Population-based care of depression: effective disease management strategies to decrease prevalence

A Randomized Control Trial of a Digital Health Tool for Safer Firearm and Medication Storage for Patients with Suicide Risk

Most patients with suicide risk do not receive recommendations to reduce access to lethal means due to a variety of barriers (e.g., lack of provider time, training). Determine if highly efficient population-based EHR messaging to visit the Lock to Live (L2L) decision aid impacts patient-reported storage behaviors. Randomized trial. Integrated health care system serving Denver, CO. Served by primary care or mental health specialty clinic in the 75-99.5th risk percentile on a suicide attempt or death prediction model. Lock to Live (L2L) is a web-based decision aid that incorporates patients' values into recommendations for safe storage of lethal means, including firearms and medications. Anonymous survey that determined readiness to change: pre-contemplative (do not believe in safe storage), contemplative (believe in safe storage but not doing it), preparation (planning storage changes) or action (safely storing). There were 21,131 patients randomized over a 6-month period with a 27% survey response rate. Many (44%) had access to a firearm, but most of these (81%) did not use any safe firearm storage behaviors. Intervention patients were more likely to be categorized as preparation or action compared to controls for firearm storage (OR = 1.30 (1.07-1.58)). When examining action alone, there were no group differences. There were no statistically significant differences for any medication storage behaviors. Selection bias in those who responded to survey. Efficiently sending an EHR invitation message to visit L2L encouraged patients with suicide risk to consider safer firearm storage practices, but a stronger intervention is needed to change storage behaviors. Future studies should evaluate whether combining EHR messaging with provider nudges (e.g., brief clinician counseling) changes storage behavior.ClinicalTrials.gov: NCT05288517.

Patients' perspectives on the quality of care of a new complex psycho-oncological care programme in Germany - external mixed methods evaluation results

BACKGROUND

Guideline-compliant provision of psycho-oncological (PO) care is still challenging in Germany. Hence, a new care programme, called integrated cross-sectoral psycho-oncology (isPO), was implemented to improve the integration of needs-oriented PO care. Quality of care (QoC) was externally evaluated from the patient's perspective. We aim to gain insight into patients' experiences with isPO and how their assessment affects relevant patient-reported outcomes (anxiety and depression, health status, and work ability).

METHODS

An explanatory, sequential mixed-methods design was applied. Patients were surveyed twice during their 1-year care trajectory: after 3 (T1) and 12 (T2) months. Data sets were matched using pseudonyms. Care documentation data, including sociodemographic characteristics and the primary outcome variable (anxiety and depression), were matched. In the survey, patients rated their satisfaction with respective isPO service providers and the programme in general (QoC). Health status (EORTC-QLQ-C30) and work ability (WAS) were measured. Descriptive analyses and t-tests for dependent samples were conducted to assess changes in outcome variables over time. Linear regression analyses were conducted to assess whether care satisfaction predicted outcome variables. Patients who completed their isPO care trajectory were asked to participate in semi-structured telephone interviews to share their experiences. Purposeful sampling was applied. All 23 interviews were audiotaped, transcribed, and analysed via content-structuring method.

RESULTS

Patients reported medium-to-high satisfaction with their isPO care. All patient-related outcomes significantly improved over time and QoC measures predicted those outcomes. Needs orientation (e.g., care intensity or mode of delivery) was perceived as essential for high QoC, and outpatient care with fixed contact persons as highly important for care continuity. Furthermore, patients identified programme optimisation needs, such as period of care or extension of care to relatives.

CONCLUSIONS

Patients assessed the isPO programme's QoC positively. They identified facilitators for QoC and optimisation needs. Therefore, data on QoC can function as an indicator for a programme's feasibility and maturity within care reality. As patients' care satisfaction positively influences important patient-related outcomes, it may be routinely considered for quality management. Based on patients' perspectives, isPO seems to be recommendable for routine psycho-oncological care in Germany, if ongoing programme optimisation within structured quality management is guaranteed.

TRIAL REGISTRATION

The study was registered in the German Clinical Trials Register (No. DRKS00015326) on 30.10.2018.

Personalized care planning and shared decision making in collaborative care programs for depression and anxiety disorders: A systematic review

BACKGROUND

Collaborative care is an evidence-based approach to improving outcomes for common mental disorders in primary care. Efforts are underway to broadly implement the collaborative care model, yet the extent to which this model promotes person-centered mental health care has been little studied. The aim of this study was to describe practices related to two patient and family engagement strategies-personalized care planning and shared decision making-within collaborative care programs for depression and anxiety disorders in primary care.

METHODS

We conducted an update of a 2012 Cochrane review, which involved searches in Cochrane CCDAN and CINAHL databases, complemented by additional database, trial registry, and cluster searches. We included programs evaluated in a clinical trials targeting adults or youth diagnosed with depressive or anxiety disorders, as well as sibling reports related to these trials. Pairs of reviewers working independently selected the studies and data extraction for engagement strategies was guided by a codebook. We used narrative synthesis to report on findings.

RESULTS

In total, 150 collaborative care programs were analyzed. The synthesis showed that personalized care planning or shared decision making were practiced in fewer than half of programs. Practices related to personalized care planning, and to a lesser extent shared decision making, involved multiple members of the collaborative care team, with care managers playing a pivotal role in supporting patient and family engagement. Opportunities for quality improvement were identified, including fostering greater patient involvement in collaborative goal setting and integrating training and decision aids to promote shared decision making.

CONCLUSION

This review suggests that personalized care planning and shared decision making could be more fully integrated within collaborative care programs for depression and anxiety disorders. Their absence in some programs is a missed opportunity to spread person-centered mental health practices in primary care.

Integrated, cross-sectoral psycho-oncology (isPO): a new form of care for newly diagnosed cancer patients in Germany

Background

The annual incidence of new cancer cases has been increasing worldwide for many years, and is likely to continue to rise. In Germany, the number of new cancer cases is expected to increase by 20% until 2030. Half of all cancer patients experience significant emotional and psychosocial distress along the continuum of their disease, treatment, and aftercare, and also as long-term survivors. Consequently, in many countries, psycho-oncological programs have been developed to address this added burden at both the individual and population level. These programs promote the active engagement of patients in their cancer therapy, aftercare and survivorship planning and aim to improve the patients' quality of life.

In Germany, the “new form of care isPO” (“nFC-isPO”; integrated, cross-sectoral psycho-oncology/integrierte, sektorenübergreifende Psycho-Onkologie) is currently being developed, implemented and evaluated. This approach strives to accomplish the goals devised in the National Cancer Plan by providing psycho-oncological care to all cancer patients according to their individual healthcare needs. The term “new form of care" is defined by the Innovation Fund (IF) of Germany's Federal Joint Committee as “a structured and legally binding cooperation between different professional groups and/or institutions in medical and non-medical care”.

The nFC-isPO is part of the isPO project funded by the IF. It is implemented in four local cancer centres and is currently undergoing a continuous quality improvement process. As part of the isPO project the nFC-isPO is being evaluated by an independent institution: the Institute for Medical Sociology, Health Services Research, and Rehabilitation Science (IMVR), University of Cologne, Germany.

The four-year isPO project was selected by the IF to be eligible for funding because it meets the requirements of the federal government's National Cancer Plan (NCP), in particular, the “further development of the oncological care structures and quality assurance" in the psycho-oncological domain. An independent evaluation is required by the IF to verify if the new form of care leads to an improvement in cross-sectoral care and to explore its potential for permanent integration into the German health care system.

Methods

The nFC-isPO consists of six components: a concept of care (C1), care pathways (C2), a psycho-oncological care network (C3), a care process organization plan (C4), an IT-supported documentation and assistance system (C5) and a quality management system (C6). The two components concept of care (C1) and care pathways (C2) represent the isPO clinical care program, according to which the individual cancer patients are offered psycho-oncological services within a period of 12 months after program enrolment following the diagnosis of cancer. The remaining components (C3-C6) represent the formal-administrative aspects of the nFC-isPO that are intended to meet the legally binding requirements of patient care in the German health care system. With the aim of systematic development of the nFC-isPO while at the same time enabling the external evaluators to examine its quality, effectiveness and efficiency under conditions of routine care, the project partners took into consideration approaches from translational psycho-oncology, practice-based health care research and program theory. In order to develop a structured, population-based isPO care program, reference was made to a specific program theory, to the stepped-care approach, and also to evidence-based guideline recommendations.

Results

The basic version, nFC-isPO, was created over the first year after the start of the isPO project in October 2017, and has since been subject to a continuous quality improvement process. In 2019, the nFC-isPO was implemented at four local psycho-oncological care networks in the federal state North Rhine-Westphalia, in Germany. The legal basis of the implementation is a contract for "special care" with the German statutory health insurance funds according to state law (§ 140a SCB V; Social Code Book V for the statutory health insurance funds). Besides the accompanying external evaluation by the IMVR, the nFC-isPO is subjected to quarterly internal and cross-network quality assurance and improvement measures (internal evaluation) in order to ensure continuous quality improvement process. These quality management measures are developed and tested in the isPO project and are to be retained in order to ensure the sustainability of the quality of nFC-isPO for later dissemination into the German health care system.

