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

The Impact of a Collaborative Care Model on Health Trajectories among Patients with Co-Morbid Depression and Diabetes: The INDEPENDENT Study

Context

Collaborative care models for depression have been successful in a variety of settings, but their success may differ by patient engagement. We conducted a post-hoc analysis of the INDEPENDENT trial to investigate the role of differential engagement of participants on health outcomes over 3 years.

Settings and Design

INDEPENDENT study was a parallel, single-blinded, randomised clinical trial conducted at four socio-economically diverse clinics in India. Participants were randomised to receive either active collaborative care or usual care for 12 months and followed up for 24 months.

Method

We grouped intervention participants by engagement, defined as moderate (≤7 visits) or high, (8 or more visits) and compared them with usual care participants. Improvements in composite measure (depressive symptoms and at least one of three cardio-metabolic) were the primary outcome.

Statistical Analysis

Mean levels of depression and cardio-metabolic measures were analysed over time using computer package IBM SPSS Statistics 25.

Results

The composite outcome was sustained the highest in the moderate engagers [27.5%, 95% confidence interval (CI): 19.5, 36.7] and the lowest in high engagers (15.8%, 95% CI: 8.1, 26.8). This pattern was observed for individual parameters - depressive symptoms and glycosylated haemoglobin. Progressive reductions in mean depressive symptom scores were observed for moderate engagers and usual care group from baseline to 36 months. However, in high engagers of collaborative care, mean depressive symptoms were higher at 36 months compared to 12 months.

Conclusion

Sustained benefits of collaborative care were larger in participants with moderate engagement compared with high engagement, although a majority of participants relapsed on one or more outcome measures by 36 months. High engagers of collaborative care for co-morbid depression and diabetes may need light touch interventions for longer periods to maintain health and reduce depressive symptoms.

Nurse-led task-shifting strategies to substitute for mental health specialists in primary care: A systematic review

AIM

The study aimed to synthesize evidence comparing task-shifting interventions led by general practice nurses and mental health specialists in improving mental health outcomes of adults in primary care.

DESIGN

This study used a systematic review of randomized controlled trials.

DATA SOURCES

Articles from the databases CINAHL, MEDLINE, APA PsycInfo, PubMed, EMBASE, Cochrane EBM Reviews, Web of Science Core Collection, and ProQuest Dissertation and Thesis published between 2000 and 2020 were included.

REVIEW METHODS

The review was arranged based on the Cochrane Collaboration guidelines and reported using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA).

RESULTS

Twelve articles met the eligibility criteria. Eight studies revealed that nurse-led intervention was significantly superior to its comparator. The review identified three major themes: training and supervision, single and collaborative care and psychosocial treatments.

CONCLUSION

Nurses could be temporarily employed to provide mental health services in the absence of mental health specialists as long as appropriate training and supervision was provided. This finding should be interpreted with caution due to the high risk of bias in the studies reviewed and the limited generalisability of their findings.

Individualized prediction of psychiatric readmissions for patients with major depressive disorder: a 10-year retrospective cohort study

Patients with major depressive disorder (MDD) are at high risk of psychiatric readmission while the factors associated with such adverse illness trajectories and the impact of the same factor at different follow-up times remain unclear. Based on machine learning (ML) approaches and real-world electronic medical records (EMR), we aimed to predict individual psychiatric readmission within 30, 60, 90, 180, and 365 days of an initial major depression hospitalization. In addition, we examined to what extent our prediction model could be made interpretable by quantifying and visualizing the features that drive the predictions at different follow-up times. By identifying 13,177 individuals discharged from a hospital located in western China between 2009 and 2018 with a recorded diagnosis of MDD, we established five prediction-modeling cohorts with different follow-up times. Four different ML models were trained with features extracted from the EMR, and explainable methods (SHAP and Break Down) were utilized to analyze the contribution of each of the features at both population-level and individual-level. The model showed a performance on the holdout testing dataset that decreased over follow-up time after discharge: AUC 0.814 (0.758-0.87) within 30 days, AUC 0.780 (0.728-0.833) within 60 days, AUC 0.798 (0.75-0.846) within 90 days, AUC 0.740 (0.687-0.794) within 180 days, and AUC 0.711 (0.676-0.747) within 365 days. Results add evidence that markers of depression severity and symptoms (recurrence of the symptoms, combination of key symptoms, the number of core symptoms and physical symptoms), along with age, gender, type of payment, length of stay, comorbidity, treatment patterns such as the use of anxiolytics, antipsychotics, antidepressants (especially Fluoxetine, Clonazepam, Olanzapine, and Alprazolam), physiotherapy, and psychotherapy, and vital signs like pulse and SBP, may improve prediction of psychiatric readmission. Some features can drive the prediction towards readmission at one follow-up time and towards non-readmission at another. Using such a model for decision support gives the clinician dynamic information of the patient's risk of psychiatric readmission and the specific features pulling towards readmission. This finding points to the potential of establishing personalized interventions that change with follow-up time.

