, multisite, comparative-effectiveness trial from 2007 to 2009 and followed for 18 months. Most patients were female (83%) and Caucasian (80%). The mean age was 50. Patients randomly assigned to PBCC received 12 months of evidence-based care from an on-site primary care provider and nurse care manager. Patients in TBCC received evidence-based care from an on-site primary care provider supported by a nurse care manager available off site by telephone, as well as by a telepharmacist, telepsychologist, and telepsychiatrist. Telephone interviews completed at baseline, six, 12, and 18 months included assessments of sociodemographic characteristics, beliefs about antidepressant treatment, depression severity, psychiatric comorbidity, medications, adherence, and side effects.

RESULTS

With controls for baseline case mix and time-variant medication characteristics, the TBCC group reported significantly fewer side effects at six and 12 months (p=.008 and .002, respectively). The number of antidepressants prescribed increased risk of side effects (p=.02).

CONCLUSIONS

Patients in the TBCC group reported fewer antidepressant-related side effects, which may have contributed to improved quality of life.

Building a platform for translational research in chronic noncommunicable diseases to address population health: lessons from NHLBI supported CRONICAS in Peru

The CRONICAS Centre of Excellence in Chronic Diseases, based at Universidad Peruana Cayetano Heredia, was created in 2009 with support from the U.S. National Heart, Lung, and Blood Institute (NHLBI). The vision of CRONICAS is to build a globally recognized center of excellence conducting quality and innovative research and generating high-impact evidence for health. The center's identity is embedded in its core values: generosity, innovation, integrity, and quality. This review has been structured to describe the development of the CRONICAS Centre, with a focus on highlighting the ongoing translational research projects and capacity-building strategies. The CRONICAS Centre of Excellence is not a risk-averse organization: it benefits from past experiences, including past mistakes, and improves upon them and thus challenges traditional research approaches. This ethos and environment are key to fostering innovation in research.

Monitoring Client Progress and Feedback in School-Based Mental Health

Research in children's mental health has suggested that emotional and behavioral problems in are inextricably tied to academic difficulties. However, evidence-based programs implemented in school-based mental health tend to focus primarily on treatment practices, with less explicit emphasis on components of evidence-based assessment (EBA), such as progress monitoring and feedback. The current paper describes two studies that incorporated standardized assessment and progress monitoring/feedback into school-based mental health programs. Barriers to implementation are identified, recommendations for clinicians implementing EBA in the school setting are provided, and examples of mental health and academic indicators are discussed.

Seasonal variation in clinical remission of primary care patients with depression: impact of gender

RATIONALE, AIMS AND OBJECTIVES

The impact of seasonal variation on clinical remission in patients with depression has not been well studied. The hypothesis for this study was that the clinical remission rate would be lower in the winter comparing to the other seasons, specifically evaluated by gender.

METHODS

The study cohort comprised 2873 primary care patients with depression as a longitudinal retrospective chart review analysis. The sample was limited to patients who were continuing in care; dropouts were excluded from the analysis.

RESULTS

Multivariate logistic regression analysis of the independent variables for those participants who achieved clinical remission demonstrated that for the male patients, the season of diagnosis did not impact the rate of remission at 6 months while controlling for all other independent variables. For female patients, those that were diagnosed with depression in the fall had increased likelihood of 6-month remission compared with those patients diagnosed in the winter months (OR 1.300, CI 1.006-1.680, P=0.045) and the spring and summer patients were not significantly different in their outcome rates. When both genders were combined, the odds of remission at 6 months were not statistically significant for any season of diagnosis.

CONCLUSIONS

This study demonstrates that in patients who were continuing care, women who were diagnosed with major depression or dysthymia in the fall season have improved 6-month clinical outcome of remission compared with those women diagnosed in the winter, when controlling for demographic and clinical characteristics. This effect was not seen in men or when the genders were combined into a single cohort. The assessment of the seasonality effect on depression outcomes requires further long-term follow-up studies.

From concept to content: assessing the implementation fidelity of a chronic care model for frail, older people who live at home

Background

Implementation fidelity, the degree to which a care program is implemented as intended, can influence program impact. Since results of trials that aim to implement comprehensive care programs for frail, older people have been conflicting, assessing implementation fidelity alongside these trials is essential to differentiate between flaws inherent to the program and implementation issues. This study demonstrates how a theory-based assessment of fidelity can increase insight in the implementation process of a complex intervention in primary elderly care.

Methods

The Geriatric Care Model was implemented among 35 primary care practices in the Netherlands. During home visits, practice nurses conducted a comprehensive geriatric assessment and wrote a tailored care plan. Multidisciplinary team consultations were organized with the aim to enhance the coordination between professionals caring for a single patient with complex needs. To assess fidelity, we identified 5 key intervention components and formulated corresponding research questions using Carroll’s framework for fidelity. Adherence (coverage, frequency, duration, content) was assessed per intervention component during and at the end of the intervention period. Two moderating factors (participant responsiveness and facilitation strategies) were assessed at the end of the intervention.

Results

Adherence to the geriatric assessments and care plans was high, but decreased over time. Adherence to multidisciplinary consultations was initially poor, but increased over time. We found that individual differences in adherence between practice nurses and primary care physicians were moderate, while differences in participant responsiveness (satisfaction, involvement) were more distinct. Nurses deviated from protocol due to contextual factors and personal work routines.

Conclusions

Adherence to the Geriatric Care Model was high for most of the essential intervention components. Study limitations include the limited number of assessed moderating factors. We argue that a longitudinal investigation of adherence per intervention component is essential for a complete understanding of the implementation process, but that such investigations may be complicated by practical and methodological challenges.

Trial registration

The Netherlands National Trial Register (NTR). Trial number: 2160.

