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Isaacs AN, Mitchell EKL. Mental health integrated care models in primary care and factors that contribute to their effective implementation: a scoping review. Int J Ment Health Syst 2024; 18:5. [PMID: 38331913 PMCID: PMC10854062 DOI: 10.1186/s13033-024-00625-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 02/01/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND In the state of Victoria, Australia, the 111-day lockdown due to the COVID-19 pandemic exacerbated the population's prevailing state of poor mental health. Of the 87% of Australians who visit their GP annually, 71% of health problems they discussed related to psychological issues. This review had two objectives: (1) To describe models of mental health integrated care within primary care settings that demonstrated improved mental health outcomes that were transferable to Australian settings, and (2) To outline the factors that contributed to the effective implementation of these models into routine practice. METHODS A scoping review was undertaken to synthesise the evidence in order to inform practice, policymaking, and research. Data were obtained from PubMed, CINAHL and APA PsycINFO. RESULTS Key elements of effective mental health integrated care models in primary care are: Co-location of mental health and substance abuse services in the primary care setting, presence of licensed mental health clinicians, a case management approach to patient care, ongoing depression monitoring for up to 24 months and other miscellaneous elements. Key factors that contributed to the effective implementation of mental health integrated care in routine practice are the willingness to accept and promote system change, integrated physical and mental clinical records, the presence of a care manager, adequate staff training, a healthy organisational culture, regular supervision and support, a standardised workflow plan and care pathways that included clear role boundaries and the use of outcome measures. The need to develop sustainable funding mechanisms has also been emphasized. CONCLUSION Integrated mental health care models typically have a co-located mental health clinician who works closely with the GP and the rest of the primary care team. Implementing mental health integrated care models in Australia requires a 'whole of system' change. Lessons learned from the Mental Health Nurse Incentive Program could form the foundation on which this model is implemented in Australia.
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Affiliation(s)
- Anton N Isaacs
- Monash University School of Rural Health, Sargeant Street, PO Box 723, Warragul, VIC, 3820, Australia.
| | - Eleanor K L Mitchell
- Monash University School of Rural Health, Corner of Victoria Street & Day Street, PO Box 1497, Bairnsdale, VIC, 3875, Australia
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Tops L, Beerten SG, Vandenbulcke M, Vermandere M, Deschodt M. Integrated Care Models for Older Adults with Depression and Physical Comorbidity: A Scoping Review. Int J Integr Care 2024; 24:1. [PMID: 38222854 PMCID: PMC10786096 DOI: 10.5334/ijic.7576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Accepted: 12/07/2023] [Indexed: 01/16/2024] Open
Abstract
Objective Multimorbidity is a growing challenge in the care for older people with mental illness. To address both physical and mental illnesses, integrated care management is required. The purpose of this scoping review is to identify core components of integrated care models for older adults with depression and physical comorbidity, and map reported outcomes and implementation strategies. Methods PubMed, EMBASE, CINAHL and Cochrane Library were searched independently by two reviewers for studies concerning integrated care interventions for older adults with depression and physical comorbidity. We used the SELFIE framework to map core components of integrated care models. Clinical and organisational outcomes were mapped. Results Thirty-eight studies describing thirteen care models were included. In all care models, a multidisciplinary team was involved. The following core components were mainly described: continuity, person-centredness, tailored holistic assessment, pro-activeness, treatment interaction, individualized care planning, and coordination tailored to complexity of care needs. Twenty-seven different outcomes were evaluated, with more attention given to clinical than to organisational outcomes. Conclusion The core components that comprise integrated care models are diverse. Future studies should focus more on implementation aspects of the intervention and describe financial parts, e.g., the cost of the intervention for the healthcare user, more transparently.
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Affiliation(s)
- Laura Tops
- Academic Centre of General Practice, KU Leuven, Kapucijnenvoer 7, Box 7001, 3000, Leuven, Belgium
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Simon Gabriël Beerten
- Academic Centre of General Practice, KU Leuven, Kapucijnenvoer 7, Box 7001, 3000, Leuven, Belgium
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Mathieu Vandenbulcke
- Department of Neurosciences, Leuven Brain Institute, KU Leuven, Leuven, Belgium
- Department of Geriatric Psychiatry, University Psychiatric Centre, KU Leuven, Leuven, Belgium
| | - Mieke Vermandere
- Academic Centre of General Practice, KU Leuven, Kapucijnenvoer 7, Box 7001, 3000, Leuven, Belgium
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Mieke Deschodt
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Competence Center for Nursing, University Hospitals Leuven, Belgium
- Gerontology and Geriatrics, University Hospitals Leuven, Belgium
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Moloi H, Daniels K, Brooke-Sumner C, Cooper S, Odendaal WA, Thorne M, Akama E, Leon N. Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence. Cochrane Database Syst Rev 2023; 7:CD013603. [PMID: 37466272 PMCID: PMC10355136 DOI: 10.1002/14651858.cd013603.pub3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
BACKGROUND Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses. OBJECTIVES To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified. SELECTION CRITERIA We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification. DATA COLLECTION AND ANALYSIS For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population. MAIN RESULTS The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations. AUTHORS' CONCLUSIONS This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.
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Affiliation(s)
- Hlengiwe Moloi
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Carrie Brooke-Sumner
- Alcohol Tobacco and Other Drug Research Unit, The South African Medical Research Council, Cape Town, South Africa
| | - Sara Cooper
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- Social & Behavioural Sciences Division, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Willem A Odendaal
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | | | - Eliud Akama
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Natalie Leon
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, USA
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Moloi H, Daniels K, Brooke-Sumner C, Cooper S, Odendaal WA, Thorne M, Akama E, Leon N. Healthcare workers' perceptions and experiences of primary healthcare integration: a scoping review of qualitative evidence. Cochrane Database Syst Rev 2023; 7:CD013603. [PMID: 37434293 PMCID: PMC10335778 DOI: 10.1002/14651858.cd013603.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/13/2023]
Abstract
BACKGROUND Primary healthcare (PHC) integration has been promoted globally as a tool for health sector reform and universal health coverage (UHC), especially in low-resource settings. However, for a range of reasons, implementation and impact remain variable. PHC integration, at its simplest, can be considered a way of delivering PHC services together that sometimes have been delivered as a series of separate or 'vertical' health programmes. Healthcare workers are known to shape the success of implementing reform interventions. Understanding healthcare worker perceptions and experiences of PHC integration can therefore provide insights into the role healthcare workers play in shaping implementation efforts and the impact of PHC integration. However, the heterogeneity of the evidence base complicates our understanding of their role in shaping the implementation, delivery, and impact of PHC integration, and the role of contextual factors influencing their responses. OBJECTIVES To map the qualitative literature on healthcare workers' perceptions and experiences of PHC integration to characterise the evidence base, with a view to better inform future syntheses on the topic. SEARCH METHODS We used standard, extensive Cochrane search methods. The latest search date was 28 July 2020. We did not search for grey literature due to the many published records identified. SELECTION CRITERIA We included studies with qualitative and mixed methods designs that reported on healthcare worker perceptions and experiences of PHC integration from any country. We excluded settings other than PHC and community-based health care, participants other than healthcare workers, and interventions broader than healthcare services. We used translation support from colleagues and Google Translate software to screen non-English records. Where translation was not feasible we categorised these records as studies awaiting classification. DATA COLLECTION AND ANALYSIS For data extraction, we used a customised data extraction form containing items developed using inductive and deductive approaches. We performed independent extraction in duplicate for a sample on 10% of studies allowed for sufficient agreement to be reached between review authors. We analysed extracted data quantitatively by counting the number of studies per indicator and converting these into proportions with additional qualitative descriptive information. Indicators included descriptions of study methods, country setting, intervention type, scope and strategies, implementing healthcare workers, and client target population. MAIN RESULTS The review included 184 studies for analysis based on 191 included papers. Most studies were published in the last 12 years, with a sharp increase in the last five years. Studies mostly employed methods with cross-sectional qualitative design (mainly interviews and focus group discussions), and few used longitudinal or ethnographic (or both) designs. Studies covered 37 countries, with close to an even split in the proportions of high-income countries (HICs) and low- and middle-income countries (LMICs). There were gaps in the geographical spread for both HICs and LMICs and some countries were more dominant, such as the USA for HICs, South Africa for middle-income countries, and Uganda for low-income countries. Methods were mainly cross-sectional observational studies with few longitudinal studies. A minority of studies used an analytical conceptual model to guide the design, implementation, and evaluation of the integration study. The main finding was the various levels of diversity found in the evidence base on PHC integration studies that examined healthcare workers' perceptions and experiences. The review identified six different configurations of health service streams that were being integrated and these were categorised as: mental and behavioural health; HIV, tuberculosis (TB) and sexual reproductive health; maternal, women, and child health; non-communicable diseases; and two broader categories, namely general PHC services, and allied and specialised services. Within the health streams, the review mapped the scope of the interventions as full or partial integration. The review mapped the use of three different integration strategies and categorised these as horizontal integration, service expansion, and service linkage strategies. The wide range of healthcare workers who participated in the implementation of integration interventions was mapped and these included policymakers, senior managers, middle and frontline managers, clinicians, allied healthcare professionals, lay healthcare workers, and health system support staff. We mapped the range of client target populations. AUTHORS' CONCLUSIONS This scoping review provides a systematic, descriptive overview of the heterogeneity in qualitative literature on healthcare workers' perceptions and experience of PHC integration, pointing to diversity with regard to country settings; study types; client populations; healthcare worker populations; and intervention focus, scope, and strategies. It would be important for researchers and decision-makers to understand how the diversity in PHC integration intervention design, implementation, and context may influence how healthcare workers shape PHC integration impact. The classification of studies on the various dimensions (e.g. integration focus, scope, strategy, and type of healthcare workers and client populations) can help researchers to navigate the way the literature varies and for specifying potential questions for future qualitative evidence syntheses.