Patient engagement strategies for adults with chronic conditions: an evidence map

BACKGROUND

Patient and family engagement (PFE) has been defined as a partnership between patients, families, and health care providers to achieve positive health care outcomes. There is evidence that PFE is critical to improving outcomes. We sought to systematically identify and map the evidence on PFE strategies for adults with chronic conditions and identify areas needing more research.

METHODS

We searched PubMed, CINAHL, EMBASE, and Cochrane, January 2015 to September 2021 for systematic reviews on strategies for engaging patients with chronic conditions and their caregivers. From each review, we abstracted search dates, number and type of studies, populations, interventions, and outcomes. PFE strategies were categorized into direct patient care, health system, and community-policy level strategies. We found few systematic reviews on strategies at the health system, and none at the community-policy level. In view of this, we also searched for original studies that focused on PFE strategies at those two levels and reviewed the PFE strategies used and study findings.

RESULTS

We found 131 reviews of direct patient care strategies, 5 reviews of health system strategies, and no reviews of community-policy strategies. Four original studies addressed PFE at the health system or community-policy levels. Most direct patient care reviews focused on self-management support (SMS) (n = 85) and shared decision-making (SDM) (n = 43). Forty-nine reviews reported positive effects, 35 reported potential benefits, 37 reported unclear benefits, and 4 reported no benefits. Health system level strategies mainly involved patients and caregivers serving on advisory councils. PFE strategies with the strongest evidence focused on SMS particularly for patients with diabetes. Many SDM reviews reported potential benefits especially for patients with cancer.

DISCUSSION

Much more evidence exists on the effects of direct patient care strategies on PFE than on the effects of health system or community-policy strategies. Most reviews indicated that direct patient care strategies had positive effects or potential benefits. A limitation of this evidence map is that due to its focus on reviews, which were plentiful, it did not capture details of individual interventions. Nevertheless, this evidence map should help to focus attention on gaps that require more research in efforts to improve PFE.

Effect of Pharmacogenetic-Based Decision Support Tools in Improving Depression Outcomes: A Systematic Review

OBJECTIVE

Evidence supporting the utility of pharmacogenetic (PGX) tests in depression is scarce. The main objectives of this study were to summarize, update, and assess the quality of the available evidence regarding PGX testing in depression as well as estimating the impact of using PGX testing tools in depression outcomes in the Middle East/North Africa (MENA) region.

METHODOLOGY

Scientific databases were systematically searched from inception to June 30, 2020 for systematic reviews and randomized controlled trials (RCTs) assessing the clinical utility of PGX tests in the treatment of depression. Meta-analyses only and RCTs that were included in eligible systematic reviews were excluded. The quality of the eligible studies was assessed using the Crowe Critical Appraisal Tool (CCAT).

RESULTS

Six systematic reviews and three RCTs met the inclusion criteria and were included in this study. The results of the systematic reviews provided weak evidence on the efficacy of PGX testing, especially in patients with moderate-severe depression at 8 weeks. In addition, there was a lack of evidence regarding safety outcomes. Newer RCTs with better quality showed clinical promise regarding efficacy outcomes, especially in patients with gene-drug interactions. No evidence was found regarding PGX testing impact in the MENA region.

CONCLUSION

This systematic review is an update and summary of the available literature on the clinical utility of PGX testing in depression. The findings of this study demonstrate that PGX testing prior to treatment initiation or during the course of therapy may improve efficacy outcomes. Further studies are warranted to assess the impact of PGX testing on safety outcomes.

Characteristics of hospital encounters and associated economic burden of patients with major depressive disorder and acute suicidal ideation or behavior

OBJECTIVES

Relatively little is known about the hospital experience among patients with major depressive disorder (MDD) and acute suicidal ideation or behavior (MDSI). The objectives of this study were to examine hospital encounter characteristics, including the associated economic burden and risk of subsequent hospital encounters of patients with MDSI in the US.