Clinical effectiveness of integrating depression care management into medicare home health: the Depression CAREPATH Randomized trial

IMPORTANCE

Among older home health care patients, depression is highly prevalent, is often inadequately treated, and contributes to hospitalization and other poor outcomes. Feasible and effective interventions are needed to reduce this burden of depression.

OBJECTIVE

To determine whether, among older Medicare Home Health recipients who screen positive for depression, patients of nurses receiving randomization to an intervention have greater improvement in depressive symptoms during 1 year than patients receiving enhanced usual care.

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized effectiveness trial conducted at 6 home health care agencies nationwide assigned nurse teams to an intervention (12 teams) or to enhanced usual care (9 teams). Between January 13, 2009, and December 6, 2012, Medicare Home Health patients 65 years and older who screened positive for depression on routine nursing assessments were recruited, underwent assessment, and were followed up at 3, 6, and 12 months by research staff blinded to intervention status. Patients were interviewed at home and by telephone. Of 502 eligible patients, 306 enrolled in the study.

INTERVENTIONS

The Depression Care for Patients at Home (Depression CAREPATH) trial requires nurses to manage depression at routine home visits by weekly symptom assessment, medication management, care coordination, education, and goal setting. Nurses' training totaled 7 hours (4 onsite and 3 via the web). Researchers telephoned intervention team supervisors every other week.

MAIN OUTCOMES AND MEASURES

Depression severity, assessed by the 24-item Hamilton Scale for Depression (HAM-D).

RESULTS

The 306 participants were predominantly female (69.6%), were racially/ethnically diverse (18.0% black and 16.0% Hispanic), and had a mean (SD) age of 76.5 (8.0) years. In the full sample, the intervention had no effect (P = .13 for intervention × time interaction). Adjusted HAM-D scores (Depression CAREPATH vs control) did not differ at 3 months (10.5 vs 11.4, P = .26) or at 6 months (9.3 vs 10.5, P = .12) but reached significance at 12 months (8.7 vs 10.6, P = .05). In the subsample with mild depression (HAM-D score, <10), the intervention had no effect (P = .90), and HAM-D scores did not differ at any follow-up points. Among 208 participants with a HAM-D score of 10 or higher, the Depression CAREPATH demonstrated effectiveness (P = .02), with lower HAM-D scores at 3 months (14.1 vs 16.1, P = .04), at 6 months (12.0 vs 14.7, P = .02), and at 12 months (11.8 vs 15.7, P = .005).

CONCLUSION AND RELEVANCE

Home health care nurses can effectively integrate depression care management into routine practice. However, the clinical benefit seems to be limited to patients with moderate to severe depression.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01979302.

Interprofessional Teamwork and Collaboration Between Community Health Workers and Healthcare Teams: An Integrative Review

OBJECTIVES

Community Health Workers (CHWs) serve as a means of improving outcomes for underserved populations. However, their relationship within health care teams is not well studied. The purpose of this integrative review was to examine published research reports that demonstrated positive health outcomes as a result of CHW intervention to identify interprofessional teamwork and collaboration between CHWs and health care teams.

METHODS

A total of 47 studies spanning 33 years were reviewed using an integrative literature review methodology for evidence to support the following assumptions of effective interprofessional teamwork between CHWs and health care teams: (1) shared understanding of roles, norms, values, and goals of the team; (2) egalitarianism; (3) cooperation; (4) interdependence; and(5) synergy.

RESULTS

Of the 47 studies, 12 reported at least one assumption of effective interprofessional teamwork. Four studies demonstrated all 5 assumptions of interprofessional teamwork.

CONCLUSIONS

Four studies identified in this integrative review serve as exemplars for effective interprofessional teamwork between CHWs and health care teams. Further study is needed to describe the nature of interprofessional teamwork and collaboration in relation to patient health outcomes.

Challenges to Standardizing the Care for Adult Cancer Survivors: Highlighting ASCO's Fatigue and Anxiety and Depression Guidelines

There are over 14 million survivors of cancer living in the United States alone and tens of millions more worldwide, with this population expected to nearly double in the next decade. The successes of prevention, early detection, and better therapies have lead to an emerging understanding of the substantial medical and psychosocial issues for this growing population that must be tackled for individuals and from the health care system and societal perspectives.

Models for treating depression in specialty medical settings: a narrative review

OBJECTIVE

This review answered two questions: (a) what types of specialty medical settings are implementing models for treating depression, and (b) do models for treating depression in specialty medical settings effectively treat depression symptoms?

METHOD

We searched Medline/Pubmed to identify articles, published between January 1990 and May 2013, reporting on models for treating depression in specialty medical settings. Included studies had to have adult participants with comorbid medical conditions recruited from outpatient, nonstandard primary care settings. Studies also had to report specific, validated depression measures.

RESULTS

Search methods identified nine studies (six randomized controlled trials, one nonrandomized controlled trial and two uncontrolled trials), all representing integrated care for depression, in three specialty settings (oncology, infectious disease, neurology). Most studies (N=7) reported greater reductions in depression among patients receiving integrated care compared to usual care, particularly in oncology clinics.

CONCLUSIONS

Integrated care for depression in specialty medical settings can improve depression outcomes. Additional research is needed to understand the effectiveness of incorporating behavioral and/or psychological treatments into existing methods. When developing or selecting a model for treating depression in specialty medical settings, clinicians and researchers will benefit from choosing specific components and measures most relevant to their target populations.

Helpful self-management strategies to cope with enduring depression from the patients' point of view: a concept map study

BACKGROUND

Despite the development of various self-management programmes that attempt to ameliorate symptoms of patients with chronic major depressive disorder (MDD), little is known about what these patients perceive as helpful in their struggle during daily live. The present study aims to explore what patients believe they can do themselves to cope with enduring MDD besides professional treatment, and which self-management strategies patients perceive as being most helpful to cope with their MDD.