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Affiliation(s)
- Hlengiwe Moloi
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
| | | | - Carrie Brooke-Sumner
- Alcohol Tobacco and Other Drug Research Unit, The South African Medical Research Council, Cape Town, South Africa
| | - Sara Cooper
- Cochrane South Africa, South African Medical Research Council, Cape Town, South Africa
- Department of Global Health, Faculty of Medicine and Health Sciences, Stellenbosch University, Stellenbosch, South Africa
- Social & Behavioural Sciences Division, School of Public Health, University of Cape Town, Cape Town, South Africa
| | - Willem A Odendaal
- HIV and Other Infectious Diseases Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Psychiatry, Stellenbosch University, Cape Town, South Africa
| | | | - Eliud Akama
- Center for Microbiology Research, Kenya Medical Research Institute, Nairobi, Kenya
- Department of Global Health, University of Washington, Seattle, Washington, USA
| | - Natalie Leon
- Health Systems Research Unit, South African Medical Research Council, Cape Town, South Africa
- Department of Epidemiology, School of Public Health, Brown University, Providence, Rhode Island, USA
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Hammarberg SAW, Hange D, André M, Udo C, Svenningsson I, Björkelund C, Petersson EL, Westman J. Care managers can be useful for patients with depression but their role must be clear: a qualitative study of GPs' experiences. Scand J Prim Health Care 2019; 37:273-282. [PMID: 31286807 PMCID: PMC6713154 DOI: 10.1080/02813432.2019.1639897] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective: Explore general practitioners' (GPs') views on and experiences of working with care managers for patients treated for depression in primary care settings. Care managers are specially trained health care professionals, often specialist nurses, who coordinate care for patients with chronic diseases. Design: Qualitative content analysis of five focus-group discussions. Setting: Primary health care centers in the Region of Västra Götaland and Dalarna County, Sweden. Subjects: 29 GPs. Main outcome measures: GPs' views and experiences of care managers for patients with depression. Results: GPs expressed a broad variety of views and experiences. Care managers could ensure care quality while freeing GPs from case management by providing support for patients and security and relief for GPs and by coordinating patient care. GPs could also express concern about role overlap; specifically, that GPs are already care managers, that too many caregivers disrupt patient contact, and that the roles of care managers and psychotherapists seem to compete. GPs thought care managers should be assigned to patients who need them the most (e.g. patients with life difficulties or severe mental health problems). They also found that transition to a chronic care model required change, including alterations in the way GPs worked and changes that made depression treatment more like treatment for other chronic diseases. Conclusion: GPs have varied experiences of care managers. As a complementary part of the primary health care team, care managers can be useful for patients with depression, but team members' roles must be clear. KEY POINTS A growing number of primary health care centers are introducing care managers for patients with depression, but knowledge about GPs' experiences of this kind of collaborative care is limited. GPs find that care managers provide support for patients and security and relief for GPs. GPs are concerned about potential role overlap and desire greater latitude in deciding which patients can be assigned a care manager. GPs think depression can be treated using a chronic care model that includes care managers but that adjusting to the new way of working will take time.
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Affiliation(s)
- Sandra af Winklerfelt Hammarberg
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden;
- Academic Primary Health Care Centre, Stockholm County Council, Stockholm, Sweden;
- CONTACT Sandra af Winklerfelt Hammarberg Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels Allé 23, Huddinge 141 52, Stockholm, Sweden
| | - Dominique Hange
- Department of Public Health and Community Medicine, Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
| | - Malin André
- Department of Public Health and Caring Sciences – Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden;
| | - Camilla Udo
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden;
- CKF, Center for Clinical Research Dalarna, Falun, Sweden;
| | - Irene Svenningsson
- Department of Public Health and Community Medicine, Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
- Närhälsan Research and Development Primary Health Care, Region Västra Götaland, Gothenburg, Sweden;
| | - Cecilia Björkelund
- Department of Public Health and Community Medicine, Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
| | - Eva-Lisa Petersson
- Department of Public Health and Community Medicine, Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
- Närhälsan Research and Development Primary Health Care, Region Västra Götaland, Gothenburg, Sweden;
| | - Jeanette Westman
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden;
- Academic Primary Health Care Centre, Stockholm County Council, Stockholm, Sweden;
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
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Liu H, Mohammed A, Shanthosh J, News M, Laba TL, Hackett ML, Peiris D, Jan S. Process evaluations of primary care interventions addressing chronic disease: a systematic review. BMJ Open 2019; 9:e025127. [PMID: 31391188 PMCID: PMC6687007 DOI: 10.1136/bmjopen-2018-025127] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVE Process evaluations (PEs) alongside randomised controlled trials of complex interventions are valuable because they address questions of for whom, how and why interventions had an impact. We synthesised the methods used in PEs of primary care interventions, and their main findings on implementation barriers and facilitators. DESIGN Systematic review using the UK Medical Research Council guidance for PE as a guide. DATA SOURCES Academic databases (MEDLINE, SCOPUS, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, EMBASE and Global Health) were searched from 1998 until June 2018. ELIGIBILITY CRITERIA We included PE alongside randomised controlled trials of primary care interventions which aimed to improve outcomes for patients with non-communicable diseases. DATA EXTRACTION AND SYNTHESIS Two independent reviewers screened and conducted the data extraction and synthesis, with a third reviewer checking a sample for quality assurance. RESULTS 69 studies were included. There was an overall lack of consistency in how PEs were conducted and reported. The main weakness is that only 30 studies were underpinned by a clear intervention theory often facilitated by the use of existing theoretical frameworks. The main strengths were robust sampling strategies, and the triangulation of qualitative and quantitative data to understand an intervention's mechanisms. Findings were synthesised into three key themes: (1) a fundamental mismatch between what the intervention was designed to achieve and local needs; (2) the required roles and responsibilities of key actors were often not clearly understood; and (3) the health system context-factors such as governance, financing structures and workforce-if unanticipated could adversely impact implementation. CONCLUSION Greater consistency is needed in the reporting and the methods of PEs, in particular greater use of theoretical frameworks to inform intervention theory. More emphasis on formative research in designing interventions is needed to align the intervention with the needs of local stakeholders, and to minimise unanticipated consequences due to context-specific barriers. PROSPERO REGISTRATION NUMBER CRD42016035572.