METHODS

In this retrospective analysis, patients ≥18 years of age with a hospital encounter (emergency department [ED] visit or inpatient admission) were selected from the de-identified Premier Hospital database between 1 January 2017 and 30 September 2018. Patients were required to have MDD as the primary and acute suicidal ideation or behavior as a secondary discharge diagnosis or vice versa. Patient demographics and characteristics of hospital encounters were examined. Rates and costs of subsequent all-cause and MDD-related hospital encounters 6 months following initial discharge were also evaluated.

RESULTS

The study population consisted of 123,179 patients with a hospital encounter for MDSI (mean age: 38 years, 50.9% female, 74.6% White); 50.2% were treated in the ED only (mean ± standard deviation cost: $693±$630), while 49.8% were admitted as inpatients ($6,478±$7,001). Among those with ED visits, very few (7.0%) received an antidepressant (AD). Among those with an inpatient admission, 87.2% received ≥1 AD and 39.0% received AD augmentation. Overall rates and costs of subsequent all-cause and MDD-related hospital encounters were 22.3% ($5,136±$11,791) and 12.0% ($3,722±$9,621), respectively; nearly half of subsequent encounters (41.3% and 44.3%, respectively) occurred in the first month following initial discharge.

CONCLUSIONS

This analysis of patients with MDSI presenting to US hospitals shows heterogeneity in treatment and a concentration of costly subsequent hospital encounters within 1-month post discharge, suggesting that healthcare systems may benefit from examination of current care pathways for this vulnerable patient population.

Integrating Cancer Screening and Mental Health Services in Primary Care: Protocol and Baseline Results of a Patient-Centered Outcomes Intervention Study

BACKGROUND

Low-income and minority women are significantly more likely to be diagnosed with preventable, late-stage cancers and suffer from depression than the general population. Intervention studies aiming to reduce depression to increase cancer screening among underserved minority women are sparse.

METHODS

This patient-centered outcomes trial compared Collaborative Care Intervention plus Cancer Prevention Care Management (CCI+PCM) versus PCM alone. Participants from six Federally Qualified Health Centers (FQHCs) were interviewed at baseline, 6-and 12-month follow-up to monitor adherence to screening guidelines, depressive symptoms, quality of life, barriers to screening, and other psychosocial and health-related variables.

RESULTS

Participants included 757 English-or Spanish-speaking women (ages 50-64) who screened positive for depression on the Patient Health Questionnaire (PHQ)-9 and were not up-to-date for breast, cervical, and/or colorectal cancer screening.

CONCLUSIONS

Study methodology and baseline participant characteristics are reported to contribute to the literature on evidence-based interventions for cancer screening among underserved, depressed women.

Increasing escitalopram dose is associated with fewer discontinuations than switch or combination approaches in patients initially on escitalopram 10mg

Purpose

To examine the relationship between different intervention approaches and subsequent real-life outcomes in patients changing treatment from escitalopram 10mg.

Method

This was a retrospective cohort study of patients starting antidepressant treatment between 2002 and 2004. Data were extracted from a US health-insurance reimbursement claims database. Eligible patients started escitalopram 10mg and changed within 3 months to: escitalopram ≥20mg; another antidepressant; or a combination of escitalopram with another antidepressant. Medication persistence and healthcare costs over 3 months were compared between the treatment groups.

Results

Overall, 37,791 patients started escitalopram 10mg. Of the 12,830 patients (34%) who changed treatment, 56% increased escitalopram dose, 26% switched antidepressant and 18% combined escitalopram with another antidepressant. Patients in the switch and combination groups had significantly higher rates of non-persistence (56% and 91%, respectively) vs the dose-increase group (39%; both P<0.001). Combination-group patients incurred significantly greater costs vs the dose-increase group ($2805 vs $1767, respectively; P<0.001).

Conclusion

Results suggest that increasing escitalopram dose in patients responding inadequately to 10mg is associated with higher persistence rates vs the other treatment approaches. Receiving an increased dose of escitalopram was associated with significantly lower costs than combining escitalopram 10mg with another antidepressant.

