Do the Effects of Quality Improvement for Depression Care Differ for Men and Women?

Collaborative Care for Low-Income Patients From Racial-Ethnic Minority Groups in Primary Care: Engagement and Clinical Outcomes

OBJECTIVE

To assess model impact and opportunities for improvement, this study examined collaborative care model (CoCM) engagement and clinical outcomes among low-income patients from racial-ethnic minority groups with depression and anxiety.

METHODS

Starting in 2015, the CoCM was implemented in seven primary care practices of an urban academic medical center serving patients from racial-ethnic minority backgrounds, predominantly Medicaid beneficiaries. Eligible individuals scored positive for depressive or anxiety symptoms (or both) on the Patient Health Questionnaire-2 (PHQ-2) and PHQ-9 and the Generalized Anxiety Disorder Scale-2 (GAD-2) and GAD-7 during systematic screening in primary care settings. Screening rates and yield, patient characteristics, and CoCM engagement and outcomes were examined. Clinical improvement was measured by the difference in PHQ-9 and GAD-7 scores at baseline and at 10-to-14-week follow-up.

RESULTS

High rates of screening (87%, N=88,236 of 101,091) and identification of individuals with depression or anxiety (13%, N=11,886) were observed, and 58% of 3,957 patients who engaged in minimally adequate CoCM treatment had significant clinical improvement. Nevertheless, only 56% of eligible patients engaged in the model, and 25% of those individuals did not return for at least one follow-up appointment. Being female with clinically significant comorbid anxiety and depressive symptoms and having Medicaid or commercial insurance increased the likelihood of CoCM engagement.

CONCLUSIONS

CoCM can help engage vulnerable patients in behavioral health care and improve clinical symptoms. However, significant opportunity exists to advance the model's impact in treating depressive and anxiety disorders and decreasing health disparities by addressing engagement barriers.

Association of Veterans Affairs Primary Care Mental Health Integration With Care Access Among Men and Women Veterans

IMPORTANCE

Women veterans increasingly seek care yet continue to face barriers in the Veterans Health Administration (VA), which predominantly cares for men. Evidence-based collaborative care models can improve patient access to treatment of depression, which is experienced at higher rates by women. While the VA has implemented these care models nationally, it is not known whether access improvements occur equitably across genders in primary care.

OBJECTIVE

To examine whether the VA's national Primary Care-Mental Health Integration (PC-MHI) initiative (beginning 2007) expanded realized access to mental health care similarly for men and women.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study included 5 377 093 million primary care patients assigned to 396 VA clinics that provided integrated mental health services nationally between October 2013 and September 2016. Data analysis occurred between May 2017 and July 2020.

EXPOSURES

Clinic PC-MHI penetration, calculated as the proportion of clinic patients who saw an integrated specialist per fiscal year.

MAIN OUTCOMES AND MEASURES

Estimates of mean VA health care utilization (mental health, primary care, other specialty care, telephone, hospitalizations) and median total costs for men and women. Multilevel models adjusted for year, clinic, patient characteristics, and interactions between patient-defined gender and clinic PC-MHI penetration.

RESULTS

This study examined 5 377 093 veterans (448 455 [8.3%] women; 3 744 140 [69.6%] White) with a mean (SD) baseline age 62.0 (16.6) years. Each percentage-point increase in the proportion of clinic patients who saw an integrated specialist was associated with 38% fewer mental health visits per year for women (incidence rate ratio [IRR], 0.62; 95% CI, 0.60-0.65), but 39% more visits for men (IRR, 1.39; 95% CI, 1.34-1.44; P < .001). Both men and women had more primary care visits (men: IRR, 1.40; 95% CI, 1.36-1.45; women: IRR, 1.22; 95% CI, 1.17-1.28; P < .001) and total costs (men: β [SE], 2.23 [0.10]; women: β [SE], 1.24 [0.15]; P = .06), but women had 74% fewer hospitalizations than men related to clinics with mental health integration (IRR, 0.26; 95% CI, 0.19-0.36 vs IRR, 1.02; 95% CI, 0.83-1.24; P < .001).

CONCLUSIONS AND RELEVANCE

While greater outpatient service use for men was observed in this study, PC-MHI was associated with a decrease in mental health specialty visits (and hospitalizations) for women veterans, potentially signifying a shift of services to primary care. With increasing patient choice for where veterans receive care, the VA must tailor medical care to the needs of rising numbers of women patients. Differences in health care utilization by gender highlight the importance of anticipating policy impacts on and tailoring services for patients in the numerical minority in the VA and other health systems.