METHODS

We used concept mapping, a method specifically designed for the conceptualisation of a specific subject, in this case patients' point of view (n = 25) on helpful self-management strategies in their coping with enduring MDD. A purposive sample of participants was invited at the Academic Medical Center and through requests on several MDD-patient websites in the Netherlands. Participants generated strategies in focus group discussions which were successively clustered on a two-dimensional concept map by hierarchical cluster analysis.

RESULTS

Fifty strategies were perceived as helpful. They were combined into three meta-clusters each comprising two clusters: A focus on the depression (sub clusters: Being aware that my depression needs active coping and Active coping with professional treatment); An active lifestyle (sub clusters: Active self-care, structure and planning and Free time activities) and Participation in everyday social life (sub clusters: Social engagement and Work-related activities).

CONCLUSIONS

MDD patients believe they can use various strategies to cope with enduring MDD in daily life. Although current developments in e-health occur, patients emphasise on face-to-face treatments and long-term relations, being engaged in social and working life, and involving their family, friends, colleagues and clinicians in their disease management. Our findings may help clinicians to improve their knowledge about what patients consider beneficial to cope with enduring MDD and to incorporate these suggested self-management strategies in their treatments.

What is integrated care?

Increasing awareness of mental illness's impact on medical and psychiatric health has accelerated global efforts to integrate medical and behavioural health services. As the field of integration has advanced, numerous integrated programmes have been implemented. In examining the impact of these programmes, it is important to maintain a standardized vocabulary to describe the various components of their integration. Additionally important is examination of how these programmes impact elements of patient care and the healthcare system. Specifically, what value do they bring? This article will discuss the importance of carefully assessing the value integrated services bring to patients, and questioning whether they do so in ways in which today's segregated world of medical and behavioural health cannot. This article will also explore the various settings in which medical and behavioural integration can bring added value.

Collaborative care versus screening and follow-up for patients with diabetes and depressive symptoms: results of a primary care-based comparative effectiveness trial

OBJECTIVE

Depressive symptoms are common and, when coexisting with diabetes, worsen outcomes and increase health care costs. We evaluated a nurse case-manager-based collaborative primary care team model to improve depressive symptoms in diabetic patients.

RESEARCH DESIGN AND METHODS

We conducted a controlled implementation trial in four nonmetropolitan primary care networks. Eligible patients had type 2 diabetes and screened positive for depressive symptoms, based on a Patient Health Questionnaire (PHQ) score of ≥10. Patients were allocated using an "on-off" monthly time series. Intervention consisted of case-managers working 1:1 with patients to deliver individualized care. The main outcome was improvement in PHQ scores at 12 months. A concurrent cohort of 71 comparable patients was used as nonscreened usual care control subjects.

RESULTS

Of 1,924 patients screened, 476 (25%) had a PHQ score >10. Of these, 95 were allocated to intervention and 62 to active control. There were no baseline differences between groups: mean age was 57.8 years, 55% were women, and the mean PHQ score was 14.5 (SD 3.7). Intervention patients had greater 12-month improvements in PHQ (7.3 [SD 5.6]) compared with active-control subjects (5.2 [SD 5.7], P = 0.015). Recovery of depressive symptoms (i.e., PHQ reduced by 50%) was greater among intervention patients (61% vs. 44%, P = 0.03). Compared with trial patients, nonscreened control subjects had significantly less improvement at 12 months in the PHQ score (3.2 [SD 4.9]) and lower rates of recovery (24%, P < 0.05 for both).

CONCLUSIONS

In patients with type 2 diabetes who screened positive for depressive symptoms, collaborative care improved depressive symptoms, but physician notification and follow-up was also a clinically effective initial strategy compared with usual care.

Integrated management of major depression for people with cancer

Major depression is an important complication of cancer. However, it is frequently inadequately treated. There are challenges both in identifying which cancer patients are depressed, and in ensuring that these patients receive effective treatment for their depression. Integration of depression management into cancer care has been advocated as a way to address these challenges. Such integrated approaches must include both the systematic identification of cases and the delivery of treatment. We describe here a system of depression care that includes both a screening programme to identify patients with depression and a linked treatment programme, based on the collaborative care model, called 'Depression Care for People with Cancer' (DCPC). The system of care was designed to be fully integrated with specialist cancer services and has been robustly evaluated in randomized trials. We describe how the system operates and explain why it is designed as it is. We also summarize the evidence for its effectiveness and cost-effectiveness and discuss its implementation in routine clinical practice.

Implementation of a collaborative care model for the treatment of depression and anxiety in a community health center: results from a qualitative case study

BACKGROUND

The collaborative care model is a systematic approach to the treatment of depression and anxiety in primary care settings that involves the integration of care managers and consultant psychiatrists, with primary care physician oversight, to more proactively manage mental disorders as chronic diseases, rather than treating acute symptoms. While collaborative care has been shown to be more effective than usual primary care in improving depression outcomes in a number of studies, less is known about the factors that support the translation of this evidence-based intervention to real-world program implementation. The purpose of this case study was to examine the implementation of a collaborative care model in a community based primary care clinic that primarily serves a low-income, uninsured Latino population, in order to better understand the interdisciplinary relationships and the specific elements that might facilitate broader implementation.

METHODS

An embedded single-case study design was chosen in order to thoroughly examine the components of one of several programs within a single organization. The main unit of analysis was semi-structured interviews that were conducted with seven clinical and administrative staff members. A grounded theory approach was used to analyze the interviews. Line-by-line initial coding resulted in over 150 initial codes, which were clustered together to rebuild the data into preliminary categories and then divided into four final categories, or main themes.