Discussion

Demands on quality, effectiveness and cost-effectiveness of in the German health care system are increasing, whereas financial resources are declining, especially for psychosocial services. At the same time, knowledge about evidence-based screening, assessment and intervention in cancer patients and about the provision of psychosocial oncological services is growing continuously. Due to the legal framework of the statutory health insurance in Germany, it has taken years to put sound psycho-oncological findings from research into practice. Ensuring the adequate and sustainable financing of a needs-oriented, psycho-oncological care approach for all newly diagnosed cancer patients, as required by the NCP, may still require many additional years. The aim of the isPO project is to develop a new form of psycho-oncological care for the individual and the population suffering from cancer, and to provide those responsible for German health policy with a sound basis for decision-making on the timely dissemination of psycho-oncological services in the German health care system.

Trial registration

The study was pre-registered at the German Clinical Trials Register (https://www.drks.de/DRKS00015326) under the following trial registration number: DRKS00015326; Date of registration: October 30, 2018.

Preventative Care in First Responder Mental Health: Focusing on Access and Utilization via Stepped Telehealth Care

First responders are at high risk for disorders that arise from repeat exposure to stress and trauma (Post Traumatic Stress Disorder, depression, and problematic alcohol use). Although mental health treatments are available, first responders often do not access them, anchored by barriers that include: lack of knowledge, stigma, negative experience with mental health providers, and time-based burdens. In this study, we designed an intervention to address these barriers, extending a Planned-Action framework. Step 1 involved self-report screening for four mental health risks (PTSD, depression, anxiety, and alcohol use risk), delivered to all personnel electronically, who were free to either consent and participate or opt-out. The detection of risk(s) in Step 1 led to scheduling a Step 2 telehealth appointment with a trained clinician. We report descriptive statistics for participation/attrition/utilization in Steps 1 and 2, rates of risk on four mental health variables, and rate of adherence to follow-up treatment recommendations. Step 1: In total, 53.3% of personnel [229 of 429 full-time employees (221 males; eight females; 95% White; 48% paramedic or Emergency Medical Technician; 25% captain; 19% engineer; 7% other)] initially opted-in by consenting and completing the brief remote screening survey. Among those who opted-in and completed (n = 229), 43% screened positive for one or more of the following mental health risks: PTSD (7.9%); depression (9.6%); anxiety (13.5%); alcohol use (36.7%). Step 2: A maximum of three attempts were made to schedule "at risk" individuals into Step 2 (n = 99). Among the 99 who demonstrated a need for mental health treatment (by screening positive for one or more risk), 56 (56.6%) engaged in the telehealth appointment. Of the 56 who participated in Step 2 clinical appointments, 38 were recommended for further intervention (16.6% of full-time personnel who participated). Among the 38 firefighters who were recommended to seek further mental health services, 29 were adherent/followed through (76.3% of those who received recommendations for further services). Taken together, evidence-based, culturally conscious, stepped care models delivered via the virtual/telehealth medium can promote access, utilization, and cost-effective mental health services for first responders. Implications are for informing larger, more rigorous dissemination and implementation efforts.

Depression Outcomes in Smokers and Nonsmokers: Comparison of Collaborative Care Management Versus Usual Care

Background: Depression is common in the primary care setting and tobacco use is more prevalent among individuals with depression. Recent research has linked smoking to poorer outcomes of depression treatment. We hypothesized that in adult primary care patients with the diagnosis of depression, current smoking would have a negative impact on clinical outcomes, regardless of treatment type (usual primary care [UC] vs collaborative care management [CCM]). Methods: A retrospective chart review study of 5155 adult primary care patients with depression in a primary care practice in southeast Minnesota was completed. Variables obtained included age, gender, marital status, race, smoking status, initial Patient Health Questionnaire-9 (PHQ-9), and 6-month PHQ-9. Clinical remission (CR) was defined as 6-month PHQ-9 <5. Persistent depressive symptoms (PDS) were defined as PHQ-9 ≥10 at 6 months. Treatment in both CCM and UC were compared. Results: Using intention to treat analysis, depressed smokers treated with CCM were 4.60 times as likely (95% CI 3.24-6.52, P < .001) to reach CR and were significantly less likely to have PDS at 6 months (adjusted odds ratio [AOR] 0.19, 95% CI 0.14-0.25, P < .001) compared with smokers in UC. After a 6-month follow-up, depressed smokers treated with CCM were 1.75 times as likely (95% CI 1.18-2.59, P = .006) to reach CR and were significantly less likely to have PDS (AOR 0.45, 95% CI 0.31-0.64, P < .001) compared with smokers in UC. Conclusions: CCM significantly improved depression outcomes for smokers at 6 months compared with UC. However, in the UC group, smoking outcomes were not statistically different at 6 months for either remission or PDS. Also, nonsmokers in CCM had the best clinical outcomes at 6 months in both achieving clinical remission and reduction of PDS when compared with smokers in UC as the reference group.

Study protocol for the COMET study: a cluster-randomised, prospective, parallel-group, superiority trial to compare the effectiveness of a collaborative and stepped care model versus treatment as usual in patients with mental disorders in primary care

INTRODUCTION

Mental healthcare is one of the biggest challenges for healthcare systems. Comorbidities between different mental disorders are common, and patients suffer from a high burden of disease. While the effectiveness of collaborative and stepped care models has been shown for single disorders, comorbid mental disorders have rarely been addressed in such care models. The aim of the present study is to evaluate the effectiveness of a collaborative and stepped care model for depressive, anxiety, somatoform and alcohol use disorders within a multiprofessional network compared with treatment as usual.

METHODS AND ANALYSIS

In a cluster-randomised, prospective, parallel-group superiority trial, n=570 patients will be recruited from primary care practices (n=19 practices per group). The intervention is a newly developed collaborative and stepped care model in which patients will be treated using treatment options of various intensities within an integrated network of outpatient general practitioners, psychiatrists, psychotherapists and inpatient institutions. It will be compared with treatment as usual with regard to effectiveness, cost-effectiveness and feasibility, with the primary outcome being a change in mental health-related quality of life from baseline to 6 months. Patients in both groups will undergo an assessment at baseline, 3, 6 and 12 months after study inclusion.

ETHICS AND DISSEMINATION

The study has been approved by the ethics committee of the Hamburg Medical Association (No. PV5595) and will be carried out in accordance with the principles of the Declaration of Helsinki. For dissemination, the results will be published in peer-reviewed journals and presented at conferences. Within the superordinate research project Hamburg Network for Health Services Research, the results will be communicated to relevant stakeholders in mental healthcare.

TRIAL REGISTRATION NUMBER

NCT03226743.

[Clinical trial of a stepped and collaborative care model for mental illnesses and comorbidities in the Hamburg Network for Health Services Research]

Healthcare for mental disorders is a big challenge for the German healthcare system. In cases of comorbid mental diseases, patients suffer from an especially high burden of disease. So far, innovative care models for collaborative and stepped care have only been investigated with respect to their effectiveness for single mental disorders.The project "Collaborative and Stepped Care in Mental Health by Overcoming Treatment Sector Barriers" (COMET), which is being carried out by the Hamburg Network for Health Services Research (HAM-NET) from 2017 until 2020, examines an innovative, guideline-based healthcare model for the improvement of healthcare for patients with mental illnesses and their potential comorbidities. In this article this new stepped and collaborative care model for patients in primary care that integrates general practitioners, psychiatrists, psychotherapists, and hospitals is presented. For the implementation and facilitation of the model, guideline-based treatment pathways, a tablet-based computer program for screening, diagnostic and guideline-based treatment recommendations, as well as a web-based transferal platform were developed.The results of this project on the effectiveness and efficacy of the model can help determine if the model can be implemented in routine healthcare. This could represent a major step towards more integrated and cross-sectoral healthcare for patients with mental illnesses.

Midday and nadir salivary cortisol appear superior to cortisol awakening response in burnout assessment and monitoring

Burnout and work-related stress symptoms of anxiety disorder and depression cause prolonged work absenteeism and early retirement. Hence, reliable identification of patients under risk and monitoring of treatment success is highly warranted. We aimed to evaluate stress-specific biomarkers in a population-based, “real-world” cohort (burnouts: n = 40, healthy controls: n = 26), recruited at a preventive care ward, at baseline and after a four-month follow up, during which patients received medical and psychological treatment. At baseline, significantly higher levels of salivary cortisol were observed in the burnout group compared to the control group. This was even more pronounced in midday- (p < 0.001) and nadir samples (p < 0.001) than for total morning cortisol secretion (p < 0.01). The treatment program resulted in a significant reduction of stress, anxiety, and depression scores (all p < 0.001), with 60% of patients showing a clinically relevant improvement. This was accompanied by a ~30% drop in midday cortisol levels (p < 0.001), as well as a ~25% decrease in cortisol nadir (p < 0.05), although not directly correlating with score declines. Our data emphasize the potential usefulness of midday and nadir salivary cortisol as markers in the assessment and biomonitoring of burnout.

An innovative model to coordinate healthcare and social services for people with serious mental illness: A mixed-methods case study of Maryland's Medicaid health home program

OBJECTIVE

We conducted a case study examining implementation of Maryland's Medicaid health home program, a unique model for integration of behavioral, somatic, and social services for people with serious mental illness (SMI) in the psychiatric rehabilitation program setting.

METHOD

We conducted interviews and surveys with health home leaders (N=72) and front-line staff (N=627) representing 46 of the 48 total health home programs active during the November 2015-December 2016 study period. We measured the structural and service characteristics of the 46 health home programs and leaders' and staff members' perceptions of program implementation.