A Comparison of Collaborative Care Outcomes in Two Health Care Systems: VA Clinics and Federally Qualified Health Centers

OBJECTIVE

Collaborative care for depression results in symptom reduction when compared with usual care. No studies have systematically compared collaborative care outcomes between veterans treated at Veterans Affairs (VA) clinics and civilians treated at publicly funded federally qualified health centers (FQHCs) after controlling for demographic and clinical characteristics.

METHODS

Data from two randomized controlled trials that used a similar collaborative care intervention for depression were combined to conduct post hoc analyses (N=759). The Telemedicine-Enhanced Antidepressant Management intervention was delivered in VA community-based outpatient clinics (CBOCs), and the Outreach Using Telemedicine for Rural Enhanced Access in Community Health intervention was delivered in FQHCs. Multivariate logistic regression was used to determine whether veteran status moderated the effect of the intervention on treatment response (>50% reduction in symptoms).

RESULTS

There was a significant main effect for intervention (odds ratio [OR]=5.23, p<.001) and a moderating effect for veteran status, with lower response rates among veterans compared with civilians (OR=.21, p=.01). The addition of variables representing medication dosage and number of mental health and general health appointments did not influence the moderating effect. A sensitivity analysis stratified by gender found a significant moderating effect of veteran status for men but not women.

CONCLUSIONS

Veteran status was a significant moderator of collaborative care effectiveness for depression, indicating that veterans receiving collaborative care at a CBOC are at risk of nonresponse. Unmeasured patient- or system-level characteristics may contribute to poorer response among veterans.

The role of gender in moderating treatment outcome in collaborative care for anxiety

OBJECTIVE

The aim of this study was to test whether gender moderates intervention effects in the Coordinated Anxiety Learning and Management (CALM) intervention, a 12-month, randomized controlled trial of a collaborative care intervention for anxiety disorders (panic disorder, generalized anxiety disorder, posttraumatic stress disorder, and social anxiety disorder) in 17 primary care clinics in California, Washington, and Arkansas.

METHODS

Participants (N=1,004) completed measures of symptoms (Brief Symptom Inventory [BSI]) and functioning (mental and physical health components of the 12-Item Short Form [MCS and PCS] and Healthy Days, Restricted Activity Days Scale) at baseline, six, 12, and 18 months. Data on dose, engagement, and beliefs about psychotherapy were collected for patients in the collaborative care group.

RESULTS

Gender moderated the relationship between treatment and its outcome on the BSI, MCS, and Healthy Days measures but not on the PCS. Women who received collaborative care showed clinical improvements on the BSI, MHC, and Healthy Days that were significantly different from outcomes for women in usual care. There were no differences for men in collaborative care compared with usual care on any measures. In the intervention group, women compared with men attended more sessions of psychotherapy, completed more modules of therapy, expressed more commitment, and viewed psychotherapy as more helpful.

CONCLUSIONS

These findings contribute to the broader literature on treatment heterogeneity, in particular the influence of gender, and may inform personalized care for people seeking anxiety treatment in primary care settings.

Collaborative care for depression and anxiety problems

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Are patient characteristics associated with quality of depression care and outcomes in collaborative care programs for depression?

OBJECTIVE

To determine whether demographic or clinical characteristics of primary care patients are associated with depression treatment quality and outcomes within a collaborative care model.

METHODS

Collaborative depression care, based on principles from the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) trial, was implemented in six community health organizations serving disadvantaged patients. Over 3 years, 2821 patients were treated. Outcomes were receipt of quality treatment and depression improvement.

RESULTS

Logistic regression analyses revealed that patients who were older, more depressed or more anxious were more likely to be retained in treatment and to receive appropriate pharmacotherapy. Whereas gender and depression severity were unrelated to depression outcomes, significantly more patients who preferred Spanish (59.1%) than English (48.5%, P<.01) improved within 12 weeks in multivariate analyses. High baseline anxiety was associated with a lower probability of improvement, and older age showed a similar trend. Survival analyses demonstrated that patients who preferred Spanish or were less anxious improved significantly more rapidly than their counterparts (P<.001).

CONCLUSIONS

Patients with more anxiety received higher quality care but experienced worse depression outcomes than less anxious patients. Spanish language preference was strongly associated with depression improvement. This collaborative care program attained admirable outcomes among disadvantaged Spanish-speaking patients without extensive cultural tailoring of care.