RESULTS

FOUR UNIQUE THEMES ABOUT HOW THE IMPLEMENTATION OF A COLLABORATIVE CARE MODEL WORKED IN THIS SETTING EMERGED FROM THE INTERVIEWS: organizational change, communication, processes and outcomes of the program, and barriers to implementation. Each main theme had a number of subthemes that provided a detailed description of the implementation process and how it was unique in this setting.

CONCLUSION

The results indicated that adequate training and preparation, acceptance and support from key personnel, communication barriers, tools for systematic follow-up and measurement, and organizational stability can significantly impact successful implementation. Further research is necessary to understand how organizational challenges may affect outcomes for patients.

Long-term effects of a collaborative care intervention on process of care in family practices in Germany: a 24-month follow-up study of a cluster randomized controlled trial

OBJECTIVE

The aims of this study were (1) to assess the long-term effects of a collaborative care intervention for patients with depression on process of care outcomes, and (2) to describe whether case management was continued after the end of the original one-year intervention.

METHODS

This 24-month follow-up of a randomized controlled trial took place 12 months after the end of the 1-year intervention. Data collection occurred by means of self-rating questionnaires and from medical records. We calculated linear mixed and logistic generalized estimating equation models.

RESULTS

Of the 626 patients included at baseline, 439 (70.1%) participated in this follow-up. Intervention recipients gave higher ratings than control recipients in terms of mean overall Patient Assessment of Chronic Illness Care (PACIC) scores (3.12 vs. 2.86; P = .019), but no difference was found in medication adherence (mean Morisky score 2.59 vs. 2.65, P = .56), prescribed antidepressant medications (60.2% vs. 55.1%; P = .25), visits to the family physician (15.96 vs. 14.46, P = .58) or mental health specialist (3.01 vs. 2.94, P = .94) over the 12 month follow-up period. Case management was continued for 47 (22.5%) selected intervention patients after the original intervention had ended.

CONCLUSION

At 24 months, intervention and control recipients had different PACIC ratings, but other process of care outcomes did not differ.

PRACTICE IMPLICATIONS

The main effects of the intervention are apparent at 12 months.

Collaborative care for depression in European countries: a systematic review and meta-analysis

OBJECTIVES

This is a systematic review and meta-analysis of randomized controlled trials (RCTs) investigating the effectiveness of collaborative care compared to Primary Care Physician's (PCP's) usual care in the treatment of depression, focusing on European countries.

METHODS

A systematic review of English and non-English articles, from inception to March 2014, was performed using database PubMed, British Nursing Index and Archive, Ovid Medline (R), PsychINFO, Books@Ovid, PsycARTICLES Full Text, EMBASE Classic+Embase, DARE (Database of Abstract of Reviews of Effectiveness) and the Cochrane Library electronic database. Search term included depression, collaborative care, physician family and allied health professional. RCTs comparing collaborative care to usual care for depression in primary care were included. Titles and abstracts were independently examined by two reviewers, who extracted from the included trials information on participants' characteristics, type of intervention, features of collaborative care and type of outcome measure.

RESULTS

The 17 papers included, regarding 15 RCTs, involved 3240 participants. Primary analyses showed that collaborative care models were associated with greater improvement in depression outcomes in the short term, within 3 months (standardized mean difference (SMD) -0.19, 95% CI=-0.33; -0.05; p=0.006), medium term, between 4 and 11 months (SMD -0.24, 95% CI=-0.39; -0.09; p=0.001) and medium-long term, from 12 months and over (SMD -0.21, 95% CI=-0.37; -0.04; p=0.01), compared to usual care.

CONCLUSIONS

The present review, specifically focusing on European countries, shows that collaborative care is more effective than treatment as usual in improving depression outcomes.

[Collaborative and home based treatment for older adults with depression: a review of the literature]

BACKGROUND

Due to the demographic development depressive disorders in old age are becoming a central and urgent healthcare challenge.

OBJECTIVES

The article reviews effective approaches towards treatment of depression in the elderly.

METHODS

A literature review of complex interventions improving depression care was carried out.

RESULTS

Robust evidence exists for the use of collaborative care models which incorporate collaboration between mental health and medical providers in the primary care setting (e.g. general practitioners and specialists), regular monitoring, case management, and evidence-based treatment. Staged treatment approaches seem to be appropriate by which initially use treatment strategies of low intensity. For patients with limited mobility, home-based approaches have proven to be particularly practical and effective.

CONCLUSION

Multidisciplinary and multimodal treatment approaches represent an effective and efficient way of healthcare provision for late life depression. In Germany, only few initiatives inspired by successful international models have so far been identified.

Primary care: proposed solutions to the physician shortage without training more physicians

The adult primary care "physician shortage" is more accurately portrayed as a gap between the adult population's demand for primary care services and the capacity of primary care, as currently delivered, to meet that demand. Given current trends, producing more adult primary care clinicians will not close the demand-capacity gap. However, primary care capacity can be greatly increased without many more clinicians: by empowering licensed personnel, including registered nurses and pharmacists, to provide more care; by creating standing orders for nonlicensed health personnel, such as medical assistants, to function as panel managers and health coaches to address many preventive and chronic care needs; by increasing the potential for more patient self-care; and by harnessing technology to add capacity.

Aligning health information technologies with effective service delivery models to improve chronic disease care

OBJECTIVE

Healthcare reforms in the United States, including the Affordable Care and HITECH Acts, and the NCQA criteria for the Patient Centered Medical Home have promoted health information technology (HIT) and the integration of general medical and mental health services. These developments, which aim to improve chronic disease care, have largely occurred in parallel, with little attention to the need for coordination. In this article, the fundamental connections between HIT and improvements in chronic disease management are explored. We use the evidence-based collaborative care model as an example, with attention to health literacy improvement for supporting patient engagement in care.

METHOD

A review of the literature was conducted to identify how HIT and collaborative care, an evidence-based model of chronic disease care, support each other.