The role of relapse prevention for depression in collaborative care: A systematic review

BACKGROUND

Relapse (the re-emergence of depression symptoms before full recovery) is common in depression and relapse prevention strategies are not well researched in primary care settings. Collaborative care is effective for treating acute phase depression but little is known about the use of relapse prevention strategies in collaborative care. We undertook a systematic review to identify and characterise relapse prevention strategies in the context of collaborative care.

METHODS

We searched for Randomised Controlled Trials (RCTs) of collaborative care for depression. In addition to published material, we obtained provider and patient manuals from authors to provide more detail on intervention content. We reported the extent to which collaborative care interventions addressed four relapse prevention components.

RESULTS

93 RCTs were identified. 31 included a formal relapse prevention plan; 42 had proactive monitoring and follow-up after the acute phase; 39 reported strategies for optimising sustained medication adherence; and 20 of the trials reported psychological or psycho-educational treatments persisting beyond the acute phase or focussing on long-term health/relapse prevention. 30 (32.3%) did not report relapse prevention approaches.

LIMITATIONS

We did not receive trial materials for approximately half of the trials, which limited our ability to identify relevant features of intervention content.

CONCLUSION

Relapse is a significant risk amongst people treated for depression and interventions are needed that specifically address and minimise this risk. Given the advantages of collaborative care as a delivery system for depression care, there is scope for more consistency and increased effort to implement and evaluate relapse prevention strategies.

Team-based suicide prevention: lessons learned from early adopters of collaborative care

Suicide prevention in clinical settings requires coordination among multiple clinicians with expertise in different disciplines. We aimed to understand the benefits and challenges of a team approach to suicide prevention in primary care, with a particular focus on Veterans. The Veterans Health Administration has both a vested interest in preventing suicide and it has rapidly and systematically adopted team-based approaches for primary care interventions, including suicide prevention. We conducted eight focus groups and eight in-depth interviews with primary care providers (PCPs), behavioral health providers and nurses located in six regions within one Veterans Administration Catchment Area in the northeast of the US. Transcripts were analyzed using simultaneous deductive and inductive content analysis. Findings revealed that different clinicians were thought to have particular expertise and roles. Nurses were recognized as being well positioned to identify subtle changes in patient behavior that could put patients at risk for suicide; behavioral health providers were recognized for their skill in suicide risk assessment; and PCPs were felt to be an integral conduit between needed services and treatment. Our findings suggest that clinician role-differentiation may be an important by-product of team-based suicide prevention efforts in VHA settings. We contextualize our findings within both a processual and relational interprofessional framework and discuss implications for the implementation of team-based suicide prevention.

ARPNet: Antidepressant Response Prediction Network for Major Depressive Disorder

Treating patients with major depressive disorder is challenging because it takes several months for antidepressants prescribed for the patients to take effect. This limitation may result in increased risks and treatment costs. To address this limitation, an accurate antidepressant response prediction model is needed. Recently, several studies have proposed models that extract useful features such as neuroimaging biomarkers and genetic variants from patient data, and use them as predictors for predicting the antidepressant responses of patients. However, it is impossible to utilize all the different types of predictors when making a clinical decision on what drugs to prescribe for a patient. Although a machine learning-based antidepressant response prediction model has been proposed to overcome this problem, the model cannot find the most effective antidepressant for a patient. Based on a neural network, we propose an Antidepressant Response Prediction Network (ARPNet) model capturing high-dimensional patterns from useful features. Based on a literature survey and data-driven feature selection, we extract useful features from patient data, and use the features as predictors. In ARPNet, the patient representation layer captures patient features and the antidepressant prescription representation layer captures antidepressant features. Utilizing the patient and antidepressant prescription representation vectors, ARPNet predicts the degree of antidepressant response. The experimental evaluation results demonstrate that our proposed ARPNet model outperforms machine learning-based models in predicting antidepressant response. Moreover, we demonstrate the applicability of ARPNet in downstream applications in use case scenarios.