Promotoras as mental health practitioners in primary care: a multi-method study of an intervention to address contextual sources of depression

We assessed the role of promotoras--briefly trained community health workers--in depression care at community health centers. The intervention focused on four contextual sources of depression in underserved, low-income communities: underemployment, inadequate housing, food insecurity, and violence. A multi-method design included quantitative and ethnographic techniques to study predictors of depression and the intervention's impact. After a structured training program, primary care practitioners (PCPs) and promotoras collaboratively followed a clinical algorithm in which PCPs prescribed medications and/or arranged consultations by mental health professionals and promotoras addressed the contextual sources of depression. Based on an intake interview with 464 randomly recruited patients, 120 patients with depression were randomized to enhanced care plus the promotora contextual intervention, or to enhanced care alone. All four contextual problems emerged as strong predictors of depression (chi square, p < .05); logistic regression revealed housing and food insecurity as the most important predictors (odds ratios both 2.40, p < .05). Unexpected challenges arose in the intervention's implementation, involving infrastructure at the health centers, boundaries of the promotoras' roles, and "turf" issues with medical assistants. In the quantitative assessment, the intervention did not lead to statistically significant improvements in depression (odds ratio 4.33, confidence interval overlapping 1). Ethnographic research demonstrated a predominantly positive response to the intervention among stakeholders, including patients, promotoras, PCPs, non-professional staff workers, administrators, and community advisory board members. Due to continuing unmet mental health needs, we favor further assessment of innovative roles for community health workers.

Depression treatment patterns among women veterans with cardiovascular conditions or diabetes

The study aimed to examine treatment patterns for depression among women veterans diagnosed with cardiovascular conditions or diabetes. We used longitudinal data from the 2002-2003 merged Veteran Health Administration (VHA) and Medicare files. Chi-square tests and multinomial logistic regression were performed to analyse depression treatment among veteran women with incident depressive episode and one of the following chronic conditions: diabetes or coronary artery disease or hypertension. Overall, 77% received treatment for depression, 54% with only antidepressants, 4% with only psychotherapy, and 19% with both. Multinomial logistic regression revealed that African American women were more likely to be in the no treatment group and were more likely than white women to receive psychotherapy rather than antidepressants. Older women and women with coronary artery disease only were less likely to receive treatment.

Clinician burden and depression treatment: disentangling patient- and clinician-level effects of medical comorbidity

BACKGROUND

Efforts to improve primary care depression treatment have assessed strategies across heterogeneous groups of patients, but few have examined clinician-level influences on depression treatment.

OBJECTIVE

To examine clinician characteristics that affect depression treatment in primary care settings, using multilevel ordinal regression modeling to disentangle patient- from clinician-level effects.

DESIGN

Secondary analysis from the Quality Improvement in Depression Study dataset.

PARTICIPANTS

The participants were 1,023 primary care patients with depression who reported on treatment in the 6-month follow-up and whose clinicians (n = 158) had at least 4 patients in the study.

MEASUREMENTS

Primary outcome variable was depression treatment intensity, derived from assessment of concordance with AHCPR depression treatment guidelines based on patient-reported data on their treatment. Primary independent variable was clinical practice burden for treating depression, derived from patient- and clinician-reported composite measures tested for significant association with clinician-reported practice burden.

RESULTS

Clinicians who treat patients with more chronic medical comorbidities perceive less burden from treating depressed patients in their practice (Spearman's rho = -.30, p < .05). Clinicians who treat patients with more chronic medical comorbidities also provide greater intensity of depression treatment (adjusted OR = 1.44, p = .02), even after adjusting for the effects of patient-level chronic medical comorbidities (adjusted OR = 0.95, p = .45).

CONCLUSIONS

Clinicians who provide more chronic care also provide greater depression treatment intensity, suggesting that clinicians who care for complex patients can integrate depression care into their practice. Targeting interventions to these clinicians to enhance their ability to provide guideline-concordant depression care is a worthwhile endeavor and deserves further investigation.

The prevalence and predictors of mental health treatment services in a national sample of depressed veterans

BACKGROUND

Few studies of acute depression care have examined the provision of psychotherapy or combined treatment in addition to medication management. This study examined acute phase depression treatment in the VA healthcare system, including measures of medication treatment (MT), psychotherapy (PT), and combined treatment (CT = MT plus PT). Both low level care (receipt of any MT, PT, or CT, but all below guideline levels) as well as guideline concordant care (GC MT, PT, and CT) were examined.