RESULTS

Five key principles of effective collaborative care are outlined: care is patient-centered, evidence-based, measurement-based, population-based, and accountable. The potential role of HIT in implementing each principle is discussed. Key features of the mobile health paradigm are described, including how they can extend evidence-based treatment beyond traditional clinical settings.

CONCLUSION

HIT, and particularly mobile health, can enhance collaborative care interventions, and thus improve the health of individuals and populations when deployed in integrated delivery systems.

Persistence in the long term of the effects of a collaborative care programme for depression in primary care

BACKGROUND

A collaborative care programme for depression in primary care has proven clinical effectiveness over a 12-months period. Because depression tends to relapse and to chronic course, our aim was to determine whether the effectiveness observed in the first year persists during 3 years of monitoring.

METHODS

Randomised controlled trial with twenty primary care centres were allocated to intervention group or usual care group. The intervention consisted of a collaborative care programme with clinical, educational and organisational procedures. Outcomes were monitored by a blinded interviewer at baseline, 12 and 36 months. Clinical outcomes were response to treatment and remission rates, depression severity and health-related quality of life.

TRIAL REGISTRATION

ISRCTN16384353.

RESULTS

A total of 338 adult patients with major depression (DSM-IV) were assessed at baseline. At 36 months, 137 patients in the intervention group and 97 in the control group were assessed (attrition 31%). The severity of depression (mean Patient Health Questionnaire-9 score) was 0.95 points lower in the intervention group [6.31 versus 7.25; p=0.324]. The treatment response rate was 5.6% higher in the intervention group than in the control group [66.4% versus 60.8%; p=0.379] and the remission rate was 9.2% higher [57.7% versus 48.5%; p=0.164]. No difference reached statistical significance.

LIMITATIONS

The number of patients lost (31%) before follow-up may have introduced a bias.

CONCLUSIONS

Clinical benefits shown in the first year were not maintained beyond: at 36 months the differences between the control group and the intervention group reduced in all the analysed variables.

Prioritizing research to reduce youth suicide and suicidal behavior

The goal of the National Action Alliance for Suicide Prevention is to reduce suicide and suicide attempts in the U.S. by 40% in the next decade. In this paper, a public health approach is applied to suicide prevention to illustrate how reductions in youth suicide and suicidal behavior might be achieved by prioritizing research in two areas: (1) increasing access to primary care-based behavioral health interventions for depressed youth and (2) improving continuity of care for youth who present to emergency departments after a suicide attempt. Finally, some scientific, clinical, and methodologic breakthroughs needed to achieve rapid, substantial, and sustained reductions in youth suicide and suicidal behavior are discussed.

Teaching psychiatry residents to work at the interface of mental health and primary care

The authors present examples of programs educating psychiatry residents to work in integrated healthcare settings.

Bipolar disorder in primary care: clinical characteristics of 740 primary care patients with bipolar disorder

OBJECTIVE

This study aimed to describe the characteristics of primary care patients with bipolar disorder enrolled in a statewide mental health integration program (MHIP).

METHODS

With the Composite International Diagnostic Interview (Version 3.0) and clinician diagnosis, 740 primary care patients with bipolar disorder were identified in Washington State between January 2008 and December 2011. Clinical rating scales were administered to patients at the time of enrollment and during treatment. Quality-of-care outcomes were obtained from a systematic review of the patient disease registry and compared with a previous study of patients with depressive symptoms in an MHIP. Descriptive analysis techniques were used to describe patients' clinical characteristics.

RESULTS

Primary care patients with bipolar disorder had high symptom severity on depression and anxiety measures: Patient Health Questionaire-9 (mean±SD score of 18.1±5.9 out of 27) and the seven-item Generalized Anxiety Disorder scale (15.7±4.7 out of 21). Psychosocial problems were common, with approximately 53% reporting concerns about housing, 15% reporting homelessness, and 22% reporting lack of a support person. Only 26% of patients were referred to specialty mental health treatment. Patients with bipolar disorder had a greater amount of contact with clinicians during treatment compared with patients with depressive symptoms from a prior study.

CONCLUSIONS

Primary care patients with bipolar disorder enrolled in MHIP had severe depression, symptoms of comorbid psychiatric illnesses, and multiple psychosocial problems. Patients with bipolar disorder received more intensive care compared with patients with depressive symptoms from a prior study. Referral to a community mental health center occurred infrequently even though most patients had persistent symptoms.

Screening, assessment, and care of anxiety and depressive symptoms in adults with cancer: an American Society of Clinical Oncology guideline adaptation

PURPOSE

A Pan-Canadian Practice Guideline on Screening, Assessment, and Care of Psychosocial Distress (Depression, Anxiety) in Adults With Cancer was identified for adaptation.

METHODS

American Society of Clinical Oncology (ASCO) has a policy and set of procedures for adapting clinical practice guidelines developed by other organizations. The guideline was reviewed for developmental rigor and content applicability.

RESULTS

On the basis of content review of the pan-Canadian guideline, the ASCO panel agreed that, in general, the recommendations were clear, thorough, based on the most relevant scientific evidence, and presented options that will be acceptable to patients. However, for some topics addressed in the pan-Canadian guideline, the ASCO panel formulated a set of adapted recommendations based on local context and practice beliefs of the ad hoc panel members. It is recommended that all patients with cancer be evaluated for symptoms of depression and anxiety at periodic times across the trajectory of care. Assessment should be performed using validated, published measures and procedures. Depending on levels of symptoms and supplementary information, differing treatment pathways are recommended. Failure to identify and treat anxiety and depression increases the risk for poor quality of life and potential disease-related morbidity and mortality. This guideline adaptation is part of a larger survivorship guideline series.