RESULTS

Health home program structure varied across sites: for example, 15% of programs had co-located primary care providers and 76% had onsite supported employment providers. Most leaders and staff viewed the health home program as having strong organizational fit with psychiatric rehabilitation programs' organizational structures and missions, but noted implementation challenges around health IT, population health management, and coordination with external providers.

CONCLUSION

Maryland's psychiatric rehabilitation-based health home is a promising model for integration of behavioral, somatic, and social services for people with SMI but may be strengthened by additional policy and implementation supports, including incentives for external providers to engage in care coordination with health home providers.

Collaborative case management to aid return to work after long-term sickness absence: a pilot randomised controlled trial

Background

Despite high levels of employment among working-age adults in the UK, there is still a significant minority who are off work with ill health at any one time (so-called ‘sickness absence’). Long-term sickness absence results in significant costs to the individual, to the employer and to wider society.

Objective

The overall objective of the intervention was to improve employee well-being with a view to aiding return to work. To meet this aim, a collaborative case management intervention was adapted to the needs of UK employees who were entering or experiencing long-term sickness absence.

Design

A pilot randomised controlled trial, using permuted block randomisation. Recruitment of patients with long-term conditions in settings such as primary care was achieved by screening of routine records, followed by mass mailing of invitations to participants. However, the proportion of patients responding to such invitations can be low, raising concerns about external validity. Recruitment in the Case Management to Enhance Occupational Support (CAMEOS) study used this method to test whether or not it would transfer to a population with long-term sickness absence in the context of occupational health (OH).

Participants

Employed people on long-term sickness absence (between 4 weeks and 12 months). The pilot was run with two different collaborators: a large organisation that provided OH services for a number of clients and a non-profit community-based organisation.

Intervention

Collaborative case management was delivered by specially trained case managers from the host organisations. Sessions were delivered by telephone and supported use of a self-help handbook. The comparator was usual care as provided by participants’ general practitioner (GP) or OH provider. This varied for participants according to the services available to them. Neither participants nor the research team were blind to randomisation.

Main outcome measures

Recruitment rates, intervention delivery and acceptability to participants were the main outcomes. Well-being, as measured by the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM), and return-to-work rates were also recorded.

Results

In total, over 1000 potentially eligible participants were identified across the sites and invited to participate. However, responses were received from just 61 of those invited (5.5%), of whom 16 (1.5%) were randomised to the trial (seven to treatment, nine to control). Detailed information on recruitment methods, intervention delivery, engagement and acceptability is presented. No harms were reported in either group.

Conclusions

This pilot study faced a number of barriers, particularly in terms of recruitment of employers to host the research. Our ability to respond to these challenges faced several barriers related to the OH context and the study set up. The intervention seemed feasible and acceptable when delivered, although caution is required because of the small number of randomised participants. However, employees’ lack of engagement in the research might imply that they did not see the intervention as valuable.

Future work

Developing effective and acceptable ways of reducing sickness absence remains a high priority. We discuss possible ways of overcoming these challenges in the future, including incentives for employers, alternative study designs and further modifications to recruitment methods.

Trial registration

Current Controlled Trials ISRCTN33560198.

Funding

This project was funded by the NIHR Public Health Research programme and will be published in full inPublic Health Research; Vol. 6, No. 2. See the NIHR Journals Library website for further project information.

Optimizing screening for depression among adults with asthma

OBJECTIVE

The Beck Depression Inventory II (BDI-II) is one of the most frequently used tools to screen for depression in patients with chronic diseases such as cardiovascular disease and asthma. However, its original cut-off score has not been validated in adult asthmatics. The present study aimed to determine the optimal BDI-II cut-off score and to verify the impact of various patient sociodemographic and clinical characteristics on performance accuracy of the BDI-II.

METHODS

A total of 801 adult asthmatic outpatients (mean ± SD, age 49 ± 14 years, 60% female) completed the BDI-II and a structured psychiatric interview (used as the standard referent to determine presence of major depressive disorder [MDD]). The sensitivity and specificity of the BDI-II were computed to determine the optimal cut-off score for identifying MDD. The optimal cut-off scores were also verified across covariate subgroups (e.g., sex, age, smoking status, asthma control levels).

RESULTS

According to the structured psychiatric interview, 108 (13%) patients had current MDD. The overall optimal BDI-II cut-off score was 12 (sensitivity = 85%, specificity = 79%). However, subgroup analyses revealed that this score could range from 11 to 15 depending on the characteristics of the individual.

CONCLUSIONS

Results suggest that the BDI-II is an appropriate screening tool for MDD in asthma populations. However, the cut-off score is influenced by the sociodemographic and clinical characteristics of patients. These findings highlight the importance of validating generic questionnaires for depression in specific populations in order to improve the accuracy of their usage.

An effectiveness-implementation hybrid trial study protocol targeting posttraumatic stress disorder and comorbidity

BACKGROUND

Each year in the USA, 1.5-2.5 million Americans are so severely injured that they require inpatient hospitalization. Multiple conditions including posttraumatic stress disorder (PTSD), alcohol and drug use problems, depression, and chronic medical conditions are endemic among physical trauma survivors with and without traumatic brain injuries.

METHODS/DESIGN

The trauma survivors outcomes and support (TSOS) effectiveness-implementation hybrid trial is designed to test the delivery of high-quality screening and intervention for PTSD and comorbidities across 24 US level I trauma center sites. The pragmatic trial aims to recruit 960 patients. The TSOS investigation employs a stepped wedge cluster randomized design in which sites are randomized sequentially to initiate the intervention. Patients identified by a 10-domain electronic health record screen as high risk for PTSD are formally assessed with the PTSD Checklist for study entry. Patients randomized to the intervention condition will receive stepped collaborative care, while patients randomized to the control condition will receive enhanced usual care. The intervention training begins with a 1-day on-site workshop in the collaborative care intervention core elements that include care management, medication, cognitive behavioral therapy, and motivational-interviewing elements targeting PTSD and comorbidity. The training is followed by site supervision from the study team. The investigation aims to determine if intervention patients demonstrate significant reductions in PTSD and depressive symptoms, suicidal ideation, alcohol consumption, and improvements in physical function when compared to control patients. The study uses implementation science conceptual frameworks to evaluate the uptake of the intervention model. At the completion of the pragmatic trial, results will be presented at an American College of Surgeons' policy summit. Twenty-four representative US level I trauma centers have been selected for the study, and the protocol is being rolled out nationally.

DISCUSSION

The TSOS pragmatic trial simultaneously aims to establish the effectiveness of the collaborative care intervention targeting PTSD and comorbidity while also addressing sustainable implementation through American College of Surgeons' regulatory policy. The TSOS effectiveness-implementation hybrid design highlights the importance of partnerships with professional societies that can provide regulatory mandates targeting enhanced health care system sustainability of pragmatic trial results.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02655354 . Registered 27 July 2015.

[Collaborative and stepped care for depression: Development of a model project within the Hamburg Network for Mental Health (psychenet.de)]

BACKGROUND

Depression is one of the most widespread mental disorders in Germany and causes a great suffering and involves high costs. Guidelines recommend stepped and interdisciplinary collaborative care models for the treatment of depression.

OBJECTIVES

Stepped and collaborative care models are described regarding their efficacy and cost-effectiveness. A current model project within the Hamburg Network for Mental Health exemplifies how guideline-based stepped diagnostics and treatment incorporating innovative low-intensity interventions are implemented by a large network of health care professionals and clinics.

MATERIALS AND METHODS

An accompanying evaluation using a cluster randomized controlled design assesses depressive symptom reduction and cost-effectiveness for patients treated within "Health Network Depression" ("Gesundheitsnetz Depression", a subproject of psychenet.de) compared with patients treated in routine care.

RESULTS

Over 90 partners from inpatient and outpatient treatment have been successfully involved in recruiting over 600 patients within the stepped care model. Communication in the network was greatly facilitated by the use of an innovative online tool for the supply and reservation of treatment capacities. The participating professionals profit from the improved infrastructure and the implementation of advanced training and quality circle work.

CONCLUSIONS

New treatment models can greatly improve the treatment of depression owing to their explicit reference to guidelines, the establishment of algorithms for diagnostics and treatment, the integration of practices and clinics, in addition to the implementation of low-intensity treatment alternatives. These models could promote the development of a disease management program for depression.

Major Depression in Canada: What Has Changed over the Past 10 Years?

OBJECTIVE

Major depressive episodes (MDE) make an important contribution to disease burden in Canada. The epidemiology of MDE in the national population has been examined in 2 mental health surveys, one conducted in 2002 and the other in 2012. Our objective was to compare selected variables from the 2 surveys to determine whether changes have occurred in the prevalence, treatment, and impact of MDE.

METHOD

The World Health Organization World Mental Health Composite International Diagnostic Interview was used in both surveys and the MDE module (which was not modified) was scored using the same algorithm. Some variables assessing impact and management of MDE were also identical in the 2 surveys. The analysis was based on frequency estimates and associated 95% confidence intervals.