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Affiliation(s)
- Hueiming Liu
- University of Sydney, Sydney, New South Wales, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Alim Mohammed
- The George Institute for Global Health, Hyderabad, India
| | - Janani Shanthosh
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Madeline News
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Tracey-Lea Laba
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
- Menzies Centre for Health Policy, University of Sydney, Sydney, New South Wales, Australia
| | - Maree L Hackett
- University of Sydney, Sydney, New South Wales, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - David Peiris
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Stephen Jan
- University of Sydney, Sydney, New South Wales, Australia
- The George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
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Overbeck G, Kousgaard MB, Davidsen AS. The work and challenges of care managers in the implementation of collaborative care: A qualitative study. J Psychiatr Ment Health Nurs 2018; 25:167-175. [PMID: 29283474 DOI: 10.1111/jpm.12449] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/20/2017] [Indexed: 11/29/2022]
Abstract
UNLABELLED WHAT IS KNOWN ON THE SUBJECT?: In collaborative care models between psychiatry and general practice, mental health nurses are used as care managers who carry out the treatment of patients with anxiety or depression in general practice and establish a collaborating relationship with the general practitioner. Although the care manager is the key person in the collaborative care model, there is little knowledge about this role and the challenges involved in it. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Our study shows that before the CMs could start treating patients in a routine collaborative relationship with GPs, they needed to carry out an extensive amount of implementation work. This included solving practical problems of location and logistics, engaging GPs in the intervention, and tailoring collaboration to meet the GP's particular preferences. Implementing the role requires high commitment and an enterprising approach on the part of the care managers. The very experienced mental health nurses of this study had these skills. However, the same expertise cannot be presumed in a disseminated model. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: When introducing new collaborative care interventions, the care manager role should be well defined and be well prepared, especially as regards the arrival of the care manager in general practice, and supported during implementation by a coordinated leadership established in collaboration between hospital psychiatry and representatives from general practice. ABSTRACT Introduction In collaborative care models for anxiety and depression, the care manager (CM), often a mental health nurse, has a key role. However, the work and challenges related to this role remain poorly investigated. Aim To explore CMs' experiences of their work and the challenges they face when implementing their role in a collaborative care intervention in the Capital Region of Denmark. Methods Interviews with eight CMs, a group interview with five CMs and a recording of one supervision session were analysed by thematic analysis. Results The CM carried out considerable implementation work. This included finding suitable locations; initiating and sustaining communication with the GPs and maintaining their engagement in the model; adapting to the patient population in general practice; dealing with personal security issues, and developing supportive peer relations and meaningful supervision. Discussion We compare our findings to previous studies of collaborative care and advanced nursing roles in general practice. The importance of organizational leadership to support the CM's bridge-building role is emphasized. Implications for practice The planners of new collaborative care interventions should not only focus on the CM's clinical tasks but also on ensuring the sufficient organizational conditions for carrying out the role.
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Affiliation(s)
- G Overbeck
- The Research Unit for General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - M B Kousgaard
- The Research Unit for General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
| | - A S Davidsen
- The Research Unit for General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, Copenhagen, Denmark
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Wood E, Ohlsen S, Ricketts T. What are the barriers and facilitators to implementing Collaborative Care for depression? A systematic review. J Affect Disord 2017; 214:26-43. [PMID: 28266319 DOI: 10.1016/j.jad.2017.02.028] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 01/26/2017] [Accepted: 02/13/2017] [Indexed: 10/20/2022]
Abstract
BACKGROUND Collaborative Care is an evidence-based approach to the management of depression within primary care services recommended within NICE Guidance. However, uptake within the UK has been limited. This review aims to investigate the barriers and facilitators to implementing Collaborative Care. METHODS A systematic review of the literature was undertaken to uncover what barriers and facilitators have been reported by previous research into Collaborative Care for depression in primary care. RESULTS The review identified barriers and facilitators to successful implementation of Collaborative Care for depression in 18 studies across a range of settings. A framework analysis was applied using the Collaborative Care definition. The most commonly reported barriers related to the multi-professional approach, such as staff and organisational attitudes to integration, and poor inter-professional communication. Facilitators to successful implementation particularly focussed on improving inter-professional communication through standardised care pathways and case managers with clear role boundaries and key underpinning personal qualities. LIMITATIONS Not all papers were independent title and abstract screened by multiple reviewers thus limiting the reliability of the selected studies. There are many different frameworks for assessing the quality of qualitative research and little consensus as to which is most appropriate in what circumstances. The use of a quality threshold led to the exclusion of six papers that could have included further information on barriers and facilitators. CONCLUSIONS Although the evidence base for Collaborative Care is strong, and the population within primary care with depression is large, the preferred way to implement the approach has not been identified.
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Affiliation(s)
- Emily Wood
- School of Health and Related Research, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, United Kingdom.
| | - Sally Ohlsen
- School of Health and Related Research, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, United Kingdom
| | - Thomas Ricketts
- School of Health and Related Research, The University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, United Kingdom; Sheffield Health and Social Care NHS FT, St George's Community Health Centre, Winter Street, Sheffield S3 7ND, United Kingdom
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9
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Overbeck G, Davidsen AS, Kousgaard MB. Enablers and barriers to implementing collaborative care for anxiety and depression: a systematic qualitative review. Implement Sci 2016; 11:165. [PMID: 28031028 PMCID: PMC5192575 DOI: 10.1186/s13012-016-0519-y] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 11/01/2016] [Indexed: 12/26/2022] Open
Abstract
Background Collaborative care is an increasingly popular approach for improving quality of care for people with mental health problems through an intensified and structured collaboration between primary care providers and health professionals with specialized psychiatric expertise. Trials have shown significant positive effects for patients suffering from depression, but since collaborative care is a complex intervention, it is important to understand the factors which affect its implementation. We present a qualitative systematic review of the enablers and barriers to implementing collaborative care for patients with anxiety and depression. Methods We developed a comprehensive search strategy in cooperation with a research librarian and performed a search in five databases (EMBASE, PubMed, PsycINFO, ProQuest, and CINAHL). All authors independently screened titles and abstracts and reviewed full-text articles. Studies were included if they were published in English and based on the original qualitative data on the implementation of a collaborative care intervention targeted at depression or anxiety in an adult patient population in a high-income country. Our subsequent analysis employed the normalization process theory (NPT). Results We included 17 studies in our review of which 11 were conducted in the USA, five in the UK, and one in Canada. We identified several barriers and enablers within the four major analytical dimensions of NPT. Securing buy-in among primary care providers was found to be critical but sometimes difficult. Enablers included physician champions, reimbursement for extra work, and feedback on the effectiveness of collaborative care. The social and professional skills of the care managers seemed critical for integrating collaborative care in the primary health care clinic. Day-to-day implementation was also found to be facilitated by the care managers being located in the clinic since this supports regular face-to-face interactions between physicians and care managers. Conclusions The following areas require special attention when planning collaborative care interventions: effective educational programs, especially for care managers; issues of reimbursement in relation to primary care providers; good systems for communication and monitoring; and promoting face-to-face interaction between care managers and physicians, preferably through co-location. There is a need for well-sampled, in-depth qualitative studies on the implementation of collaborative care in settings outside the USA and the UK. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0519-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gritt Overbeck
- The Research Unit for General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, København, Denmark.
| | - Annette Sofie Davidsen
- The Research Unit for General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, København, Denmark
| | - Marius Brostrøm Kousgaard
- The Research Unit for General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, København, Denmark
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Eckstrom J, Williams D, Avery M, Unützer J. The utility of a caseload registry: perceptions of behavioral health clinicians working in an integrated primary care and mental health program. Gen Hosp Psychiatry 2015; 37:329-34. [PMID: 25907986 DOI: 10.1016/j.genhosppsych.2015.03.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Revised: 03/20/2015] [Accepted: 03/23/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVES This study evaluated the perceived benefits and limitations of a Web-based clinical support tool for behavioral health clinicians serving patients in an integrated primary care and mental health program in Washington State community health centers. METHODS We surveyed 71 clinicians who utilize a Web-based clinical support tool ("the caseload registry") in treating patients. Follow-up interviews were scheduled with a subset (n=32) of respondents. Comments made during these interviews were analyzed using qualitative methods. RESULTS Survey responses were favorable on 4 of 7 questions regarding specific benefits of the caseload registry. Notably, clinicians agreed that the caseload registry helps track patients and their clinical progress. Clinicians also agreed that the caseload registry adds an additional documentation burden to their work duties. The most common positive themes identified during follow-up interviews were that the registry is useful and improves care. The most common critical themes identified were that the tool is burdensome and sometimes does not encompass important elements of care. CONCLUSIONS Behavioral health clinicians working in an integrated primary care and mental health program report that use of a caseload registry adds value and improves care. They express that it helps provide more comprehensive care and tracks patient progress.
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Affiliation(s)
- Jessica Eckstrom
- Medical Student Research Training Program, University of Washington School of Medicine, Seattle, WA 98105, USA.
| | - Dallas Williams
- Medical Student Research Training Program, University of Washington School of Medicine, Seattle, WA 98105, USA.
| | - Marc Avery
- AIMS Center, Division of Integrated Care and Public Health, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195-6560, USA.
| | - Jürgen Unützer
- AIMS Center, Division of Integrated Care and Public Health, Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA 98195-6560, USA.