CONCLUSION

Although clinicians may not be able to prevent some of the chronic or late medical effects of cancer, they have a vital role in mitigating the negative emotional and behavioral sequelae. Recognizing and treating effectively those who manifest symptoms of anxiety or depression will reduce the human cost of cancer.

Primary care practice characteristics associated with the quality of care received by patients with depression and comorbid chronic conditions

OBJECTIVE

This study aimed to identify primary care practice characteristics associated with the quality of depression care in patients with comorbid chronic medical and/or psychiatric conditions.

METHOD

Using data from cross-sectional organizational and patient surveys conducted within 61 primary care clinics in Quebec, Canada, the relationships between primary care practice characteristics, comorbidity profile, and the recognition and minimally adequate treatment of depression were assessed using multilevel logistic regression analysis with 824 adults with past-year depression and comorbid chronic conditions.

RESULTS

Likelihood of depression recognition was higher in clinics where accessibility of mental health professionals was not viewed to be a major barrier to depression care [odds ratio (OR)=1.61; 95% confidence interval (CI) 1.13-2.30]. Four practice characteristics were associated with minimal treatment adequacy: greater use of treatment algorithms for depression (OR=1.77; 95% CI=1.18-2.65), high value given to teamwork (OR=2.48; 95% CI=1.40-4.38), having at least one general practitioner at the clinic devote significant time in practice to mental health (OR=1.54; 95% CI=1.07-2.21) and low perceived barriers to depression care due to inadequate payment models (OR=2.12; 95% CI=1.30-3.46).

CONCLUSIONS

Several primary care practice characteristics significantly influence the quality of care provided to patients with depression and comorbid chronic conditions and should be targeted in quality improvement efforts.

Facilitating professional liaison in collaborative care for depression in UK primary care; a qualitative study utilising normalisation process theory

Background

Collaborative care (CC) is an organisational framework which facilitates the delivery of a mental health intervention to patients by case managers in collaboration with more senior health professionals (supervisors and GPs), and is effective for the management of depression in primary care. However, there remains limited evidence on how to successfully implement this collaborative approach in UK primary care. This study aimed to explore to what extent CC impacts on professional working relationships, and if CC for depression could be implemented as routine in the primary care setting.

Methods

This qualitative study explored perspectives of the 6 case managers (CMs), 5 supervisors (trial research team members) and 15 general practitioners (GPs) from practices participating in a randomised controlled trial of CC for depression. Interviews were transcribed verbatim and data was analysed using a two-step approach using an initial thematic analysis, and a secondary analysis using the Normalisation Process Theory concepts of coherence, cognitive participation, collective action and reflexive monitoring with respect to the implementation of CC in primary care.

Results

Supervisors and CMs demonstrated coherence in their understanding of CC, and consequently reported good levels of cognitive participation and collective action regarding delivering and supervising the intervention. GPs interviewed showed limited understanding of the CC framework, and reported limited collaboration with CMs: barriers to collaboration were identified. All participants identified the potential or experienced benefits of a collaborative approach to depression management and were able to discuss ways in which collaboration can be facilitated.

Conclusion

Primary care professionals in this study valued the potential for collaboration, but GPs’ understanding of CC and organisational barriers hindered opportunities for communication. Further work is needed to address these organisational barriers in order to facilitate collaboration around individual patients with depression, including shared IT systems, facilitating opportunities for informal discussion and building in formal collaboration into the CC framework.

Trial registration

ISRCTN32829227 30/9/2008.

Screening for depression in the primary care population

Despite strong efforts, the diagnosis and treatment of depression bring many challenges in the primary care setting. Screening for depression has been shown to be effective only if reliable systems of care are in place to ensure appropriate treatment by clinicians and adherence by patients. New evidence-based models of care for depression exist, but spread has been slow because of inadequate funding structures and conflicts within current clinical culture. The Affordable Care Act introduces potential opportunities to reorganize funding structures, conceivably leading to increased adoption of these collaborative care models. Suicide screening remains controversial.

Stepped collaborative depression care: primary care results before and after implementation of a stepped collaborative depression programme

BACKGROUND

Numerous intensive research projects to assess the effects of stepped collaborative care (SCC) for depressed patients have been reported in primary care, yet it is unclear how SCC is sustained in usual care.

OBJECTIVE

To assess how SCC for depression is actually being used and how it performs in usual primary care by studying medical data that are routinely collected in family practice, outside the research setting.

METHODS

Retrospective before and after comparison of electronic medical records (EMR) regarding the implementation of an SCC depression programme in a large primary care organization from 2003 to 2012. Depression care parameters included prevalences, minimal interventions, Beck Depression Inventory-2 (BDI-2), antidepressants, referrals to psychologists and psychiatrists and primary health care consumption.

RESULTS

After programme implementation, differentiation between levels of depression severity increased, more patients were treated with minimal interventions and more patients were monitored with BDI-2. These effects occurred in both nonseverely and severely depressed patients, although they were larger for patients registered as nonseverely depressed. Antidepressant prescription rates and referral rates seemed not to have been influenced by the SCC programme. Health care consumption of the depressed patients increased significantly.

CONCLUSIONS

The depression care parameters changed to a different extent and at a different pace than after previous implementation initiatives. Future research should identify whether SCC uptake in primary care is best enhanced by intensive external guidance or by making care providers themselves responsible for the implementation. Analyses of EMR can be valuable in monitoring the implementation effects, especially after research projects are completed.

Cost-effectiveness analysis of a collaborative care programme for depression in primary care

BACKGROUND

Collaborative care programmes lead to better outcomes in the management of depression. A programme of this nature has demonstrated its effectiveness in primary care in Spain. Our objective was to evaluate the cost-effectiveness of this programme compared to usual care.