Patient experiences in behavioral health integrated primary care settings: the role of stigma in shaping patient outcomes over time

Behavioral health integration (BHI) models seek to improve patient experience and outcomes by bridging physical and behavioral health services. Past BHI research has not focused on stigma in these settings, which has been previously found to impact patient engagement and outcomes. We surveyed patients over a two year period at 12 integrated clinics in Oregon using measures developed by a Patient Advisory Team. Over a quarter of respondents reported stigmatization (26.81%). Compared to non-stigmatized patients, those who reported stigma had five times the odds of reporting unmet health needs (OR=5.14, p<0.0001), three times the odds reporting issues accessing care (OR=2.93, p<0.0001), six times the odds reporting hassle to get care (OR=6.49, p<0.0001), and three times the odds of reporting poor communication between providers (OR=3.45, p<0.0001). After examining the interaction between stigmatization and time, we found that stigmatized patients had lower odds at year two of reporting unmet health needs (OR=0.68, p=0.0034), issues accessing care (OR=0.77, p=0.0400), hassle getting care (OR=0.57, p=0.0001), and poor provider communication (OR=0.77, p=0.0544). We found that stigma remained prevalent for patients seeking care in the integrated clinics studied despite integration. Systems should consider integration efforts and reducing stigmatizing experiences in tandem to truly improve patient outcomes.

Depression, cardiac mortality and all-cause mortality

Depression is an illness that kills. The links between depression and medical illness are well established and bi-directional, but evidence is mounting that depression increases mortality as well as morbidity in adults, particularly older adults. We examine the evidence that the increase in mortality in depression applies to all-cause mortality as well as cardiac mortality, and describe plausible physiological theories for the association. We conclude that excess mortality arising from depression is a major public health problem that is largely unrecognised and needs to be addressed by a range of clinicians.

Management of depression in later life

Both antidepressants and psychological treatments are effective in the management of late-life depression. Nevertheless, there remains a considerable challenge to improve the prognosis for depression in older people. Endlessly increasing the range of antidepressants does not seem to be the answer, so attention is turning to new combinations of treatments and new ways of delivering care and improving treatment uptake. Collaboration between specialist and primary care, case management and multifaceted interventions are currently the most exciting prospects. There is good evidence for the role of both medication and psychological treatment in keeping the patient well after recovery.

Urinary incontinence is strongly associated with depression in middle-aged and older Korean women: Data from the Korean longitudinal study of ageing

OBJECTIVE

To investigate the relationship between urinary incontinence (UI) and depression in middle-aged and older Korean women.

STUDY DESIGN

A total of 1116 participants diagnosed with UI among 7486 respondents were included in this study, using data from a well-established survey that investigated a nationally representative population: the Korean Longitudinal Study of Ageing (KLoSA). Computer-assisted personal interviewing was used to assess the status of UI and depression. Depression was assessed using the 10-item Center for Epidemiological Studies-Depression (CES-D 10) scale. Odds ratios (ORs) and 95% confidence intervals (95% CIs) for depression were adjusted for age, household income level, marital status, education level, working status, smoking behavior, alcohol drinking behavior, exercise level, residence, and accompanying chronic diseases.

RESULTS

The proportion of patients with depression was significantly higher among women with UI (9.1%) than among women without UI (6.3%) (P<0.0001). The depression scores became worse with worsening UI symptoms (OR of better vs. same vs. worse, 1.00 vs. 1.51 vs. 2.15, respectively; P for trend=0.0001), with an increased number of days experiencing UI during the prior month during the 2 years of the panel study period (OR of none vs. 1≤days≤10days vs. 10days<were 1.00 vs. 2.15 vs. 4.36; P for trend=0.003).

CONCLUSIONS

Inadequately controlled and frequent UI is strongly associated with depression in middle-aged and older Korean women. The management of worsening UI may be of value as part of the assessment and management of depression.

Rapid evidence review of the comparative effectiveness, harms, and cost-effectiveness of pharmacogenomics-guided antidepressant treatment versus usual care for major depressive disorder

OBJECTIVE

This study aims to conduct an evidence review of the effectiveness, harms, and cost-effectiveness of pharmacogenomics-guided antidepressant treatment for major depressive disorder.

METHODS

We searched MEDLINE®, the Cochrane Central Registry of Controlled Trials, and PsycINFO through February 2017. We used prespecified criteria to select studies, abstract data, and rate internal validity and strength of the evidence (PROSPERO number CRD42016036358).