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11
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Williams D, Eckstrom J, Avery M, Unützer J. Perspectives of Behavioral Health Clinicians in a Rural Integrated Primary Care/Mental Health Program. J Rural Health 2015; 31:346-53. [DOI: 10.1111/jrh.12114] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Dallas Williams
- Medical Student Research Training Program; University of Washington School of Medicine; Seattle Washington
- Advancing Integrated Mental Health Solutions (AIMS) Center, Division of Integrated Care and Public Health, Department of Psychiatry and Behavioral Sciences; University of Washington; Seattle Washington
| | - Jessica Eckstrom
- Medical Student Research Training Program; University of Washington School of Medicine; Seattle Washington
- Advancing Integrated Mental Health Solutions (AIMS) Center, Division of Integrated Care and Public Health, Department of Psychiatry and Behavioral Sciences; University of Washington; Seattle Washington
| | - Marc Avery
- Advancing Integrated Mental Health Solutions (AIMS) Center, Division of Integrated Care and Public Health, Department of Psychiatry and Behavioral Sciences; University of Washington; Seattle Washington
- Medical Student Research Training Program; University of Washington School of Medicine; Seattle Washington
| | - Jürgen Unützer
- Advancing Integrated Mental Health Solutions (AIMS) Center, Division of Integrated Care and Public Health, Department of Psychiatry and Behavioral Sciences; University of Washington; Seattle Washington
- Medical Student Research Training Program; University of Washington School of Medicine; Seattle Washington
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Eghaneyan BH, Sanchez K, Mitschke DB. Implementation of a collaborative care model for the treatment of depression and anxiety in a community health center: results from a qualitative case study. J Multidiscip Healthc 2014; 7:503-13. [PMID: 25395860 PMCID: PMC4226460 DOI: 10.2147/jmdh.s69821] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND The collaborative care model is a systematic approach to the treatment of depression and anxiety in primary care settings that involves the integration of care managers and consultant psychiatrists, with primary care physician oversight, to more proactively manage mental disorders as chronic diseases, rather than treating acute symptoms. While collaborative care has been shown to be more effective than usual primary care in improving depression outcomes in a number of studies, less is known about the factors that support the translation of this evidence-based intervention to real-world program implementation. The purpose of this case study was to examine the implementation of a collaborative care model in a community based primary care clinic that primarily serves a low-income, uninsured Latino population, in order to better understand the interdisciplinary relationships and the specific elements that might facilitate broader implementation. METHODS An embedded single-case study design was chosen in order to thoroughly examine the components of one of several programs within a single organization. The main unit of analysis was semi-structured interviews that were conducted with seven clinical and administrative staff members. A grounded theory approach was used to analyze the interviews. Line-by-line initial coding resulted in over 150 initial codes, which were clustered together to rebuild the data into preliminary categories and then divided into four final categories, or main themes. RESULTS FOUR UNIQUE THEMES ABOUT HOW THE IMPLEMENTATION OF A COLLABORATIVE CARE MODEL WORKED IN THIS SETTING EMERGED FROM THE INTERVIEWS: organizational change, communication, processes and outcomes of the program, and barriers to implementation. Each main theme had a number of subthemes that provided a detailed description of the implementation process and how it was unique in this setting. CONCLUSION The results indicated that adequate training and preparation, acceptance and support from key personnel, communication barriers, tools for systematic follow-up and measurement, and organizational stability can significantly impact successful implementation. Further research is necessary to understand how organizational challenges may affect outcomes for patients.
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Affiliation(s)
| | - Katherine Sanchez
- School of Social Work, The University of Texas at Arlington, Arlington, TX, USA
| | - Diane B Mitschke
- School of Social Work, The University of Texas at Arlington, Arlington, TX, USA
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Sims S, Hewitt G, Harris R. Evidence of collaboration, pooling of resources, learning and role blurring in interprofessional healthcare teams: a realist synthesis. J Interprof Care 2014; 29:20-5. [DOI: 10.3109/13561820.2014.939745] [Citation(s) in RCA: 102] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Markle-Reid M, McAiney C, Forbes D, Thabane L, Gibson M, Browne G, Hoch JS, Peirce T, Busing B. An interprofessional nurse-led mental health promotion intervention for older home care clients with depressive symptoms. BMC Geriatr 2014; 14:62. [PMID: 24886344 PMCID: PMC4019952 DOI: 10.1186/1471-2318-14-62] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 04/24/2014] [Indexed: 11/10/2022] Open
Abstract
Background Depressive symptoms in older home care clients are common but poorly recognized and treated, resulting in adverse health outcomes, premature institutionalization, and costly use of health services. The objectives of this study were to examine the feasibility and acceptability of a new six-month interprofessional (IP) nurse-led mental health promotion intervention, and to explore its effects on reducing depressive symptoms in older home care clients (≥ 70 years) using personal support services. Methods A prospective one-group pre-test/post-test study design was used. The intervention was a six-month evidence-based depression care management strategy led by a registered nurse that used an IP approach. Of 142 eligible consenting participants, 98 (69%) completed the six-month and 87 (61%) completed the one-year follow-up. Outcomes included depressive symptoms, anxiety, health-related quality of life (HRQoL), and the costs of use of all types of health services at baseline and six-month and one-year follow-up. An interpretive descriptive design was used to explore clients’, nurses’, and personal support workers’ perceptions about the intervention’s appropriateness, benefits, and barriers and facilitators to implementation. Results Of the 142 participants, 56% had clinically significant depressive symptoms, with 38% having moderate to severe symptoms. The intervention was feasible and acceptable to older home care clients with depressive symptoms. It was effective in reducing depressive symptoms and improving HRQoL at six-month follow-up, with small additional improvements six months after the intervention. The intervention also reduced anxiety at one year follow-up. Significant reductions were observed in the use of hospitalization, ambulance services, and emergency room visits over the study period. Conclusions Our findings provide initial evidence for the feasibility, acceptability, and sustained effects of the nurse-led mental health promotion intervention in improving client outcomes, reducing use of expensive health services, and improving clinical practice behaviours of home care providers. Future research should evaluate its efficacy using a randomized clinical trial design, in different settings, with an adequate sample of older home care recipients with depressive symptoms. Trial registration Clinicaltrials.gov identifier: NCT01407926.
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Riebe G, Fan MY, Unützer J, Vannoy S. Activity scheduling as a core component of effective care management for late-life depression. Int J Geriatr Psychiatry 2012; 27:1298-304. [PMID: 22367982 PMCID: PMC3429703 DOI: 10.1002/gps.3784] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2011] [Accepted: 01/12/2012] [Indexed: 11/05/2022]
Abstract
BACKGROUND Activity scheduling is an established component of evidenced-based treatment for late-life depression in primary care. We examined participant records from the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial to identify activity scheduling strategies used in the context of successful depression care management (CM), associations of activity scheduling with self-reported activity engagement, and depression outcomes. METHODS This study used observational mixed methods analysis of 4335 CM session notes from 597 participants in the intervention arm of the IMPACT trial. Grounded theory was used to identify 17 distinct activity categories from CM notes. Logistic regression was used to evaluate associations between activity scheduling, activity engagement, and depression outcomes at 12 months. All relevant institutional review boards approved the research protocol. RESULTS Seventeen distinct activity categories were generated. Most patients worked on at least one social and one solitary activity during their course of treatment. Common activity categories included physical activity (32%), medication management (22%), active-non-physical (19%), and passive (14%) activities. We found significant, positive associations between activity scheduling, self-reported engagement in activities at 12 months, and depression outcomes at 12 months. CONCLUSION Older primary care patients in CM for depression worked on a wide range of activities. Consistent with depression theory that has placed emphasis on social activities, the data indicate a benefit for intentional social engagement versus passive social and solitary activities. Care managers should encourage patients to balance instrumental activities (e.g., attending to medical problems) with social activities targeting direct interpersonal engagement.