METHODS

A bottom-up cost-effectiveness analysis was conducted within a randomized controlled trial (2007-2010). The intervention consisted of a collaborative care programme with clinical, educational and organizational procedures. Outcomes were monitored over a 12 months period. Primary outcomes were incremental cost-effectiveness ratios (ICER): mean differences in costs divided by quality-adjusted life years (QALY) and mean differences in costs divided by depression-free days (DFD). Analyses were performed from a healthcare system perspective (considering healthcare costs) and from a society perspective (including healthcare costs plus loss of productivity costs).

RESULTS

Three hundred and thirty-eight adult patients with major depression were assessed at baseline. Only patients with complete data were included in the primary analysis (166 in the intervention group and 126 in the control group). From a healthcare perspective, the average incremental cost of the programme compared to usual care was €182.53 (p<0.001). Incremental effectiveness was 0.045 QALY (p=0.017) and 40.09 DFD (p=0.011). ICERs were €4,056/QALY and €4.55/DFD. These estimates and their uncertainty are graphically represented in the cost-effectiveness plane.

LIMITATIONS

The amount of 13.6% of patients with incomplete data may have introduced a bias. Available data about non-healthcare costs were limited, although they may represent most of the total cost of depression.

CONCLUSIONS

The intervention yields better outcomes than usual care with a modest increase in costs, resulting in favourable ICERs. This supports the recommendation for its implementation.

Physical activity patterns among U.S. adults with and without serious psychological distress

OBJECTIVE

A physically active lifestyle is recommended for overall health--both physical and mental. Serious psychological distress (SPD) is associated with adverse health behaviors. We compared patterns of physical activity (PA) among adults with and without SPD using current public health guidelines for PA and examined whether adults with SPD were physically active at recommended levels.

METHODS

We used data from the 2009 Behavioral Risk Factor Surveillance System (BRFSS) to assess SPD using the Kessler 6 (K6) scale of nonspecific psychological distress and PA categories based on the 2008 U.S. Department of Health and Human Services guidelines. Complete data were available for 78,886 adults in 16 states that used an optional BRFSS mental illness and stigma module containing the K6 scale. We performed multiple logistic regression analyses to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs).

RESULTS

The unadjusted prevalence of SPD was 3.9% (95% CI 3.6, 4.2), and the age-adjusted prevalence of SPD was 3.8% (95% CI 3.5, 4.1). After adjusting for age, sex, race/ethnicity, education, employment, body mass index, smoking status, and heavy drinking, adults with SPD were significantly less likely to be physically active at recommended levels than adults without SPD. PRs were attenuated but remained significant after further adjustment for limitations to PA.

CONCLUSION

Adults with SPD are less likely to meet current PA recommendations than adults without SPD, highlighting the need for targeted interventions.

Impact of symptom remission on outpatient visits in depressed primary care patients treated with collaborative care management and usual care

Depression symptoms contribute to significant morbidity and health care utilization. The aim of this study was to determine the impact of symptom improvement (to remission) on outpatient clinical visits by depressed primary care patients. This study was a retrospective chart review analysis of 1733 primary care patients enrolled into collaborative care management (CCM) or usual care (UC) with 6-month follow-up data. Baseline data (including demographic information, clinical diagnosis, and depression severity) and 6-month follow-up data (Patient Health Questionnaire scores and the number of outpatient visits utilized) were included in the data set. To control for individual patient complexity and pattern of usage, the number of outpatient visits for 6 months prior to enrollment also was measured as was the presence of medical comorbidities. Multiple logistic regression analysis demonstrated that clinical remission at 6 months was an independent predictor of outpatient visit outlier status (>8 visits) (odds ratio [OR] 0.609, confidence interval (CI) 0.460-0.805, P<0.01) when controlling for all other independent variables including enrollment into CCM or UC. The OR of those patients not in remission at 6 months having outpatient visit outlier status was the inverse of this at 1.643 (CI 1.243-2.173). The most predictive variable for determining increased outpatient visit counts after diagnosis of depression was increased outpatient visits prior to diagnosis (OR 4.892, CI 3.655-6.548, P<0.01). In primary care patients treated for depression, successful treatment to remission at 6 months decreased the likelihood of the patient having more than 8 visits during the 6 months after diagnosis.

Differences in specific depressive symptoms among community-dwelling middle-aged Japanese adults before and after a universal screening intervention

PURPOSE

This study investigated changes in depressive symptoms after the implementation of a universal screening for depression and subsequent care support.

METHODS

A cluster-randomized study design used 10 subdistricts (2,400 inhabitants aged 40-64 years) in northern Japan randomly assigned in a 2:3 ratio to intervention and control conditions. All 900 residents aged 40-64 in the intervention districts were invited to participate in a 2-year depressive screening program, with a participation rate of 49.2%. A 4-year ongoing education program occurred in both intervention and control districts. The Center for Epidemiologic Studies Depression Scale (CES-D) was used to assess depressive symptomatology. Repeated cross-sectional samples were surveyed before (n = 1,516, response rate 63.6%) and after (n = 1,596, 66.4%) intervention, and the data, clustered according to district, were analyzed at the individual level using a mixed-effects model.

RESULTS

Significant changes in mean scores between baseline and 5-year follow-up in the intervention group were observed in the Depressive Affect, Somatic Symptoms, and Interpersonal Problems subscales. The difference between the changes over time in the two groups was significant for the three subscales and marginally for the CES-D total scale, but not for the Positive Affect subscale.

CONCLUSIONS

Universal depression screening and subsequent support can be effective in preventing general depressive symptoms, but may not influence psychological well-being, among middle-aged adults in a community setting.

Practice nurse involvement in primary care depression management: an observational cost-effectiveness analysis

Background

Most evidence on the effect of collaborative care for depression is derived in the selective environment of randomised controlled trials. In collaborative care, practice nurses may act as case managers. The Primary Care Services Improvement Project (PCSIP) aimed to assess the cost-effectiveness of alternative models of practice nurse involvement in a real world Australian setting. Previous analyses have demonstrated the value of high level practice nurse involvement in the management of diabetes and obesity. This paper reports on their value in the management of depression.