RESULTS

The annual prevalence of MDE was 4.7% (95% CI 4.3% to 5.1%) in 2012, nearly identical to 4.8% (95% CI 4.5% to 5.1%) in 2002. Receipt of potentially adequate treatment (defined as taking an antidepressant or 6 or more visits to a health professional for mental health reasons) increased from 41.3% in 2002 to 52.2% in 2012, mostly due to an increase in respondents reporting 6 or more visits. Use of second generation antipsychotics also increased. There was no evidence of diminishing prevalence or impact (as assessed by symptoms of distress).

CONCLUSIONS

There appears to have been an increase in receipt of treatment for people with MDE and a changing pattern of management. However, it was not possible to confirm that the impact of MDE is diminishing as a result.

Why is major depression prevalence not changing?

BACKGROUND

Increasing provision of treatment should theoretically lead to a decreased burden of major depressive episodes (MDE) in the population. However, there is no evidence yet that this has occurred. Among possible explanations are that: (1) treatment may not be sufficiently accessible, effective or effectively delivered to make a difference at the population level or (2) treatment benefits such as diminished episode duration may be offset by other trends such as increasing episode incidence, or vice versa.

METHODS

MDE prevalence has been assessed in a series of national surveys and in a single national longitudinal study in Canada. These studies included a short form version of the Composite International Diagnostic Interview module for major depression. Indicators of incidence and episode duration of MDE were estimated. Meta-regression methods were used to examine trends over time.

RESULTS

No evidence of increasing incidence nor of diminishing duration of MDE was found. The analysis failed to uncover evidence that the epidemiology of this condition has been changing.

LIMITATIONS

Most studies included in this analysis used an abbreviated interview for MDE which may lack sensitivity and/or specificity. These studies could not address potential benefits of treatment on prevention of suicide. Some potentially offsetting effects could not be assessed, e.g. economic or societal changes.

CONCLUSION

These results suggest that more effective efforts to prevent MDE, or to improve the volume or quality of treatment, are necessary to reduced burden of MDE in the population.

Beck Depression Inventory II: determination and comparison of its diagnostic accuracy in cardiac outpatients

OBJECTIVES

To evaluate the impact of covariates on performance accuracy of the Beck Depression Inventory II (BDI-II) and to determine the optimal cut-off score for the BDI-II in cardiac outpatients. Differences of optimal cut-off scores were also verified across covariate subgroups.

DESIGN AND SETTING

Prospective cross-sectional study at the Department of Nuclear Medicine of the Montreal Heart Institute (Quebec, Canada).

METHODS

A total of 750 adult cardiac outpatients (mean ± SD age 58 ± 10 years, 31% women) completed the BDI-II and the Primary Care Evaluation of Mental Disorders (PRIME-MD; a psychiatric interview used as the reference standard for determining diagnosis of major depressive disorder). The receiver operating characteristics (ROC) curve of the BDI-II was adjusted for age, sex, level of education, smoking status, obesity, anxiety disorder, psychotropic medication, and history of coronary artery disease. The ROC analyses were conducted to determine optimal cut-off scores.

RESULTS

Forty-two (6%) patients met criteria for current major depressive disorder according to the PRIME-MD. After adjusted for covariates, the area under the ROC curve was significantly smaller than the unadjusted curve (0.76, 95% CI 0.66 to 0.85 vs. 0.84, 95% CI 0.77 to 0.89; ΔAUC = -0.07, 95% CI -0.13 to -0.02). While the optimal cut-off score was 10 for the total sample (sensitivity 83%, specificity 73%), the analyses indicated different cut-off scores across covariate subgroups: e.g. sex (women 13; men 10), and anxiety disorders (yes 15; no 10).

CONCLUSIONS

BDI-II is a good screening instrument for depression in cardiac outpatients. However, the present results suggest that covariates can affect the classification accuracy of the BDI-II's original recommended cut-off score. Scholars and clinicians should be aware of the principle that a screening score established in one population may not be relevant to another.

Depressive episode characteristics and subsequent recurrence risk

BACKGROUND

Clinical practice guidelines increasingly recognize the heterogeneity associated with major depressive episodes (MDE), e.g. through strategies such as watchful waiting. However, the implications of episode heterogeneity for long-term prognosis have not been adequately explored.

METHODS

In this project, we used data from a Canadian longitudinal study to evaluate recurrence risks for MDE after an initial episode in the mid-1990s. This study collected data from a community cohort between 1994/1995 and 2008/2009 using biannual interviews. Characteristics of the index episode: syndromal versus sub-syndromal, duration of symptoms, and indicators of seriousness (activity restriction, high distress or suicidal ideation) were recorded. The ability of these variables to predict MDE recurrence was explored using proportional hazards modeling. Additional analyses using generalized estimating equations were used to assess robustness.

RESULTS

Even brief, sub-syndromal episodes not characterized by indicators of seriousness were associated with an increased risk of subsequent MDE. However, episodes meeting diagnostic criteria for MDE, those lasting longer than four weeks and those associated with indicators of seriousness were associated with much higher recurrence risk. Sub-syndromal episodes associated with these characteristics generally predicted subsequent MDE as strongly as the occurrence of MDE itself.

LIMITATIONS

The data source did not include assessment of all potentially relevant covariates. The assessment of MDE used an abbreviated instrument.

CONCLUSIONS

Brief sub-syndromal episodes of depression are not usually targets of acute treatment, but such episodes have implications for subsequent MDE risk. Episode characteristics identify a range of outcomes that have potential implications for long-term management.

Collaborative care for depression and anxiety problems

BACKGROUND

Common mental health problems, such as depression and anxiety, are estimated to affect up to 15% of the UK population at any one time, and health care systems worldwide need to implement interventions to reduce the impact and burden of these conditions. Collaborative care is a complex intervention based on chronic disease management models that may be effective in the management of these common mental health problems.

OBJECTIVES

To assess the effectiveness of collaborative care for patients with depression or anxiety.

SEARCH METHODS

We searched the following databases to February 2012: The Cochrane Collaboration Depression, Anxiety and Neurosis Group (CCDAN) trials registers (CCDANCTR-References and CCDANCTR-Studies) which include relevant randomised controlled trials (RCTs) from MEDLINE (1950 to present), EMBASE (1974 to present), PsycINFO (1967 to present) and the Cochrane Central Register of Controlled Trials (CENTRAL, all years); the World Health Organization (WHO) trials portal (ICTRP); ClinicalTrials.gov; and CINAHL (to November 2010 only). We screened the reference lists of reports of all included studies and published systematic reviews for reports of additional studies.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of collaborative care for participants of all ages with depression or anxiety.

DATA COLLECTION AND ANALYSIS

Two independent researchers extracted data using a standardised data extraction sheet. Two independent researchers made 'Risk of bias' assessments using criteria from The Cochrane Collaboration. We combined continuous measures of outcome using standardised mean differences (SMDs) with 95% confidence intervals (CIs). We combined dichotomous measures using risk ratios (RRs) with 95% CIs. Sensitivity analyses tested the robustness of the results.

MAIN RESULTS

We included seventy-nine RCTs (including 90 relevant comparisons) involving 24,308 participants in the review. Studies varied in terms of risk of bias.The results of primary analyses demonstrated significantly greater improvement in depression outcomes for adults with depression treated with the collaborative care model in the short-term (SMD -0.34, 95% CI -0.41 to -0.27; RR 1.32, 95% CI 1.22 to 1.43), medium-term (SMD -0.28, 95% CI -0.41 to -0.15; RR 1.31, 95% CI 1.17 to 1.48), and long-term (SMD -0.35, 95% CI -0.46 to -0.24; RR 1.29, 95% CI 1.18 to 1.41). However, these significant benefits were not demonstrated into the very long-term (RR 1.12, 95% CI 0.98 to 1.27).The results also demonstrated significantly greater improvement in anxiety outcomes for adults with anxiety treated with the collaborative care model in the short-term (SMD -0.30, 95% CI -0.44 to -0.17; RR 1.50, 95% CI 1.21 to 1.87), medium-term (SMD -0.33, 95% CI -0.47 to -0.19; RR 1.41, 95% CI 1.18 to 1.69), and long-term (SMD -0.20, 95% CI -0.34 to -0.06; RR 1.26, 95% CI 1.11 to 1.42). No comparisons examined the effects of the intervention on anxiety outcomes in the very long-term.There was evidence of benefit in secondary outcomes including medication use, mental health quality of life, and patient satisfaction, although there was less evidence of benefit in physical quality of life.

AUTHORS' CONCLUSIONS

Collaborative care is associated with significant improvement in depression and anxiety outcomes compared with usual care, and represents a useful addition to clinical pathways for adult patients with depression and anxiety.

Improving quality of depression care using organized systems of care: a review of the literature

OBJECTIVE

To establish the need for a chronic disease management strategy for major depressive disorder (MDD), discuss the challenges involved in implementing guideline-level treatment for MDD, and provide examples of successful implementation of collaborative care programs.

DATA SOURCES

A systematic literature search of MEDLINE and the US National Library of Medicine was performed.

STUDY SELECTION

We reviewed clinical studies evaluating the effectiveness of collaborative care interventions for the treatment of depression in the primary care setting using the keywords collaborative care, depression, and MDD. This review includes 45 articles relevant to MDD and collaborative care published through May 2010 and excludes all non-English-language articles.