RESULTS

We included two randomized trials (RCT), five controlled cohort studies, and six modeling studies of mostly women in their mid-40s with few comorbidities. CNSDose (ABCB1, ABCC1, CYP2C19, CYP2D6, UGT1A1) is the only pharmacogenomics test that significantly improved remission (one additional remitting patient in 12 weeks per three genotyped, 95% CI 1.7 to 3.5) and reduced intolerability in an RCT. ABCB1 genotyping leads to one additional remitting patient in 5 weeks per three genotyped (95% CI 3 to 20), but tolerability was not reported. In an RCT, GeneSight (CYP2D6, CYPC19, CYP1A2, SLC6A4, HTR2A) did not statistically significantly improve remission, and evidence is inconclusive about its tolerability. Evidence is generally low strength because RCTs were few and underpowered. Cost-effectiveness is unclear due to lack of directly observed cost-effectiveness outcomes. We found no studies that evaluated whether pharmacogenomics shortens time to optimal treatment, whether improvements were due to switches to genetically congruent medication, or whether effectiveness varies based on test and patient characteristics.

CONCLUSIONS

Certain pharmacogenomics tools show promise of improving short-term remission rates in women in their mid-40s with few comorbidities. But, important evidence limitations preclude recommending their widespread use and indicate a need for further research.

The effectiveness of a Supported Self-management task-shifting intervention for adult depression in Vietnam communities: study protocol for a randomized controlled trial

Background

Depressive disorders are one of the leading causes of disease and disability worldwide. In Vietnam, although epidemiological evidence suggests that depression rates are on par with global averages, services for depression are very limited. In a feasibility study that was implemented from 2013 to 2015, we found that a Supported Self-management (SSM) intervention showed promising results for adults with depression in the community in Vietnam.

This paper describes the Mental Health in Adults and Children: Frugal Innovations (MAC-FI) trial protocol that will assess the effectiveness of the SSM intervention, delivered by primary care and social workers, to community-based populations of adults with depression in eight Vietnamese provinces.

Methods/design

The MAC-FI program will be assessed using a stepped-wedge, randomized controlled trial. Study participants are adults aged 18 years and over in eight provinces of Vietnam. Study participants will be screened at primary care centres and in the community by health and social workers using the Self-reporting Questionnaire-20 (SRQ-20). Patients scoring >7, indicating depression caseness, will be invited to participate in the study in either the SSM intervention group or the enhanced treatment as usual control group. Recruited participants will be further assessed using the World Health Organization’s Disability Assessment Scale (WHODAS 2.0) and the Cut-down, Annoyed, Guilty, Eye-opener (CAGE) Questionnaire for alcohol misuse. Intervention-group participants will receive the SSM intervention, delivered with the support of a social worker or social collaborator, for a period of 2 months. Control- group participants will receive treatment as usual and a leaflet with information about depression. SRQ-20, WHODAS 2.0 and CAGE scores will be taken by blinded outcome assessors at baseline, after 1 month and after 2 months. The primary analysis method will be intention-to-treat.

Discussion

This study has the potential to add to the knowledge base about the effectiveness of a SSM intervention for adult depression that has been validated for the Vietnamese context. This trial will also contribute to the growing body of evidence about the effectiveness of low-cost, task-shifting interventions for use in low-resource settings, where specialist mental health services are often limited.

Trial registration

Retrospectively registered at ClinicalTrials.gov, identifier: NCT03001063. Registered on 20 December 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-1924-5) contains supplementary material, which is available to authorized users.

Detecting the effects of physician training in self-care interviewing skills: Coding of standardized patient (SP) visit recordings versus SP post-visit ratings

OBJECTIVE

To compare how coder ratings of standardized patient (SP) visit recordings and SP ratings of the visits detect primary care physician (PCP) training in self-efficacy enhancing interviewing techniques (SEE IT).

METHODS

Analyses of data from 50 PCPs who participated in a randomized controlled trial of SEE IT training, which led to increased SEE IT use during three SP visits 1-3 months post-intervention. Untrained SPs rated SEE IT use post-visit. Subsequently, three trained coders generated a consensus SEE IT rating from visit audio recordings. SPs and coders were blinded to provider study arm, and coders to SP ratings.

RESULTS

SP and coder ratings were correlated (r=0.62). In detecting the intervention effect, the areas under the receiver operating characteristic curve were 0.80 (95% CI 0.74-0.87) and 0.76 (95% CI 0.69-0.84) for consensus coder and SP ratings, respectively (difference 0.04, 95% CI -0.04-0.11; z=1.04, p=0.30).

CONCLUSION

SP ratings were not significantly different from coder ratings of SP visit recordings in detecting PCP SEE IT training.

PRACTICE IMPLICATIONS

If similar findings are observed in larger studies, it would suggest a greater role for SP ratings in detecting provider interviewing skills training, given the relative simplicity, low cost, and non-intrusiveness of the approach.