Methods

General practices were assigned to a low or high model of care based on observed levels of practice nurse involvement in clinical-based activities for the management of depression (i.e. percentage of depression patients seen, percentage of consultation time spent on clinical-based activities). Linked, routinely collected data was used to determine patient level depression outcomes (proportion of depression-free days) and health service usage costs. Standardised depression assessment tools were not routinely used, therefore a classification framework to determine the patient’s depressive state was developed using proxy measures (e.g. symptoms, medications, referrals, hospitalisations and suicide attempts). Regression analyses of costs and depression outcomes were conducted, using propensity weighting to control for potential confounders.

Results

Capacity to determine depressive state using the classification framework was dependent upon the level of detail provided in medical records. While antidepressant medication prescriptions were a strong indicator of depressive state, they could not be relied upon as the sole measure. Propensity score weighted analyses of total depression-related costs and depression outcomes, found that the high level model of care cost more (95% CI: -$314.76 to $584) and resulted in 5% less depression-free days (95% CI: -0.15 to 0.05), compared to the low level model. However, this result was highly uncertain, as shown by the confidence intervals.

Conclusions

Classification of patients’ depressive state was feasible, but time consuming, using the classification framework proposed. Further validation of the framework is required. Unlike the analyses of diabetes and obesity management, no significant differences in the proportion of depression-free days or health service costs were found between the alternative levels of practice nurse involvement.

Trends in smoking among adults with mental illness and association between mental health treatment and smoking cessation

IMPORTANCE

Significant progress has been made in reducing the prevalence of tobacco use in the United States. However, tobacco cessation efforts have focused on the general population rather than individuals with mental illness, who demonstrate greater rates of tobacco use and nicotine dependence.

OBJECTIVES

To assess whether declines in tobacco use have been realized among individuals with mental illness and examine the association between mental health treatment and smoking cessation.

DESIGN, SETTING, AND PARTICIPANTS

Use of nationally representative surveys of noninstitutionalized US residents to compare trends in smoking rates between adults with and without mental illness and across multiple disorders (2004-2011 Medical Expenditure Panel Survey [MEPS]) and to compare rates of smoking cessation among adults with mental illness who did and did not receive mental health treatment (2009-2011 National Survey of Drug Use and Health [NSDUH]).The MEPS sample included 32,156 respondents with mental illness (operationalized as reporting severe psychological distress, probable depression, or receiving treatment for mental illness) and 133,113 without mental illness. The NSDUH sample included 14,057 lifetime smokers with mental illness.

MAIN OUTCOMES AND MEASURES

Current smoking status (primary analysis; MEPS sample) and smoking cessation, operationalized as a lifetime smoker who did not smoke in the last 30 days (secondary analysis; NSDUH sample).

RESULTS

Adjusted smoking rates declined significantly among individuals without mental illness (19.2% [95% CI, 18.7-19.7%] to 16.5% [95% CI, 16.0%-17.0%]; P < .001) but changed only slightly among those with mental illness (25.3% [95% CI, 24.2%-26.3%] to 24.9% [95% CI, 23.8%- 26.0%]; P = .50), a significant difference in difference of 2.3% (95% CI, 0.7%-3.9%) (P = .005). Individuals with mental illness who received mental health treatment within the previous year were more likely to have quit smoking (37.2% [95% CI, 35.1%-39.4%]) than those not receiving treatment (33.1% [95% CI, 31.5%-34.7%]) (P = .005).

CONCLUSIONS AND RELEVANCE

Between 2004 and 2011, the decline in smoking among individuals with mental illness was significantly less than among those without mental illness, although quit rates were greater among those receiving mental health treatment. This suggests that tobacco control policies and cessation interventions targeting the general population have not worked as effectively for persons with mental illness.

Enhanced patient support services improve patient persistence with multiple sclerosis treatment

BACKGROUND

Subcutaneous interferon beta-1a (sc IFN β-1a) therapy (44 µg or 22 µg, three times weekly) improves relapse rates and disability progression in patients with relapsing multiple sclerosis (MS). While early treatment with disease-modifying drugs may maximize therapeutic benefit, patients with low adherence or long treatment gaps are at increased risk of relapse. MySupport is an industry-sponsored program that provides support to patients with MS who have been prescribed sc IFN β-1a in the UK or Republic of Ireland (ROI), via telephone and text messaging, website access, and (in some cases) face-to-face support from a dedicated MySupport Nurse. The aim of this audit was to assess if the MySupport program in the ROI could improve persistence to sc IFN β-1a therapy.

METHODS

Anonymized data were supplied retrospectively from the MySupport program, for ROI patients who were registered in January 2010 to receive sc IFN β-1a three times weekly. Patients were recorded as "new" at their first drug delivery; "active", if they continued to receive scheduled deliveries; "interrupted", if their medication delivery was halted; or "stopped", if no deliveries were made for 12 months. The number of "active" patients was recorded monthly for 24 months. Results were compared with data from UK patients with MS, who were receiving National Health Service (NHS) support only, or this support plus MySupport.

RESULTS

A greater proportion of ROI patients receiving MySupport (compared against UK patients receiving NHS support only) were on treatment at 12 months (87.8% versus 79.3%) and at 24 months (76.2% versus 61.8%). The odds of being on treatment were significantly greater, at all time points, for ROI patients receiving MySupport, versus UK patients receiving NHS support only (P<0.0001).

CONCLUSION

A personalized support program, utilizing one-to-one nursing support and additional support materials, can increase the probability of patients with MS remaining on disease-modifying drug treatment.