RESULTS

Collaborative care interventions include a greater role for nonmedical specialists and a supervising psychiatrist with the major goal of improving quality of depression care in primary care systems. Collaborative care programs restructure clinical practice to include a patient care strategy with specific goals and an implementation plan, support for self-management training, sustained patient follow-up, and decision support for medication changes. Key components associated with the most effective collaborative care programs were improvement in antidepressant adherence, use of depression case managers, and regular case load supervision by a psychiatrist. Across studies, primary care patients randomized to collaborative care interventions experienced enhanced treatment outcomes compared with those randomized to usual care, with overall outcome differences approaching 30%.

CONCLUSIONS

Collaborative care interventions may help to achieve successful, guideline-level treatment outcomes for primary care patients with MDD. Potential benefits of collaborative care strategies include reduced financial burden of illness, increased treatment adherence, and long-term improvement in depression symptoms and functional outcomes.

Improving access to psychosocial interventions for common mental health problems in the United Kingdom: narrative review and development of a conceptual model for complex interventions

BACKGROUND

In the United Kingdom and worldwide, there is significant policy interest in improving the quality of care for patients with mental health disorders and distress. Improving quality of care means addressing not only the effectiveness of interventions but also the issue of limited access to care. Research to date into improving access to mental health care has not been strongly rooted within a conceptual model, nor has it systematically identified the different elements of the patient journey from identification of illness to receipt of care. This paper set out to review core concepts underlying patient access to mental health care, synthesise these to develop a conceptual model of access, and consider the implications of the model for the development and evaluation of interventions for groups with poor access to mental health care such as older people and ethnic minorities.

METHODS

Narrative review of the literature to identify concepts underlying patient access to mental health care, and synthesis into a conceptual model to support the delivery and evaluation of complex interventions to improve access to mental health care.

RESULTS

The narrative review adopted a process model of access to care, incorporating interventions at three levels. The levels comprise (a) community engagement (b) addressing the quality of interactions in primary care and (c) the development and delivery of tailored psychosocial interventions.

CONCLUSIONS

The model we propose can form the basis for the development and evaluation of complex interventions in access to mental health care. We highlight the key methodological challenges in evaluating the overall impact of access interventions, and assessing the relative contribution of the different elements of the model.

Open-label treatment with desvenlafaxine in postmenopausal women with major depressive disorder not responding to acute treatment with desvenlafaxine or escitalopram

BACKGROUND

Preliminary clinical evidence indicates that menopausal status might impact on the efficacy of certain classes of antidepressants.

OBJECTIVE

The aim of this study was to evaluate open-label desvenlafaxine treatment (administered as desvenlafaxine succinate) in postmenopausal women who did not achieve clinical response to acute, double-blind treatment with desvenlafaxine or escitalopram.

STUDY DESIGN

This phase IIIb, multicentre study included a 6-month open-label extension phase of patients who did not respond in the initial 8-week, randomized, double-blind acute phase.

PATIENTS

Postmenopausal women aged 40-70 years with a primary diagnosis of major depressive disorder were recruited. PRIMARY INTERVENTION: Non-responders to acute treatment with double-blind desvenlafaxine or escitalopram received flexible-dose, open-label desvenlafaxine 100-200 mg/day for the 6-month extension phase.

MAIN OUTCOME MEASURE

The primary efficacy assessment was the 17-item Hamilton Rating Scale for Depression (HAM-D(17)) total score. Secondary efficacy outcome measures were the Clinical Global Impressions-Improvement (CGI-I) and -Severity scales, Hamilton Rating Scale for Anxiety, Quick Inventory of Depressive Symptomatology-Self-Report, Visual Analogue Scale-Pain Intensity and the Montgomery-Åsberg Depression Rating Scale (MADRS). Secondary health assessments were the Changes in Sexual Functioning Questionnaire, 5-Dimension EuroQoL Index, Health State Today, Menopause Rating Scale, Sheehan Disability Scale, treatment response (≥ 50% decrease in total HAM-D(17) and MADRS score from acute-phase baseline and CGI-I total score ≤ 2), HAM-D(17) remission (total score ≤ 7) and safety. Descriptive statistics were used to summarize outcomes.

RESULTS

The efficacy analysis included 123 patients (desvenlafaxine/desvenlafaxine = 64; escitalopram/desvenlafaxine = 59). At final evaluation of the open-label extension phase, mean reductions from acute-phase baseline in HAM-D(17) total scores were -11.33 for the desvenlafaxine/desvenlafaxine group and -11.41 for the escitalopram/desvenlafaxine group. HAM-D(17) response or remission after 6 months of open-label extension phase desvenlafaxine treatment were achieved in 56-58% and 41-48% of patients, respectively. The results of the other secondary efficacy outcome measures and other definitions of treatment response were generally consistent with the primary analyses. The observed adverse events were similar to those reported during previous desvenlafaxine clinical trials.

CONCLUSIONS

Postmenopausal women with major depressive disorder who did not respond to acute, double-blind treatment with escitalopram or desvenlafaxine achieved modest, continued improvement with long-term, open-label desvenlafaxine therapy. Further interpretation of these findings is limited by aspects of the study design (i.e. open-label, non-placebo-controlled) and the lack of randomized comparison groups in the extension phase, which prevents statistical assessment of the efficacy of longer term treatment with desvenlafaxine. Clinicaltrials.gov identifier: NCT00406640.

Benchmarks for effective primary care-based nursing services for adults with depression: a Delphi study

AIM

This paper is a report of a study conducted to identify and gain consensus on appropriate benchmarks for effective primary care-based nursing services for adults with depression.

BACKGROUND

Worldwide evidence suggests that between 5% and 16% of the population have a diagnosis of depression. Most of their care and treatment takes place in primary care. In recent years, primary care nurses, including community mental health nurses, have become more involved in the identification and management of patients with depression; however, there are no appropriate benchmarks to guide, develop and support their practice.

METHOD

In 2006, a three-round electronic Delphi survey was completed by a United Kingdom multi-professional expert panel (n = 67).

FINDINGS

Round 1 generated 1216 statements relating to structures (such as training and protocols), processes (such as access and screening) and outcomes (such as patient satisfaction and treatments). Content analysis was used to collapse statements into 140 benchmarks. Seventy-three benchmarks achieved consensus during subsequent rounds. Of these, 45 (61%) were related to structures, 18 (25%) to processes and 10 (14%) to outcomes.

CONCLUSION

Multi-professional primary care staff have similar views about the appropriate benchmarks for care of adults with depression. These benchmarks could serve as a foundation for depression improvement initiatives in primary care and ongoing research into depression management by nurses.

Collaborative stepped care for anxiety disorders in primary care: aims and design of a randomized controlled trial

BACKGROUND

Panic disorder (PD) and generalized anxiety disorder (GAD) are two of the most disabling and costly anxiety disorders seen in primary care. However, treatment quality of these disorders in primary care generally falls beneath the standard of international guidelines. Collaborative stepped care is recommended for improving treatment of anxiety disorders, but cost-effectiveness of such an intervention has not yet been assessed in primary care. This article describes the aims and design of a study that is currently underway. The aim of this study is to evaluate effects and costs of a collaborative stepped care approach in the primary care setting for patients with PD and GAD compared with care as usual.

METHODS/DESIGN

The study is a two armed, cluster randomized controlled trial. Care managers and their primary care practices will be randomized to deliver either collaborative stepped care (CSC) or care as usual (CAU). In the CSC group a general practitioner, care manager and psychiatrist work together in a collaborative care framework. Stepped care is provided in three steps: 1) guided self-help, 2) cognitive behavioral therapy and 3) antidepressant medication. Primary care patients with a DSM-IV diagnosis of PD and/or GAD will be included. 134 completers are needed to attain sufficient power to show a clinically significant effect of 1/2 SD on the primary outcome measure, the Beck Anxiety Inventory (BAI). Data on anxiety symptoms, mental and physical health, quality of life, health resource use and productivity will be collected at baseline and after three, six, nine and twelve months.

DISCUSSION

It is hypothesized that the collaborative stepped care intervention will be more cost-effective than care as usual. The pragmatic design of this study will enable the researchers to evaluate what is possible in real clinical practice, rather than under ideal circumstances. Many requirements for a high quality trial are being met. Results of this study will contribute to treatment options for GAD and PD in the primary care setting. Results will become available in 2011.

TRIAL REGISTRATION

NTR1071.

[Major depression in primary care and clinical impacts of treatment strategies: a literature review]

Major or clinical depression represents a frequent mental illness that is often associated with a high level of morbidity and mortality. Yet, major depression remains under-diagnosed and under-treated. On the level of treatment, it would appear desirable for reasons of better prognosis, to aim more than the simple reduction of depressive symptoms and target their remission resolutely and the fastest return to the individual's optimal functioning. This article presents a systematic review of the literature relating to the clinical impacts of treatment strategies aiming at the improvement of services offered to people who suffer of clinical depression and who consult in primary care. The authors summarize results drawn from 41 studies that include a measurement of the clinical impacts (reduction of symptoms, response, remission and functioning) of various treatment strategies. It appears that using complex treatment strategies favour positive outcomes. The authors propose various paths of research to further increase current knowledge.

Population-based care of depression: team care approaches to improving outcomes

OBJECTIVE

To describe evidence-based quality improvement interventions in the primary care system that have been shown in randomized trials to the improve quality of care and outcomes of patients with depression.

METHODS

Medical literature review, focused on the concept of population-based care and research-proven ways to decrease the prevalence of depression in primary care, including several meta-analyses that described the effect of collaborative care interventions in improving the quality and outcomes of primary care patients with depression.