Physician training in self-efficacy enhancing interviewing techniques (SEE IT): Effects on patient psychological health behavior change mediators

OBJECTIVE

To explore how physician training in self-efficacy enhancing interviewing techniques (SEE IT) affects patient psychological health behavior change mediators (HBCMs).

METHODS

We analyzed data from 131 patients visiting primary care physicians ≥4 months after the physicians participated in a randomized controlled trial. Experimental arm physicians (N=27) received SEE IT training during three ≤20min standardized patient instructor (SPI) visits. Control physicians (N=23) viewed a diabetes medications video during one SPI visit. Physicians were blinded to patient participation. Outcomes were self-care self-efficacy, readiness, and health locus of control (Internal, Chance, Powerful Others), examined as a summary HBCM score (average of standardized means) and individually. Analyses adjusted for pre-visit values of the dependent variables.

RESULTS

Patients visiting SEE IT-trained physicians had higher summary HBCM scores (+0.42, 95% CI 0.07-0.77; p=0.021). They also had greater self-care readiness (AOR 3.04, 95% CI 1.02-9.03, p=0.046) and less Chance health locus of control (-0.27 points, 95% CI -0.50-0.04, p=0.023), with no significant differences in other HBCMs versus controls.

CONCLUSION

Improvement in psychological HBCMs occurred among patients visiting SEE IT-trained physicians, PRACTICE IMPLICATIONS: If further research shows the observed HBCM effects improve health behaviors and outcomes, SEE IT training might be offered widely to physicians.

Training Primary Care Physicians to Employ Self-Efficacy-Enhancing Interviewing Techniques: Randomized Controlled Trial of a Standardized Patient Intervention

BACKGROUND

Primary care providers (PCPs) have few tools for enhancing patient self-efficacy, a key mediator of myriad health-influencing behaviors.

OBJECTIVE

To examine whether brief standardized patient instructor (SPI)-delivered training increases PCPs' use of self-efficacy-enhancing interviewing techniques (SEE IT).

DESIGN

Randomized controlled trial.

PARTICIPANTS

Fifty-two family physicians and general internists from 12 primary care offices drawn from two health systems in Northern California.

INTERVENTIONS

Experimental arm PCPs received training in the use of SEE IT training during three outpatient SPI visits scheduled over a 1-month period. Control arm PCPs received a single SPI visit, during which they viewed a diabetes treatment video. All intervention visits (experimental and control) were timed to last 20 min. SPIs portrayed patients struggling with self-care of depression and diabetes in the first 7 min, then delivered the appropriate intervention content during the remaining 13 min.

MAIN MEASURES

The primary outcome was provider use of SEE IT (a count of ten behaviors), coded from three audio-recorded standardized patient visits at 1-3 months, again involving depression and diabetes self-care. Two five-point scales measured physician responses to training: Value (7 items: quality, helpfulness, understandability, relevance, feasibility, planned use, care impact), and Hassle (2 items: personal hassle, flow disruption).

KEY RESULTS

Pre-intervention, study PCPs used a mean of 0.7 behaviors/visit, with no significant between-arm difference (P = 0.23). Post-intervention, experimental arm PCPs used more of the behaviors than controls (mean 2.7 vs. 1.0 per visit; adjusted difference 1.7, 95 % CI 1.1-2.2; P < 0.001). Experimental arm PCPs had higher training Value scores than controls (mean difference 1.05, 95 % CI 0.68-1.42; P < 0.001), and similarly low Hassle scores.

CONCLUSIONS

Primary care physicians receiving brief SPI-delivered training increased their use of SEE IT and found the training to be of value. Whether patients visiting SEE IT-trained physicians experience improved health behaviors and outcomes warrants study. CLINICALTRIALS.

GOV IDENTIFIER

NCT01618552.

Practice nurse-led proactive care for chronic depression in primary care: a randomised controlled trial

BACKGROUND

Management of long-term depression is a significant problem in primary care populations with considerable on-going morbidity, but few studies have focused on this group.

AIMS

To evaluate whether structured, nurse-led proactive care of patients with chronic depression in primary care improves outcomes.

METHOD

Participants with chronic/recurrent major depression or dysthymia were recruited from 42 UK general practices and randomised to general practitioner (GP) treatment as usual or nurse intervention over 2 years (the ProCEED trial, trial registration:ISRCTN36610074).