METHODS

The sample included 41,412 patients with new depression diagnoses. Analyses examined the relationship between demographics and psychiatric comorbidities (eg, substance use disorders, post-traumatic stress disorder, depression with both substance use disorders and post-traumatic stress disorder) and receipt of each type of care (low level and guideline concordant MT, PT, and CT).

RESULTS

The majority (75%) received at least some treatment, with 35% of the sample receiving guideline concordant care (particularly GC MT). Those with psychiatric comorbidities generally were more likely to receive GC care, older veterans were less likely to receive each type of care, and African Americans were less likely to receive GC MT but more likely to receive GC PT and GC CT than whites.

CONCLUSIONS

Although it is difficult to benchmark, the VA overall seems similar or better than the private sector in providing guideline concordant acute phase treatment for its depressed patients. The majority of veterans received some acute phase depression treatment, but only a minority seem to receive guideline concordant care (particularly PT and CT).

Increase in antidepressant medication in the US adult population between 1990 and 2003

BACKGROUND

The rate of antidepressant treatment in the US has significantly increased in the past decade. There are, however, concerns about undertreatment among traditionally underserved groups and overtreatment in less severely ill individuals. This study examines trends in the prevalence of antidepressant drug treatment in two US general population surveys.

METHODS

The prevalence of antidepressant treatment within a 12-month period was compared in the US National Comorbidity Survey (1990-1992) and the National Comorbidity Survey-Replication (2001-2003). Variations in trends across groups were examined using bivariate and multivariate logistic regression models.

RESULTS

The rate of antidepressant drug treatment increased more than four times between early 1990s and early 2000s. The trend was similar across sociodemographic groups. Younger adults, men and racial/ethnic minorities continued to receive antidepressant treatment at a lower rate compared to middle-aged adults, women and non-Hispanic whites, respectively. The rate of antidepressant treatment increased more in the group of less severely ill individuals than in those with more severe psychopathology.

CONCLUSIONS

Sociodemographic disparities in antidepressant treatment persisted over the last decade in the US, lending support to concerns about undertreatment among traditionally underserved groups, whereas the greater increase in the rate of antidepressant treatment in the less severely ill group lends support to concerns about antidepressant overtreatment in this population.

An association between negatively biased response to neutral stimuli and antidepressant nonadherence

OBJECTIVE

Our primary objective was to test whether negatively biased response to neutral physical or visual stimuli was associated with antidepressant nonadherence.

METHODS

We surveyed 22 primary care adults receiving pharmacological treatment for depression. Somatoform complaints, in addition to interpretation of and response to neutral facial expressions (NFEs), were assessed with surveys. Seven response anchors to NFE were classified as "negative" or "neutral/positive." Antidepressant adherence was ascertained after 3 months by self-report and pharmacy refill records.

RESULTS

Elevated somatoform complaints were associated with early antidepressant discontinuation (P=.01). Exclusively negative emotional response to NFE, reported by 55% (12/22) of subjects, was associated with clinically significant missed antidepressant doses (R=-.69, P=.0004). Two multivariate models adjusted for depressive symptoms demonstrated that exclusively positive or neutral emotional response to NFE was associated with improved adherence relative to an exclusively negative response (beta=34.0, t=3.7, P=.002); the somatoform complaints subscale "health concerns" adversely influenced depressive symptom improvement (beta=-.3, t=-3.0, P=.008).

CONCLUSION

Negatively biased responses to neutral stimuli in the physical and visual axes were associated with early antidepressant discontinuation and missed doses, respectively. If substantiated, these initial findings might contribute to improved understanding and treatment of antidepressant nonadherence.

Systematic review of multifaceted interventions to improve depression care

OBJECTIVE

Depression is a prevalent high-impact illness with poor outcomes in primary care settings. We performed a systematic review to determine to what extent multifaceted interventions improve depression outcomes in primary care and to define key elements, patients who are likely to benefit and resources required for these interventions.

METHOD

We searched Medline, HealthSTAR, CINAHL, PsycINFO and a specialized registry of depression trials from 1966 to February 2006; reviewed bibliographies of pertinent articles; and consulted experts. Searches were limited to the English language. We included 28 randomized controlled trials that: (a) involved primary care patients receiving acute-phase treatment; (b) tested a multicomponent intervention involving a patient-directed component; and (c) reported effects on depression severity. Pairs of investigators independently abstracted information regarding (a) setting and subjects, (b) components of the intervention and (c) outcomes.