RESULTS

A total of 37 randomized trials of collaborative care interventions have shown that collaborative care, compared with usual primary care, is associated with 2-fold increases in antidepressant adherence, improvements in depressive outcomes that last up to 2 to 5 years, increased patient satisfaction with depression care, and improved primary care satisfaction with treating depression. From a health plan perspective, cost-effectiveness analyses suggest that for most depressed primary care patients, collaborative care is associated with a modest increase in medical costs, but markedly improved depression and functional outcomes. The few studies that have used a societal perspective that included examination of both direct and indirect costs found that collaborative care was associated with overall cost savings. For patients with depression and diabetes and depression and panic disorder, there is evidence that the increase in mental health care costs associated with collaborative care is offset by greater savings in medical costs.

CONCLUSION

Collaborative care is a high value intervention associated with improved quality of care, depression outcomes, and improved patient and primary care physician satisfaction.

Caregivers' experiences with major depression concealed by physical illness in patients recruited from central Ugandan Primary Health Care Centers

In this article, we present caregivers' grapples with major depression seen among their physically ill patients. A thematic analysis of 29 in-depth caregiver interviews identified four themes: (a) caregivers' perceptions of depression, (b) barriers to caregivers' focus on depression, (c) resources and opportunities for managing depression, and (d) caregivers' perspectives on consequences of depression. Patients' physical illnesses concealed depressive episodes. Caregivers could not apply the label of "depression" but enumerated its indicative features. Stigmatization of depression, common with other mental illnesses and poverty, undermined caregiving. Vital caregiving resources included caregivers' willingness to meet patients' basic needs, facilitating patients' access to health care, informal counseling of patients, and ensuring patients' spiritual nourishment. Caregivers' management of depression in physically ill patients was expensive, but they coped; however, caregiving was burdensome. Ongoing support should be given not only to patients but caregivers, as well. To provide appropriate care, caregivers deserve sensitization about depression in the context of physical illness.

Reducing the burden of depression

OBJECTIVE

To consider why the burden of depression persists.

METHOD

The epidemiology and disability associated with depression were reviewed to consider whether depression persists because: the causes are overwhelming, prevention is ineffective, the disease is difficult to detect or diagnose, the condition remits and recurs, treatments do not work, individuals do not seek treatment, or effective care is not provided when they do seek it.

RESULTS

The first 5 possibilities were not considered significant reasons for the persistence of the burden.

CONCLUSION

The burden persists because individuals do not seek treatment for their depression when they relapse and effective proactive treatment is not always provided when they do seek it.

The design, implementation and acceptability of an integrated intervention to address multiple behavioral and psychosocial risk factors among pregnant African American women

BACKGROUND

African American women are at increased risk for poor pregnancy outcomes compared to other racial-ethnic groups. Single or multiple psychosocial and behavioral factors may contribute to this risk. Most interventions focus on singular risks. This paper describes the design, implementation, challenges faced, and acceptability of a behavioral counseling intervention for low income, pregnant African American women which integrated multiple targeted risks into a multi-component format.

METHODS

Six academic institutions in Washington, DC collaborated in the development of a community-wide, primary care research study, DC-HOPE, to improve pregnancy outcomes. Cigarette smoking, environmental tobacco smoke exposure, depression and intimate partner violence were the four risks targeted because of their adverse impact on pregnancy. Evidence-based models for addressing each risk were adapted and integrated into a multiple risk behavior intervention format. Pregnant women attending six urban prenatal clinics were screened for eligibility and risks and randomized to intervention or usual care. The 10-session intervention was delivered in conjunction with prenatal and postpartum care visits. Descriptive statistics on risk factor distributions, intervention attendance and length (i.e., with < 4 sessions considered minimal adherence) for all enrolled women (n = 1,044), and perceptions of study participation from a sub-sample of those enrolled (n = 152) are reported.

RESULTS

Forty-eight percent of women screened were eligible based on presence of targeted risks, 76% of those eligible were enrolled, and 79% of those enrolled were retained postpartum. Most women reported a single risk factor (61%); 39% had multiple risks. Eighty-four percent of intervention women attended at least one session (60% attended > or = 4 sessions) without disruption of clinic scheduling. Specific risk factor content was delivered as prescribed in 80% or more of the sessions; 78% of sessions were fully completed (where all required risk content was covered). Ninety-three percent of the subsample of intervention women had a positive view of their relationship with their counselor. Most intervention women found the session content helpful. Implementation challenges of addressing multiple risk behaviors are discussed.

CONCLUSION

While implementation adjustments and flexibility are necessary, multiple risk behavioral interventions can be implemented in a prenatal care setting without significant disruption of services, and with a majority of referred African American women participating in and expressing satisfaction with treatment sessions.

Population-based care of depression: team care approaches to improving outcomes

OBJECTIVE

To describe evidence-based quality improvement interventions in the primary care system that have been shown in randomized trials to the improve quality of care and outcomes of patients with depression.

METHODS

Medical literature review, focused on the concept of population-based care and research-proven ways to decrease the prevalence of depression in primary care, including several meta-analyses that described the effect of collaborative care interventions in improving the quality and outcomes of primary care patients with depression.

RESULTS

A total of 37 randomized trials of collaborative care interventions have shown that collaborative care, compared with usual primary care, is associated with 2-fold increases in antidepressant adherence, improvements in depressive outcomes that last up to 2 to 5 years, increased patient satisfaction with depression care, and improved primary care satisfaction with treating depression. From a health plan perspective, cost-effectiveness analyses suggest that for most depressed primary care patients, collaborative care is associated with a modest increase in medical costs, but markedly improved depression and functional outcomes. The few studies that have used a societal perspective that included examination of both direct and indirect costs found that collaborative care was associated with overall cost savings. For patients with depression and diabetes and depression and panic disorder, there is evidence that the increase in mental health care costs associated with collaborative care is offset by greater savings in medical costs.

CONCLUSION

Collaborative care is a high value intervention associated with improved quality of care, depression outcomes, and improved patient and primary care physician satisfaction.

Frequency and adequacy of depression treatment in a Canadian population sample

OBJECTIVE

Population-based data about depression treatment are largely restricted to estimates of the frequency of antidepressant (AD) use. Such frequencies are difficult to interpret in the absence of information about dosages, reasons for taking the medications, and participation in nonpharmacologic treatment. The objective of this study was to describe the pattern of treatment for major depression (MD) in Alberta.

METHOD

Telephone survey methods were employed. Random digit dialing was used to select a sample of 3345 household residents aged 18 to 64 years in Alberta. A computer-assisted telephone interview that included the Mini Neuropsychiatric Diagnostic Interview and questions about pharmacotherapy and psychotherapy was administered. Estimates were weighted for design features and population demographics.

RESULTS

The point prevalence of MD was 4.4% (95% confidence interval [CI], 3.4% to 5.5%), and the overall prevalence of current AD use was 7.4% (95% CI, 6.2% to 8.6%). The ADs taken most commonly, serotonin-specific reuptake inhibitors, were taken at therapeutic dosages 87.4% of the time. Most (80.7%) of those taking ADs reported taking them for more than 1 year. The frequency of receiving counselling, psychotherapy, or talk therapy was 3.9% overall and 14.3% in respondents with MD. However, most of these subjects were unable to name the type of counselling they were receiving.

CONCLUSIONS

When compared with previous estimates, these results suggest continued progress in the delivery of evidence-based care to the population. There is room for additional improvement, especially in the provision of nonpharmacologic treatment.

Self-reported confidence and skills of general practitioners in management of mental health disorders

OBJECTIVE

To identify the predictors of self-reported confidence and skills of GPs in management of patients with mental health problems.

DESIGN

Cross-sectional survey, with questionnaire presented to 246 GPs working in 62 practices throughout Gippsland.

SETTING

Rural general practices in Gippsland.

PARTICIPANTS

One hundred and thirty-four GPs across Gippsland.

MAIN OUTCOME MEASURES

GPs completed a questionnaire assessing self-perception of knowledge and skills in recognition and management of common mental health problems.

RESULTS

Of 134 GPs, 45% reported that they have a specific interest in mental health, and 39% of GPs reported that they had previous mental health training. Only 22% of GPs describe having both an interest and prior training in mental health care. Age and years since graduation are not significantly related to self-reported confidence and skills.

CONCLUSIONS

The results of this study highlight that self-professed interest and prior training in mental health are associated. Self-professed interest in mental health care predicts confidence and self-perceived skills in recognition, assessment and management of common mental health disorders. Similarly, prior training in mental health care predicts confidence and self-perceived skills in recognition, assessment and management of common mental health problems. Self-professed interest in mental health issues is also associated with hours of participation in continuing medical education related to mental health care. Unfortunately, only a minority described having both interest and prior training in mental health care.

Chronic disease management for depression in primary care: a summary of the current literature and implications for practice

OBJECTIVE

To review randomized controlled trials (RCTs) evaluating chronic disease management models for depression in primary care and to look at the implications for clinical practice in Canada.

METHODS

We reviewed all RCTs conducted between 1992 and 2006, including other reviews and analyses of pooled data. Using various search terms, we searched PsycINFO, Cinahl (1982 to May 2005), MEDLINE (1995 to 2005), EMBASE, The Cochrane Library, and PubMed.