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Affiliation(s)
- Genevieve Riebe
- University of Washington School of Medicine, Seattle, WA, USA.
| | - Ming-Yu Fan
- University of Washington; Department of Psychiatry
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Huang H, Bauer AM, Wasse JK, Ratzliff A, Chan YF, Harrison D, Unützer J. Care managers' experiences in a collaborative care program for high risk mothers with depression. PSYCHOSOMATICS 2012. [PMID: 23194928 DOI: 10.1016/j.psym.2012.07.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES The aim of this study was to understand care managers' experiences in caring for depressed mothers in an integrated behavioral health program. METHODS As part of a quality improvement project, we conducted a focus group interview with six care managers caring for low income mothers with behavioral health needs in a safety net program in King County, WA. Using thematic analysis, codes were organized into themes that described the care managers' experiences. RESULTS Two organizing themes along with associated themes emerged: (1) Assets for improving depression outcomes: patient-provider interactions, including the importance of engagement; program resources such as care coordination and (2) Barriers to improved depression outcomes: patient-provider interactions, including difficulty engaging patient; patient-related factors such as multiple stressors; program resources such as need for more psychiatric support; and difficulty accessing outside resources. CONCLUSIONS Numerous potentially modifiable factors including levels of engagement, motivational interviewing, and increased psychiatric support were identified by care managers as affecting depression care and outcomes. Implications for care management training and approaches to psychiatric consultations are discussed.
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Affiliation(s)
- Hsiang Huang
- Cambridge Health Alliance, Department of Psychiatry, Harvard Medical School, 1493 Cambridge Street, Cambridge, MA 02139, USA.
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The incidence of depression and its risk factors in Dutch nursing homes and residential care homes. Am J Geriatr Psychiatry 2012; 20:932-42. [PMID: 22828203 DOI: 10.1097/jgp.0b013e31825d08ac] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVE Although it is known that depression is highly prevalent in institutionalized older adults, little is known about its incidence and risk factors in nursing homes and residential care homes. The aim of this study was to investigate and compare the incidence and associated risk factors for depression in Dutch nursing homes and residential care homes. DESIGN Data on depression were extracted from the Vrije Universiteit naturalistic cohort on routine care monitoring with the Minimum Data Set of the Resident Assessment Instrument. PARTICIPANTS A total of 1,324 residents in six nursing homes and 1,723 residents in 23 residential care homes with an average follow-up of 1.2 years. MEASUREMENTS Depression was defined as a clinical diagnosis according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria and the use of antidepressants. Residents with prevalent depression at baseline were excluded. RESULTS The incidence rate was 13.6 per 100 person years in the nursing homes and 10.2 per 100 person years in the residential care homes. The independent risk factors for in-home depression for residents in nursing homes included dementia (OR: 1.7; 95% CI: 1.02-2.95) and a score of 3 or more on the Depression Rating Scale (odds ratio [OR]: 2.1; 95% confidence interval [CI]: 1.23-3.70). A protective effect was seen on the use of a hearing aid (OR: 0.3; 95% CI: 0.12-0.80). In the residential care homes, being male (OR: 2.1; 95% CI: 1.27-3.30), having cancer (OR: 2.9; 95% CI: 1.64-4.95), and a score of 2 or higher on the Cognitive Performance Scale (OR: 1.5; 95% CI: 1.05-2.22) increased the risk to develop depression. Age greater than 85 years (OR: 0.5; 95% CI: 0.31-0.67) and hearing impairment (OR: 0.8; 95% CI: 0.60-1.00) appeared to be protective. CONCLUSIONS The incidence rate for depression in residents of Dutch nursing homes and residential care homes was high and the associated risk factors found may have important implications for staff.
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Archer J, Bower P, Gilbody S, Lovell K, Richards D, Gask L, Dickens C, Coventry P. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev 2012; 10:CD006525. [PMID: 23076925 DOI: 10.1002/14651858.cd006525.pub2] [Citation(s) in RCA: 445] [Impact Index Per Article: 37.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
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.
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Affiliation(s)
- Janine Archer
- School of Nursing, Midwifery and Social Work, The University of Manchester, Manchester, UK.
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Ladin K. Decomposing differences in utilization of health services between depressed and non-depressed elders in Europe. Eur J Ageing 2012; 9:51-64. [PMID: 23087601 DOI: 10.1007/s10433-011-0213-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Utilization rates of non-psychiatric health services are often higher in depressed compared to non-depressed adults. We examine whether these differences can be explained by the increased prevalence or the increased impact of demographic, socioeconomic, geographic, and health-related factors. The sample was taken from The Survey of Health, Ageing and Retirement in Europe (Wave 1 Release 2), a prospective observational study of 31,115 randomly selected people ages 50+ living in Austria, Germany, Sweden, the Netherlands, Spain, Italy, France, Denmark, Greece, Switzerland, Belgium, and Israel. Blinder-Oaxaca decomposition methods for multivariate linear regression models were used to estimate the influence of prevalence and impact of covariates on utilization among depressed and non-depressed participants. We find robust evidence that the gap in utilization between depressed and non-depressed can be accounted for by both prevalence (explained) and impact (unexplained) differences. The prevalence effect accounted for 57.7% whereas differences in the impact of covariates between depressed and non-depressed persons explained 42.3% of differences in utilization rates. Despite cross-national differences in quality and coverage of health services, in all countries, the prevalence effect was explained entirely by health measures, including: chronic diseases, functional mobility, painful symptoms, and self-reported health. The impact effect varied cross-nationally, but was largely explained by socioeconomic status and urbanicity. Hospitalization among depressed adults was twice that of non-depressed adults. Policies aimed at improving adherence and improving disease management among depressed adults should be explored.
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Affiliation(s)
- Keren Ladin
- Interfaculty Initiative on Health Policy, Harvard University, 14 Story St., 4th Floor, Cambridge, MA 02138, USA,
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Kelly BJ, Perkins DA, Fuller JD, Parker SM. Shared care in mental illness: A rapid review to inform implementation. Int J Ment Health Syst 2011; 5:31. [PMID: 22104323 PMCID: PMC3235059 DOI: 10.1186/1752-4458-5-31] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2011] [Accepted: 11/21/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND While integrated primary healthcare for the management of depression has been well researched, appropriate models of primary care for people with severe and persistent psychotic disorders are poorly understood. In 2010 the NSW (Australia) Health Department commissioned a review of the evidence on "shared care" models of ambulatory mental health services. This focussed on critical factors in the implementation of these models in clinical practice, with a view to providing policy direction. The review excluded evidence about dementia, substance use and personality disorders. METHODS A rapid review involving a search for systematic reviews on The Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects (DARE). This was followed by a search for papers published since these systematic reviews on Medline and supplemented by limited iterative searching from reference lists. RESULTS Shared care trials report improved mental and physical health outcomes in some clinical settings with improved social function, self management skills, service acceptability and reduced hospitalisation. Other benefits include improved access to specialist care, better engagement with and acceptability of mental health services. Limited economic evaluation shows significant set up costs, reduced patient costs and service savings often realised by other providers. Nevertheless these findings are not evident across all clinical groups. Gains require substantial cross-organisational commitment, carefully designed and consistently delivered interventions, with attention to staff selection, training and supervision. Effective models incorporated linkages across various service levels, clinical monitoring within agreed treatment protocols, improved continuity and comprehensiveness of services. CONCLUSIONS "Shared Care" models of mental health service delivery require attention to multiple levels (from organisational to individual clinicians), and complex service re-design. Re-evaluation of the roles of specialist mental health staff is a critical requirement. As expected, no one model of "shared" care fits diverse clinical groups. On the basis of the available evidence, we recommended a local trial that examined the process of implementation of core principles of shared care within primary care and specialist mental health clinical services.