RESULTS

Twenty of 28 interventions improved depression outcomes over 3-12 months (an 18.4% median absolute increase in patients with 50% improvement in symptoms; range, 8.3-46%). Sustained improvements at 24-57 months were demonstrated in three studies addressing acute-phase and continuation-phase treatments. All interventions involved care management and required additional resources or staff reassignment to implement; interventions were delivered exclusively or predominantly by telephone in 16 studies. The most commonly used intervention features were: patient education and self-management, monitoring of depressive symptoms and treatment adherence, decision support for medication management, a patient registry and mental health supervision of care managers. Other intervention features were highly variable.

CONCLUSION

There is strong evidence supporting the short-term benefits of care management for depression; critical elements for successful programs are emerging.

Health service use by adults with depression: community survey in five European countries. Evidence from the ODIN study

BACKGROUND

Little is known about patterns of healthcare use by people with depression in Europe.

AIMS

To examine the use and cost of services by adults with depressive or adjustment disorders in five European countries, and predictive factors.

METHOD

People aged 18-65 years with depressive or adjustment disorders (n=427) in Ireland, Finland, Norway, Spain and the UK provided information on predisposition (demographics, social support), enablement (country, urban/rural, social function) and need (symptom severity, perceived health status) for services. Outcome measures were self-reported use Client Services Receipt Interview and costs of general practice, generic, psychiatric or social services in the past 6 months.

RESULTS

Less frequent use was made of generic services in Norway and psychiatric services in the UK. Severity of depression, perceived health status, social functioning and level of social support were significant predictors of use; the number of people able to provide support was positively associated with greater health service use.

CONCLUSIONS

Individual participant factors provided greater explanatory power than national differences in healthcare delivery. The association between social support and service use suggests that interventions may be needed for those who lack social support.

Rurality, gender, and mental health treatment

Mental health problems are common and costly, yet many individuals with these problems either do not receive care or receive care that is inadequate. Gender and place of residence contribute to disparities in the use of mental health services. The objective of this study was to identify the influence of gender and rurality on mental health services utilization by using more sensitive indices of rurality. Pooled data from 4 panels of the Medical Expenditure Panel Survey (1996-2000) yielded a sample of 32,219 respondents aged 18 through 64. Variables were stratified by residence using rural-urban continuum codes. We used logistic and linear regression to model effects of gender and rurality on treatment rates. We found that rural women are less likely to receive mental health treatment either through the general healthcare system or through specialty mental health systems when compared to women in metropolitan statistical areas (MSA) or urbanized non-MSA areas. Rural men receive less mental health treatment than do rural women and less specialty mental health treatment than do men in MSAs or least rural non-MSA areas. Reported mental health deteriorates as the level of rurality increases. There is a considerable unmet need for mental health services in most rural areas. The general health sector does not seem to contribute remarkably to mental health services for women in these areas.

Gender patterns in cost effectiveness of quality improvement for depression: results of a randomized, controlled trial

BACKGROUND

Little is known about gender differences in the costs and outcomes of primary care quality improvement strategies for depression.

METHODS

Intent-to-treat analysis of data from a group-level controlled trial, in which matched primary care clinics in the US were randomized to usual care or to one of two interventions designed to increase the rate of effective depression treatment. One intervention facilitated medication management ("QI-Meds") and the other psychotherapy ("QI-Therapy"), but patients and clinicians could choose the type of treatment, or none. The study involved 46 clinics in 6 non-academic, managed care organizations; 181 primary care providers; and 375 male and 981 female patients with current depression. Outcomes are health care costs, quality-adjusted life years (QALY), depression burden, employment, and costs/QALY, over 24 months of follow-up.

RESULTS

Relative to usual care, QI-Therapy significantly reduced depression burden and increased employment, for men and women; but QI-Meds significantly reduced depression burden only among women. Average health care costs increased 429 USD in QI-Meds and 983 USD in QI-Therapy among men; corresponding cost increases were 424 and 275 USD for women. The estimated cost per QALY for men ranged between 16,600 and 42,600 USD under QI-Therapy. For women, estimated costs per QALY were 23,600 USD or below for QI-Meds and 12,500 USD or below under QI-Therapy.

LIMITATIONS

This study may be underpowered for some relevant outcomes, particularly costs. The study population is limited to patients who sought health care in primary care settings.

CONCLUSIONS

Both men and women can benefit substantially from quality improvement interventions for depression in primary care. Results are particularly favorable for the QI-Therapy intervention.