RESULTS

There is conclusive evidence for the benefits of changing systems of care delivery to support the more effective management of depression in primary care. Most studies have demonstrated improved outcomes in terms of symptom reduction, relapse prevention, functioning in the community, adherence to treatment, community and workplace involvement, and satisfaction with care received.

CONCLUSIONS

Primary care practices need to examine how they can incorporate different concepts and models for managing depression. Components to consider include case registries, care managers or coordinators, treatment algorithms, follow-up and monitoring after a treated episode, care and relapse prevention plans, visits by psychiatrists, and training and ongoing education for all providers.

Comorbid anxiety and depression: illumination of a controversy

Depression and anxiety frequently coexist in the same individual, either concurrently or at different times, and numerous studies show that the presence of an anxiety disorder is the single strongest risk factor for development of depression. When the two coexist simultaneously, either as diagnosed disorders or subsyndromal states, they may be viewed as mixed anxiety-depression or as comorbid syndromes, i.e. separate disorders occurring concurrently. Controversy continues over the nature of the relationship between depression and anxiety, some believing they are distinct, separate entities while others - now the majority - view them as overlapping syndromes that present at different points on a phenomenological and/or chronological continuum, and share a common neurobiology, the degree of overlap depending on whether each is described at the level of symptoms, syndrome or diagnosis. Community data likely underestimate true prevalence, since affected individuals frequently present in primary care with somatic, rather than psychological, complaints. Irrespective of the nature of the relationship, patients with both disorders experience significant vocational and interpersonal impairment, and more frequent recurrence, with greater likelihood of suicide, than individuals with single disorders. Various classes of antidepressant drugs offer symptom relief for these patients, the most selective of th SSRIs holding the greatest promise for sustained clinical improvement. Yet, the crucial parameter of successful pharmacotherapy seems to be the length of treatment, ensuring enhancement of the compromised neuroprotective and neuroplastic mechanisms. Further clarification of the relationship is a prerequisite for offering effective treatment to the many patients who experience lifetime depression and anxiety.

Managing future Gulf War Syndromes: international lessons and new models of care

After the 1991 Gulf War, veterans of the conflict from the United States, United Kingdom, Canada, Australia and other nations described chronic idiopathic symptoms that became popularly known as 'Gulf War Syndrome'. Nearly 15 years later, some 250 million dollars in United States medical research has failed to confirm a novel war-related syndrome and controversy over the existence and causes of idiopathic physical symptoms has persisted. Wartime exposures implicated as possible causes of subsequent symptoms include oil well fire smoke, infectious diseases, vaccines, chemical and biological warfare agents, depleted uranium munitions and post-traumatic stress disorder. Recent historical analyses have identified controversial idiopathic symptom syndromes associated with nearly every modern war, suggesting that war typically sets into motion interrelated physical, emotional and fiscal consequences for veterans and for society. We anticipate future controversial war syndromes and maintain that a population-based approach to care can mitigate their impact. This paper delineates essential features of the model, describes its public health and scientific underpinnings and details how several countries are trying to implement it. With troops returning from combat in Afghanistan, Iraq and elsewhere, the model is already getting put to the test.

Epidemiologic trends and costs of fragmentation

The data that were reviewed in this article documented that in health systems, which manage behavioral health disorders independently from general medical disorders, the estimated 10% to 30% of patients with behavioral health service needs can expect (1) poor access or barriers to medical or mental health care; (2) when services are available, most provided will not meet minimum standards for expected outcome change; and (3) as a consequence of (1) and (2), medical and behavioral disorders will be more persistent with increased complications, will be associated with greater disability, and will lead to higher total health care and disability costs than will treatment of patients who do not have behavioral health disorders. This article proposes that these health system deficiencies will persist unless behavioral health services become an integral part of medical care (ie, integrated). By doing so, it creates a win-win situation for virtually all parties involved. Complex patients will receive coordinated general medical and behavioral health care that leads to improved outcomes. Clinicians and the hospitals that support integrated programs will be less encumbered by cross-disciplinary roadblocks as they deliver services that augment patient outcomes. Health plans (insurers) will be able to decrease administrative and claims costs because the complex patients who generate more than 80% of service use will have less complicated claims adjudication and better clinical outcomes. As a result, purchaser premiums, whether government programs, employers, or individuals, will decrease and the impact on national budgets will improve. Ongoing research will be important to assure that application of the best clinical and administrative practices are used to achieve these outcomes.

A major depression prognosis calculator based on episode duration

Background

Epidemiological data have shown that the probability of recovery from an episode declines with increasing episode duration, such that the duration of an episode may be an important factor in determining whether treatment is required. The objective of this study is to incorporate episode duration data into a calculator predicting the probability of recovery during a specified interval of time.

Methods

Data from two Canadian epidemiological studies were used, both studies were components of a program undertaken by the Canadian national statistical agency. One component was a cross-sectional psychiatric epidemiological survey (n = 36,984) and the other was a longitudinal study (n = 17,262).

Results

A Weibull distribution provided a good description of episode durations reported by subjects with major depression in the cross-sectional survey. This distribution was used to develop a discrete event simulation model for episode duration calibrated using the longitudinal data. The resulting estimates were then incorporated into a predictive calculator. During the early weeks of an episode, recovery probabilities are high. The model predicts that approximately 20% will recover in the first week after diagnostic criteria for major depression are met. However, after six months of illness, recovery during a subsequent week is less than 1%.

Conclusion

The duration of an episode is relevant to the probability of recovery. This epidemiological feature of depressive disorders can inform prognostic judgments. Watchful waiting may be an appropriate strategy for mild episodes of recent onset, but the risks and benefits of this strategy must be assessed in relation to time since onset of the episode.

An Efficient Method of Identifying Major Depression and Panic Disorder in Primary Care

The research literature is replete with evidence of and concerns about the prevalence and undertreatment of mental disorders in primary care. Although screening, on its own, may not directly affect clinical outcomes, it is still the most efficient and effective way to identify psychologically distressed patients for either research purposes or to provide patients with or refer patients to appropriate care. The current study sought to establish the utility of the MHI-5 for the detection of patients suffering from major depression or panic disorder, two of the most common psychiatric conditions seen in primary care settings. This study was conducted in a family medicine clinic and 246 adult outpatients participated. Patients completed the Mental Health Index-5 (MHI-5) as the screening measure and the PRIME-MD Patient Health Questionnaire (PHQ) as the diagnostic instrument. ROC analyses indicated that a cut-off score of 23 on the MHI-5 yielded a sensitivity of 91% and a specificity of 58% for predicting provisional diagnoses of major depression or panic disorder from the PHQ. Using a single item to screen for a PHQ diagnosis of major depression yielded a sensitivity of 88% and a specificity of 62% and a second question had a sensitivity of 100% and specificity of 63% for PHQ diagnosis of panic disorder. These results indicate that it is possible to use a small number of items to efficiently and effectively screen for mental disorders affecting a significant portion of primary care patients.

District nurses' involvement and attitudes to mental health problems: a three-area cross-sectional study

AIMS AND OBJECTIVES

The main aims of this study were to obtain information on the extent of staff contact and input with mental health problems and to determine their experience, training and attitudes to such problems.

BACKGROUND

Historical changes and policy shifts have resulted in primary care providers playing an increasing role in the care of mental health problems. Such problems are common within community settings and a major cause of suffering and disability. District nurses in particular are likely to encounter a high level of psychological co-morbidity in their patients. Information is lacking on their involvement, attitudes and specific training for this area of their work.

DESIGN AND METHODS

A cross-sectional study was conducted of the staff of district nursing services in three areas, Jersey (Channel Islands), Lewisham and Hertfordshire, using a postal questionnaire.

RESULTS

Questionnaires were sent to 331 staff; 66% responded. Community and district nurses estimated a 16% prevalence of mental health problems among their patients, most commonly dementia, depression and anxiety disorders. Staff noted participation in a wide range of psychological care activities, but identified a lack of training for this aspect of their role (three-quarter of nurses had received no such training during the past five years). They reported a willingness to develop their understanding and skills by means of educational programmes. Attitude measures revealed generally optimistic views concerning depression treatment, a rejection of deterministic attitudes about this condition and confidence in the role of district nursing staff in managing such problems.

CONCLUSIONS

The need for primary care mental health training is widely noted and based upon consistent evidence of the limited detection and treatment of these problems. This study has employed quantitative methods to clarify the extent and nature of district nursing staff involvement in this area of practice and indicates that training needs are acknowledged by community nurses from geographically distinct settings.

RELEVANCE TO CLINICAL PRACTICE

Staff are interested in developing knowledge and skills pertinent to the psychological problems of their patients and their views reveal a consensus that the most important areas for learning are recognition of mental disorders, anxiety management, crisis intervention and pharmacological treatments for depression.

Antidepressant utilization in Canada

OBJECTIVE

Antidepressant utilization can be used as an indicator of appropriate treatment for major depression. The objective of this study was to characterize antidepressant utilization in Canada, including the relationships of antidepressant use with sociodemographic variables, past-year and lifetime depression, number of past depressive episodes, and other possible indications for antidepressants.

METHOD

We examined data from the Canadian Community Health Survey (CCHS) Cycle 1.2. The CCHS was a nationally representative mental health survey (N=36,984) conducted in 2002 that included a diagnostic instrument for past-year and lifetime major depressive episodes and other psychiatric disorders and a record of past-year antidepressant use.