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Affiliation(s)
- Brian J Kelly
- Centre for Brain and Mental Health Research, School of Medicine and Public Health, Faculty of Health University of Newcastle, University Drive, Callaghan 2308, Australia
| | - David A Perkins
- School of Nursing & Midwifery, Flinders University, Sturt Rd, Bedford Park 5024, Australia
| | - Jeffrey D Fuller
- Centre for Remote Health Research, Broken Hill University Department of Rural Health, University of Sydney, Corrindah Court, Broken Hill 2880, Australia
| | - Sharon M Parker
- Centre for Remote Health Research, Broken Hill University Department of Rural Health, University of Sydney, Corrindah Court, Broken Hill 2880, Australia
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Markle-Reid MF, McAiney C, Forbes D, Thabane L, Gibson M, Hoch JS, Browne G, Peirce T, Busing B. Reducing depression in older home care clients: design of a prospective study of a nurse-led interprofessional mental health promotion intervention. BMC Geriatr 2011; 11:50. [PMID: 21867539 PMCID: PMC3184267 DOI: 10.1186/1471-2318-11-50] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2011] [Accepted: 08/25/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Very little research has been conducted in the area of depression among older home care clients using personal support services. These older adults are particularly vulnerable to depression because of decreased cognition, comorbid chronic conditions, functional limitations, lack of social support, and reduced access to health services. To date, research has focused on collaborative, nurse-led depression care programs among older adults in primary care settings. Optimal management of depression among older home care clients is not currently known. The objective of this study is to evaluate the feasibility, acceptability and effectiveness of a 6-month nurse-led, interprofessional mental health promotion intervention aimed at older home care clients with depressive symptoms using personal support services. METHODS/DESIGN This one-group pre-test post-test study aims to recruit a total of 250 long-stay (> 60 days) home care clients, 70 years or older, with depressive symptoms who are receiving personal support services through a home care program in Ontario, Canada. The nurse-led intervention is a multi-faceted 6-month program led by a Registered Nurse that involves regular home visits, monthly case conferences, and evidence-based assessment and management of depression using an interprofessional approach. The primary outcome is the change in severity of depressive symptoms from baseline to 6 months using the Centre for Epidemiological Studies in Depression Scale. Secondary outcomes include changes in the prevalence of depressive symptoms and anxiety, health-related quality of life, cognitive function, and the rate and appropriateness of depression treatment from baseline to 12 months. Changes in the costs of use of health services will be assessed from a societal perspective. Descriptive and qualitative data will be collected to examine the feasibility and acceptability of the intervention and identify barriers and facilitators to implementation. DISCUSSION Data collection began in May 2010 and is expected to be completed by July 2012. A collaborative nurse-led strategy may provide a feasible, acceptable and effective means for improving the health of older home care clients by improving the prevention, recognition, and management of depression in this vulnerable population. The challenges involved in designing a practical, transferable and sustainable nurse-led intervention in home care are also discussed. TRIAL REGISTRATION ClinicalTrials.gov: NCT01407926.
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Fuller JD, Perkins D, Parker S, Holdsworth L, Kelly B, Roberts R, Martinez L, Fragar L. Effectiveness of service linkages in primary mental health care: a narrative review part 1. BMC Health Serv Res 2011; 11:72. [PMID: 21481236 PMCID: PMC3079614 DOI: 10.1186/1472-6963-11-72] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Accepted: 04/11/2011] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND With the move to community care and increased involvement of generalist health care providers in mental health, the need for health service partnerships has been emphasised in mental health policy. Within existing health system structures the active strategies that facilitate effective partnership linkages are not clear. The objective of this study was to examine the evidence from peer reviewed literature regarding the effectiveness of service linkages in primary mental health care. METHODS A narrative and thematic review of English language papers published between 1998 and 2009. Studies of analytic, descriptive and qualitative designs from Australia, New Zealand, UK, Europe, USA and Canada were included. Data were extracted to examine what service linkages have been used in studies of collaboration in primary mental health care. Findings from the randomised trials were tabulated to show the proportion that demonstrated clinical, service delivery and economic benefits. RESULTS A review of 119 studies found ten linkage types. Most studies used a combination of linkage types and so the 42 RCTs were grouped into four broad linkage categories for meaningful descriptive analysis of outcomes. Studies that used multiple linkage strategies from the suite of "direct collaborative activities" plus "agreed guidelines" plus "communication systems" showed positive clinical (81%), service (78%) and economic (75%) outcomes. Most evidence of effectiveness came from studies of depression. Long term benefits were attributed to medication concordance and the use of case managers with a professional background who received expert supervision. There were fewer randomised trials related to collaborative care of people with psychosis and there were almost none related to collaboration with the wider human service sectors. Because of the variability of study types we did not exclude on quality or attempt to weight findings according to power or effect size. CONCLUSION There is strong evidence to support collaborative primary mental health care for people with depression when linkages involve "direct collaborative activity", plus "agreed guidelines" and "communication systems".
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Affiliation(s)
- Jeffrey D Fuller
- School of Nursing and Midwifery, Flinders University, Adelaide, Australia
- Northern Rivers University Department of Rural Health, School of Public Health, Sydney University, Lismore, Australia
| | - David Perkins
- Broken Hill University Department of Rural Health, School of Public Health, Sydney University, Broken Hill, Australia
| | | | - Louise Holdsworth
- Northern Rivers University Department of Rural Health, School of Public Health, Sydney University, Lismore, Australia
- School of Tourism & Hospitality Management, Centre for Gambling Education & Research, Southern Cross University, Lismore, Australia
| | - Brian Kelly
- Faculty of Medicine, University of Newcastle, Newcastle, Australia
| | - Russell Roberts
- Greater Western Area Health Service, Orange, New South Wales, Australia
| | - Lee Martinez
- South Australian Department of Health, Adelaide, Australia
| | - Lyn Fragar
- Australian Centre for Agricultural Health and Safety, School of Public Health, Sydney University, Moree, Australia
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Fuller JD, Perkins D, Parker S, Holdsworth L, Kelly B, Roberts R, Martinez L, Fragar L. Building effective service linkages in primary mental health care: a narrative review part 2. BMC Health Serv Res 2011; 11:66. [PMID: 21435273 PMCID: PMC3070626 DOI: 10.1186/1472-6963-11-66] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2010] [Accepted: 03/25/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Primary care services have not generally been effective in meeting mental health care needs. There is evidence that collaboration between primary care and specialist mental health services can improve clinical and organisational outcomes. It is not clear however what factors enable or hinder effective collaboration. The objective of this study was to examine the factors that enable effective collaboration between specialist mental health services and primary mental health care. METHODS A narrative and thematic review of English language papers published between 1998 and 2009. An expert reference group helped formulate strategies for policy makers. Studies of descriptive and qualitative design from Australia, New Zealand, UK, Europe, USA and Canada were included. Data were extracted on factors reported as enablers or barriers to development of service linkages. These were tabulated by theme at clinical and organisational levels and the inter-relationship between themes was explored. RESULTS A thematic analysis of 30 papers found the most frequently cited group of factors was "partnership formation", specifically role clarity between health care workers. Other factor groups supporting clinical partnership formation were staff support, clinician attributes, clinic physical features and evaluation and feedback. At the organisational level a supportive institutional environment of leadership and change management was important. The expert reference group then proposed strategies for collaboration that would be seen as important, acceptable and feasible. Because of the variability of study types we did not exclude on quality and findings are weighted by the number of studies. Variability in local service contexts limits the generalisation of findings. CONCLUSION The findings provide a framework for health planners to develop effective service linkages in primary mental health care. Our expert reference group proposed five areas of strategy for policy makers that address organisational level support, joint clinical problem solving, local joint care guidelines, staff training and supervision and feedback.
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Affiliation(s)
- Jeffrey D Fuller
- School of Nursing and Midwifery, Flinders University, Adelaide, Australia
- Northern Rivers University Department of Rural Health, School of Public Health, University of Sydney, Lismore, Australia
| | - David Perkins
- Broken Hill University Department of Rural Health, School of Public Health, University of Sydney, Broken Hill, Australia
| | | | - Louise Holdsworth
- Northern Rivers University Department of Rural Health, School of Public Health, University of Sydney, Lismore, Australia
- School of Tourism & Hospitality Management, Centre for Gambling Education & Research, Southern Cross University, Lismore, Australia
| | - Brian Kelly
- Faculty of Medicine, University of Newcastle, Newcastle, Australia
| | - Russell Roberts
- Greater Western Area Health Service, Orange, New South Wales, Australia
| | - Lee Martinez
- South Australian Department of Health, Adelaide, Australia
| | - Lyn Fragar
- Australian Centre for Agricultural Health and Safety, School of Public Health, Sydney University, Moree, Australia
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Finley PR, Bluml BM, Bunting BA, Kiser SN. Clinical and economic outcomes of a pilot project examining pharmacist-focused collaborative care treatment for depression. J Am Pharm Assoc (2003) 2011; 51:40-9. [DOI: 10.1331/japha.2011.09147] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Rose RD, Lang AJ, Welch SS, Campbell-Sills L, Chavira DA, Sullivan G, Sherbourne C, Bystritsky A, Stein MB, Roy-Byrne PP, Craske MG. Training primary care staff to deliver a computer-assisted cognitive-behavioral therapy program for anxiety disorders. Gen Hosp Psychiatry 2011; 33:336-42. [PMID: 21762829 PMCID: PMC3139130 DOI: 10.1016/j.genhosppsych.2011.04.011] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2011] [Revised: 04/22/2011] [Accepted: 04/23/2011] [Indexed: 10/18/2022]
Abstract
OBJECTIVES This paper describes the training approach used with primary care staff to deliver an evidence-based computer-assisted cognitive-behavioral therapy (CBT) program for anxiety disorders within a collaborative care treatment delivery model. METHODS We describe the training and proficiency evaluation procedures utilized in the Coordinated Anxiety Learning and Management (CALM) study, a large multisite study of collaborative care for anxiety disorders in primary care. Training incorporated readings, didactic presentations, video demonstrations of CBT skills, role-plays, computer-assisted practice, CBT training cases and ongoing group supervision provided by study psychologists. RESULTS Proficiency training case data from 15 clinicians are presented. The anxiety clinical specialists (ACSs) were highly proficient at delivering the CBT component of the CALM intervention. The ACSs also provided Likert-scale ratings and open-ended responses about their experiences with the training. Overall, the training was rated very positively and was described as very thorough, indicating a high level of acceptability to clinicians. Recommendations for future training are described. CONCLUSIONS Primary care staff with none or minimal prior CBT experience can be trained to deliver a computer-assisted, evidence-based treatment for anxiety disorders. The implications for dissemination and transportability of evidenced-based interventions are discussed.