RESULTS

Overall, 5.8% of Canadians were taking antidepressants, higher than the annual prevalence of major depressive episode (4.8%) in the survey. Among persons with a past-year major depressive episode, the frequency of antidepressant use was 40.4%. After application of adjustments for probable successful outcomes of treatment, the estimated frequency of antidepressant use for major depression was more than 50%. Frequency of antidepressant treatment among those with a history of depression but without a past-year episode increased with the number of previous episodes. Among those taking antidepressants over the past year, only 33.1% had had a past-year episode of major depression. Migraine, fibromyalgia, anxiety disorder, or past depression was present in more than 60% of those taking antidepressants without a past-year episode of depression.

CONCLUSIONS

The CCHS results suggest that antidepressant use has increased substantially since the early 1990s, and also that these medications are employed extensively for indications other than depression.

Treatment of depression in the medically ill

Most studies on treatment methods in elderly depressive patients have included primarily patients in good physical health, excluding medical comorbidity, despite the fact that depression with medical comorbidity is the norm rather than the exception. In addition, depression is known to increase disability and mortality among the medically ill. This, therefore, becomes an extremely important issue. Although data are limited, the available evidence suggests that depression concomitant with medical illness can be treated. One or more of the selective serotonin reuptake inhibitors have demonstrated potential usefulness in depressed patients with ischemic heart disease, diabetes, dementia, and Parkinson's disease and in patients after stroke and after myocardial infarction. Large-scale trials are needed to assess not only the safety and effectiveness of agents for the treatment of depression in comorbid illness, but also the effects of depression on the course of the medical illness itself.

Modelling major depression epidemiology and assessing the impact of antidepressants on population health

Randomized controlled trials indicate that antidepressant treatment increases the probability of remission in acute treatment of major depression, diminishes the frequency of relapse during continuation phase treatment and diminishes the risk of recurrence during maintenance treatment. As antidepressant coverage increases in the population, the benefits of antidepressant treatment should begin to translate into improved population health. However, adverse effects can also occur, as can unnecessary treatment. Monitoring the impact of antidepressant treatment on population health should be a priority for health surveillance. Quantitative description of the relationship between treatment provision and population health status will require the use of epidemiological models. A variety of such models have been reported in the literature. None of the existing models, however, are fully satisfactory.

Improving depression care for older, minority patients in primary care

OBJECTIVE

Few older minorities receive adequate treatment of depression in primary care. This study examines whether a collaborative care model for depression in primary care is as effective in older minorities as it is in nonminority elderly patients in improving depression treatment and outcomes.

STUDY DESIGN

A multisite randomized clinical trial of 1801 older adults comparing collaborative care for depression with treatment as usual in primary care. Twelve percent of the sample were black (n = 222), 8% were Latino (n = 138), and 3% (n = 53) were from other minority groups. We compared the 3 largest ethnic groups (non-Latino white, black, and Latino) on depression severity, quality of life, and mental health service use at baseline, 3, 6, and 12 months after randomization to collaborative care or usual care.

PRINCIPAL FINDINGS

Compared with care as usual, collaborative care significantly improved rates and outcomes of depression care in older adults from ethnic minority groups and in older whites. At 12 months, intervention patients from ethnic minorities (blacks and Latinos) had significantly greater rates of depression care for both antidepressant medication and psychotherapy, lower depression severity, and less health-related functional impairment than usual care participants (64%, 95% confidence interval [CI] 55-72 versus 45%, CI 36-55, P = 0.003 for antidepressant medication; 37%, CI 28-47 versus 13%, CI 6-19, P = 0.002 for psychotherapy; mean = 0.9, CI 0.8-1.1 versus mean = 1.4, CI 1.3-1.5, P < 0.001 for depression severity, range 0-4; mean = 3.7, CI 3.2-4.1, versus mean = 4.7, CI 4.3-5.1, P < 0.0001 for functional impairment, range 0-10).

CONCLUSIONS

Collaborative Care is significantly more effective than usual care for depressed older adults, regardless of their ethnicity. Intervention effects in ethnic minority participants were similar to those observed in whites.

A randomized effectiveness trial of cognitive-behavioral therapy and medication for primary care panic disorder

BACKGROUND

Panic disorder is a prevalent, often disabling condition among patients in the primary care setting. Although numerous studies have assessed the effectiveness of treatments for depression in primary care, few such studies have been conducted for panic disorder.

OBJECTIVE

To implement and test the effectiveness of a combined pharmacotherapy and cognitive-behavioral intervention for panic disorder tailored to the primary care setting.

DESIGN

Randomized, controlled study comparing intervention to treatment as usual.

SETTING

Six primary care clinics associated with 3 university medical schools, serving an ethnically and socioeconomically diverse patient population.

PARTICIPANTS

Two hundred thirty-two primary care patients meeting DSM-IV criteria for panic disorder. Comorbid mental and physical disorders were permitted, provided these did not contraindicate the treatment to be provided and were not acutely life threatening.

INTERVENTION

Patients were randomized to receive either treatment as usual or an intervention consisting of a combination of up to 6 sessions (across 12 weeks) of cognitive-behavioral therapy (CBT) modified for the primary care setting, with up to 6 follow-up telephone contacts during the next 9 months, and algorithm-based pharmacotherapy provided by the primary care physician with guidance from a psychiatrist. Behavioral health specialists, the majority inexperienced in CBT for panic disorder, were trained to deliver the CBT and coordinated overall care, including pharmacotherapy.

MAIN OUTCOMES MEASURES

Proportion of subjects remitted (no panic attacks in the past month, minimal anticipatory anxiety, and agoraphobia subscale score <10 on Fear Questionnaire) and responding (Anxiety Sensitivity Index score <20) and change over time in World Health Organization Disability Scale and short form 12 scores.

RESULTS

The combined cognitive-behavioral and pharmacotherapeutic intervention resulted in sustained and gradually increasing improvement relative to treatment as usual, with significantly higher rates at all points of both the proportion of subjects remitted (3 months, 20% vs 12%; 12 months, 29% vs 16%) and responding (3 months, 46% vs 27%; 12 months, 63% vs 38%) and significantly greater improvements in World Health Organization Disability Scale (all points) and short form 12 mental health functioning (3 and 6 months) scores. These effects were obtained in spite of similar rates of delivery of guideline-concordant pharmacotherapy to the 2 groups.

CONCLUSION

Delivery of evidence-based CBT and medication using the collaborative care model and a CBT-naive, midlevel behavioral health specialist is feasible and significantly more effective than usual care for primary care panic disorder.

Women's and doctors' accounts of their experiences of depression in primary care: the influence of social and moral reasoning on patients' and doctors' decisions

BACKGROUND

Little is known about how general practitioners (GPs) manage depression within everyday clinical practice, particularly in relation to the issue of 'problem definition'. In addition, there has been relatively little research on the patients' perspective of depression and its management in primary care.

METHODS

Qualitative interviews explored women's and GPs' experiences of recognizing depression and their experiences of the management of depression. Thirty-seven women and 20 GPs were recruited from practices in four National Health Service Board areas of Scotland. Each participant was interviewed at the start of the study, and 30 women and 19 GPs were revisited approximately 9-12 months later so that the process of care could be reviewed.

RESULTS

The findings demonstrate the social and moral reasoning that lies behind women's decisions to seek help and to subsequently accept their GPs' explanation and advice, and that the acceptance of antidepressants created a moral dilemma for the women. For GPs, the diagnosis and management of depression led to contemplating the boundaries of their professional role, and social and moral reasoning was also evident in their decision-making processes.

DISCUSSION

The implication is that, for the majority of women, a chronic-disease model for the management for depression in primary care would be likely to increase rather than reduce the moral dilemma. In addition, the management of depression is not solely based on clinical decisions, so the applicability of a chronic-disease model to primary care requires further consideration.

Disease management for chronic pain: barriers of program implementation with primary care physicians

OBJECTIVE

This study investigated the implementation of a disease management (DM) program for chronic pain among primary care physicians. Its aim was the dissemination of guidelines for the treatment of chronic pain to help primary care physicians identify, treat, and manage patients highly impaired by pain. The goals of the program were: 1) To identify those pain patients who are at greatest disability due to pain; 2) To assess the impact of a DM program for pain on clinical practice; and 3) To evaluate the effect of the program on physician's use, compliance, and satisfaction with guidelines.

METHODS

Thirty primary care physicians followed 82 patients who were identified as having chronic migraine headaches, back pain, or painful peripheral neuropathy. All patients were categorized according to their level of disability based on ratings of pain intensity, activity interference, emotional distress, perceived support, and work disability. Treatment algorithms developed for this study were placed in the charts of those patients considered to have moderate or high disability. Physicians completed pre- and poststudy questionnaires.

RESULTS

Chronic pain patients could be successfully classified according to the disability from their pain and physicians were open to accepting guidelines for treatment. By the end of the study, primary care physicians reported improved confidence in treating chronic pain. Most felt that chronic pain management was a problem in their practice, and they recognized the benefit of treatment algorithms. Many of the physicians, however, expressed reluctance to regularly consult the algorithms when treating chronic pain.

DISCUSSION

The identification of barriers for implementation of DM programs for pain is presented, and recommendations for future implementation are discussed.