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Affiliation(s)
- Raphael D. Rose
- University of California, Los Angeles, Department of Psychology
| | - Ariel J. Lang
- University of California, San Diego, Department of Psychiatry,VA San Diego Healthcare System
| | - Stacy Shaw Welch
- University of Washington at Harborview Medical Center and CHAMMP
| | | | | | | | | | - Alexander Bystritsky
- University of California, Los Angeles, Department of Psychiatry and Biobehavioral Sciences
| | - Murray B. Stein
- University of California, San Diego, Department of Psychiatry and Department of Family & Preventive Medicine
| | | | - Michelle G. Craske
- University of California, Los Angeles, Department of Psychology,University of California, Los Angeles, Department of Psychiatry and Biobehavioral Sciences
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Abstract
OBJECTIVE The aim of this study is to explore primary care physicians' (PCPs) and depression care managers' (DCMs) approaches to diagnosing and treating depression in older men. The authors focus on older men because studies have shown that they are undertreated compared with women and younger groups. The authors contribute to previous research by identifying facilitators of care for older men from the perspective of clinicians. METHODS Participants in this study were part of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial, an effectiveness study of collaborative care for late-life depression in 18 diverse primary care practices. Nine PCPs and 11 DCMs were interviewed to collect information on specific roles in caring for depressed patients and their experiences in working with depressed older men. All interviews were tape-recorded, transcribed verbatim, and analyzed thematically in several steps using standard qualitative data analysis techniques. RESULTS : The authors identified three general approaches to building trust and talking about the depression: 1) an indirect approach ("call it something else"), 2) a gradual approach ("building up to depression"), and 3) a direct approach ("shock and awe"). The authors also found specific strategies that PCPs and DCMs used to manage depression among elderly male patients, such as increased monitoring of mood, treating somatic symptoms first, medicalizing depression, and enlisting the cooperation of family. In our interviews, enlisting family involvement was the most prominent strategy used by clinicians. CONCLUSIONS A variety of approaches and strategies are used by clinicians for diagnosing and treating depressed older men. Clinicians change strategies as a response to a patient's compliance with treatment and the decision about which strategy to pursue is usually made on an "on-the-go" basis throughout the course of clinician-patient interaction. Based on clinicians' experience, depression management requires concerted efforts and persistence, and the family seems to play an important role in how older men receive the diagnosis of depression and adhere to clinicians' prescribed treatment. However, more research is needed to discover the best way of engaging and working with family members to facilitate effective depression care for older adults.
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Alexander JL, Richardson G, Grypma L, Hunkeler EM. Collaborative depression care, screening, diagnosis and specificity of depression treatments in the primary care setting. Expert Rev Neurother 2008; 7:S59-80. [PMID: 18039069 DOI: 10.1586/14737175.7.11s.s59] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
The identification, referral and specific treatment of midlife patients in primary care who are distressed by mood, anxiety, sleep and stress-related symptoms, with or without clinically confirmed menopausal symptoms, are confounded by many structural issues in the delivery of women's healthcare. Diagnosis, care delivery, affordability of treatment, time commitment for treatment, treatment specificity for a particular patient's symptoms and patient receptiveness to diagnosis and treatment all play roles in the successful amelioration of symptoms in this patient population. The value of screening for depression in primary care, the limitations of commonly used screening instruments relative to culture and ethnicity, and which clinical care systems make best use of diagnostic screening programs will be discussed in the context of the midlife woman. The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) program illustrates the relatively high rate of unremitted patients, regardless of clinical setting, who are receiving antidepressants. Nonmedication treatment approaches, referred to in the literature as 'nonsomatic treatments', for depression, anxiety and stress, include different forms of cognitive-behavioral therapy, interpersonal therapy, structured daily activities, mindfulness therapies, relaxation treatment protocols and exercise. The specificity of these treatments, their mechanisms of action, the motivation and time commitment required of patients, and the availability of trained practitioners to deliver them are reviewed. Midlife women with menopausal symptoms and depression/anxiety comorbidity represent a challenging patient population for whom an individualized treatment plan is often necessary. Treatment for depression comorbid with distressing menopausal symptoms would be facilitated by the implementation of a collaborative care program for depression in the primary care setting.
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Ersek M, Turner JA, Cain KC, Kemp CA. Results of a randomized controlled trial to examine the efficacy of a chronic pain self-management group for older adults [ISRCTN11899548]. Pain 2007; 138:29-40. [PMID: 18086516 DOI: 10.1016/j.pain.2007.11.003] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2007] [Revised: 10/13/2007] [Accepted: 11/02/2007] [Indexed: 12/13/2022]
Abstract
Chronic pain is a common, disabling problem in older adults. Pain self-management training is a multimodal therapy that has been found to be effective in young to middle-aged adult samples; however, few studies have examined the effectiveness of this therapy in older adults. In this randomized, controlled trial, we evaluated a pain self-management training group (SMG) intervention as compared with an education-only (BOOK) control condition. Participants, 65 years of age or older who experienced persistent, noncancer pain that limited their activities, were recruited from 43 retirement communities in the Pacific Northwest of the United States. The primary outcome was physical disability, as measured by the Roland-Morris Disability Questionnaire. Secondary outcomes were depression (Geriatric Depression Scale), pain intensity (Brief Pain Inventory), and pain-related interference with activities (Brief Pain Inventory). Randomization occurred by facility to minimize cross-contamination between groups. Two-hundred and fifty-six individuals, mean age=81.8 (SD: 6.5), enrolled and 218 completed the study. No significant differences in outcomes were found between groups at post-intervention, 6-month follow-up, or 12-month follow-up. The SMG group showed a significantly greater increase over time, relative to the BOOK group, in two process measures, as measured by the Chronic Pain Coping Inventory: use of relaxation and use of exercise/stretching. In both cases, the increase was greatest from baseline to the post-intervention assessment. Study findings indicate that additional research is needed to determine the most effective content and delivery methods for self-management therapies targeted at older adults with chronic pain.
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Affiliation(s)
- Mary Ersek
- Pain and Palliative Care Research Department, Swedish Medical Center - Cherry Hill Campus, 500 17th Avenue, Professional Building, Suite 405, Seattle, WA 98122-5711, USA Division of Gerontology and Geriatric Medicine, University of Washington School of Medicine, Seattle, WA, USA Department of Psychiatry and Behavioral Sciences and Department of Rehabilitation Medicine, University of Washington School of Medicine, Box 356560, Seattle, WA 98195-6560, USA Office for Nursing Research, University of Washington School of Nursing, Box 357265, Seattle, WA 98195-7265, USA Department of Biostatistics, University of Washington School of Public Health and Community Medicine, Box 357232, Seattle, WA 98195-7232, USA Oregon Health & Science University School of Nursing, Portland, OR, USA
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Wolf NJ, Hopko DR. Psychosocial and pharmacological interventions for depressed adults in primary care: a critical review. Clin Psychol Rev 2007; 28:131-161. [PMID: 17555857 DOI: 10.1016/j.cpr.2007.04.004] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2006] [Revised: 02/09/2007] [Accepted: 04/20/2007] [Indexed: 11/25/2022]
Abstract
Primary care settings are the principal context for treating clinical depression, with researchers beginning to explore the efficacy of psychosocial and pharmacological treatments for depression within this infrastructure. Feasibility and process variables also are being assessed, including issues of cost-effectiveness, viability of collaborative care models, predictors of treatment outcome, and effectiveness of treatment providers without specialized mental health training. The Agency for Health Care Policy and Research and American Psychiatric Association initially released guidelines for the treatment of depression in primary care [American Psychiatric Association, 1993. Practice Guidelines for major depressive disorder in adults. American Journal of Psychiatry, 150, 1-26., American Psychiatric Association, 2000. Practice Guideline for the treatment of patients with major depressive disorder (revision). American Journal of Psychiatry, 157, 1-45], however, a vast literature has accumulated over the past several years, calling for a systematic re-evaluation of the status of depression treatment in primary care. The present study provides a contemporary review of outcome data for psychosocial and pharmacological interventions in primary care and extends beyond AHCPR guidelines insofar as focusing on feasibility and process variables, including the training and proficiency of primary care treatment providers, cost-effectiveness of primary care interventions, and predictors of treatment response and relapse. Based on current guidelines, problem-solving therapy (PST-PC), interpersonal psychotherapy, and pharmacotherapy would be considered efficacious interventions for major depression, with cognitive-behavioral and cognitive therapy considered possibly efficacious. Psychotherapy and pharmacotherapy generally are of comparable efficacy, and both modalities are superior to usual care in treating depression. Methodological limitations and directions for future research are discussed.
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Affiliation(s)
- Nicole J Wolf
- The University of Tennessee - Knoxville, United States
| | - Derek R Hopko
- The University of Tennessee - Knoxville, United States.
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Hinton L, Zweifach M, Oishi S, Tang L, Unützer J. Gender disparities in the treatment of late-life depression: qualitative and quantitative findings from the IMPACT trial. Am J Geriatr Psychiatry 2006; 14:884-92. [PMID: 17001028 DOI: 10.1097/01.jgp.0000219282.32915.a4] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The objectives of this study were to examine gender differences in recruitment, depression presentation, and depression treatment history in a large effectiveness trial; and to use qualitative data to generate hypotheses about reasons for observed gender differences. METHODS Data from IMPACT, a multisite trial of a disease management program for late-life depression in primary care were used to examine gender differences quantitatively. Qualitative interviews were conducted with 30 key informants from IMPACT (referring physicians, depression care managers, and study recruiters) to learn more about challenges in recruiting and treating depressed older men and then analyzed thematically. RESULTS Compared with older women, older men were significantly less likely to be referred to IMPACT, to endorse core depressive symptoms, and to have received prior depression treatment. Gender differences in prior depression treatment persisted after adjustment for covariates. Qualitative themes identified as important contributors to gender disparities included 1) how men experience and express their depression, 2) traditional masculine values, and 3) the stigma of chronic mental illness. CONCLUSION This study provides further evidence of the gender gap in depression care, identifies possible contributing factors, and suggests avenues for future research.
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Affiliation(s)
- Ladson Hinton
- Department of Psychiatry and Behavioral Sciences, University of California-Davis School of Medicine, Sacramento, California 95817, USA.
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Abstract
This paper provides an overview of five key bodies of evidence identifying: (1) Characteristics of depression among older adults -- its prevalence, risk factors and illness course, and impact on functional status, mortality, use of health services, and health care costs; (2) Effective Interventions, including pharmacologic, psychotherapies, care management, and combined intervention models; (3) Known Barriers to depression care including patient, provider and service system barriers; (4) Effective Organizational and Educational Strategies to reduce barriers to depression care; and (5) Key Factors in Translating Research into Practice. There is strong empirical support for implementing strategies to improve depression care for older adults.
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Affiliation(s)
- Kathleen Ell
- School of Social Work, University of Southern Califonia, Los Angeles, CA 90089-0411, USA.
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Geron SM, Keefe B. Moving Evidence-Based Interventions to Populations: A Case Study Using Social Workers in Primary Care. Home Health Care Serv Q 2006; 25:95-113. [PMID: 16803740 DOI: 10.1300/j027v25n01_06] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
This article describes a study to expand a proven evidence- based practice for depression to a population-based intervention for frail older adults. Problem-Solving Therapy (PST) has been proven effective in reducing depression and other mental health conditions in cognitively intact adults in many studies. The current study employs a randomized controlled trial to test the effectiveness of a social work intervention for frail older adults that uses PST to address depression and other psychosocial issues. The intervention employs Master's trained social workers integrated into a large primary care practice. The study population is comprised of home-dwelling older adults with multiple chronic conditions, a recent history of unnecessary hospitalizations, and no more than mild cognitive impairment.
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Affiliation(s)
- Scott Miyake Geron
- Institute for Geriatric Social Work, Boston University School of Social Work, 232 Bay State Rd, Boston, MA 02215, USA
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Grypma L, Haverkamp R, Little S, Unützer J. Taking an evidence-based model of depression care from research to practice: making lemonade out of depression. Gen Hosp Psychiatry 2006; 28:101-7. [PMID: 16516059 DOI: 10.1016/j.genhosppsych.2005.10.008] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2005] [Revised: 10/22/2005] [Accepted: 10/24/2005] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial [randomized controlled trial (RCT)] found that collaborative care management of depression in older primary care patients was significantly more effective than the usual care. We examined how an adapted version of IMPACT is working in the "real-world" setting of an HMO 3 years after the conclusion of the trial. METHOD Two hundred ninety-seven adults treated according to IMPACT protocol "poststudy" (PS) at a large group model HMO were compared to the 141 participants (historical control) in the intervention arm of the RCT at the same site. The Patient Health Questionnaire (PHQ-9) was used to compare depression severity at baseline and 6 months. We also compared treatment contacts, use of antidepressants and psychotherapy and total health care costs. RESULTS The RCT and PS groups were equivalent regarding baseline depression scores (14.5 vs. 14.2, P=.72), 6-month scores (5.6 vs. 6.3, P=.28) and percent experiencing 50% improvement in depression (68% vs. 70%, P=.83). Antidepressant use was similar (85% and 90%, P=.57). Treatment contacts were fewer in PS than RCT (14 vs. 20, P<.001). CONCLUSIONS An adapted version of the IMPACT program implemented at a large HMO achieved similar clinical improvements in depression as the clinical trial despite a lower number of intervention contacts.
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Affiliation(s)
- Lydia Grypma
- Southern California Permanente Medical Group, San Diego, CA 92120, USA.
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Unützer J, Powers D, Katon W, Langston C. From establishing an evidence-based practice to implementation in real-world settings: IMPACT as a case study. Psychiatr Clin North Am 2005; 28:1079-92. [PMID: 16325741 DOI: 10.1016/j.psc.2005.09.001] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Box 356560, Seattle, WA 98195, USA.
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Harpole LH, Stechuchak KM, Saur CD, Steffens DC, Unützer J, Oddone E. Implementing a disease management intervention for depression in primary care: a random work sampling study. Gen Hosp Psychiatry 2003; 25:238-45. [PMID: 12850655 DOI: 10.1016/s0163-8343(03)00023-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
We describe the daily work activities of 13 Depression Clinical Specialists (DCSs) at 7 national sites who served as care managers in an effective multisite randomized trial of a disease management model for depression in primary care. DCSs carried portable random-reminder beepers for a total of 147 consecutive workdays and recorded 4,030 work activities. Patient care activity comprised the largest percentage of the workday, 49.4% (95% confidence interval [CI], 42.0 to 56.7%), followed by research-related activity, 18.3 % (95% CI, 14.7 to 21.9%), administrative work, 17.9% (95% CI, 12.2 to 23.7%), personal time, 9.4% (95% CI, 5.4 to 13.4%), and time in transit, 5.1% (95% CI, 2.8 to 7.4%). The DCSs delivered 19.2% (95% CI, 14.4 to 24.1%) of direct patient care by telephone. The DCSs spent a significant portion of the day alone 48.7% (95% CI, 43.3 to 54.1%), followed by time spent with patients, 37.5% (95% CI, 31.6 to 43.3%). Less than 10% (7.8%) (95% CI, 5.1 to 10.6%) of their time was spent with local study staff. Less than 4% of their time was spent with other health care providers. Our results demonstrate that the DCSs' time was primarily devoted to clinical care, a significant portion of which was delivered by telephone. They functioned independently, making efficient use of the limited amount of time that they interacted with other health care providers. This information will be helpful to those who may wish to implement this disease management strategy.
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Affiliation(s)
- Linda H Harpole
- Department of Medicine, Duke University Medical Center, Durham, NC, USA.
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Current awareness in geriatric psychiatry. Int J Geriatr Psychiatry 2003; 18:563-70. [PMID: 12858863 DOI: 10.1002/gps.788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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