RESULTS

In total 282 people received the intervention and there were 276 controls. At 24 months there was no significant improvement in Beck Depression Inventory (BDI-II) score or quality of life (Euroquol-EQ-VAS), but a significant improvement in functional impairment (Work and Social Activity Schedule, WSAS) of 2.5 (95% CI 0.6-4.3,P= 0.010) in the intervention group. The impact per practice-nurse intervention session was -0.37 (95% CI -0.68 to -0.07,P= 0.017) on the BDI-II score and 70.33 (95% CI 70.55 to -0.10,P= 0.004) on the WSAS score, indicating that attending all 10 intervention sessions could lead to a BDI-II score reduction of 3.7 points compared with controls.

CONCLUSIONS

The intervention improved functioning in these patients, the majority of whom had complex long-term difficulties, but only had a significant impact on depressive symptoms in those engaging with the full intervention.

Cross-trial prediction of treatment outcome in depression: a machine learning approach

BACKGROUND

Antidepressant treatment efficacy is low, but might be improved by matching patients to interventions. At present, clinicians have no empirically validated mechanisms to assess whether a patient with depression will respond to a specific antidepressant. We aimed to develop an algorithm to assess whether patients will achieve symptomatic remission from a 12-week course of citalopram.

METHODS

We used patient-reported data from patients with depression (n=4041, with 1949 completers) from level 1 of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D; ClinicalTrials.gov, number NCT00021528) to identify variables that were most predictive of treatment outcome, and used these variables to train a machine-learning model to predict clinical remission. We externally validated the model in the escitalopram treatment group (n=151) of an independent clinical trial (Combining Medications to Enhance Depression Outcomes [COMED]; ClinicalTrials.gov, number NCT00590863).

FINDINGS

We identified 25 variables that were most predictive of treatment outcome from 164 patient-reportable variables, and used these to train the model. The model was internally cross-validated, and predicted outcomes in the STAR*D cohort with accuracy significantly above chance (64·6% [SD 3·2]; p<0·0001). The model was externally validated in the escitalopram treatment group (N=151) of COMED (accuracy 59·6%, p=0.043). The model also performed significantly above chance in a combined escitalopram-buproprion treatment group in COMED (n=134; accuracy 59·7%, p=0·023), but not in a combined venlafaxine-mirtazapine group (n=140; accuracy 51·4%, p=0·53), suggesting specificity of the model to underlying mechanisms.

INTERPRETATION

Building statistical models by mining existing clinical trial data can enable prospective identification of patients who are likely to respond to a specific antidepressant.

FUNDING

Yale University.

Cost-effectiveness of collaborative care for the treatment of depressive disorders in primary care: a systematic review

BACKGROUND

For the treatment of depressive disorders, the framework of collaborative care has been recommended, which showed improved outcomes in the primary care sector. Yet, an earlier literature review did not find sufficient evidence to draw robust conclusions on the cost-effectiveness of collaborative care.

PURPOSE

To systematically review studies on the cost-effectiveness of collaborative care, compared with usual care for the treatment of patients with depressive disorders in primary care.

METHODS

A systematic literature search in major databases was conducted. Risk of bias was assessed using the Cochrane Collaboration's tool. Methodological quality of the articles was assessed using the Consensus on Health Economic Criteria (CHEC) list. To ensure comparability across studies, cost data were inflated to the year 2012 using country-specific gross domestic product inflation rates, and were adjusted to international dollars using purchasing power parities (PPP).

RESULTS

In total, 19 cost-effectiveness analyses were reviewed. The included studies had sample sizes between n = 65 to n = 1,801, and time horizons between six to 24 months. Between 42% and 89% of the CHEC quality criteria were fulfilled, and in only one study no risk of bias was identified. A societal perspective was used by five studies. Incremental costs per depression-free day ranged from dominance to US$PPP 64.89, and incremental costs per QALY from dominance to US$PPP 874,562.

CONCLUSION

Despite our review improved the comparability of study results, cost-effectiveness of collaborative care compared with usual care for the treatment of patients with depressive disorders in primary care is ambiguous depending on willingness to pay. A still considerable uncertainty, due to inconsistent methodological quality and results among included studies, suggests further cost-effectiveness analyses using QALYs as effect measures and a time horizon of at least 1 year.

Chronic care management for substance dependence in primary care among patients with co-occurring disorders

OBJECTIVE

Co-occurring mental and substance use disorders are associated with worse outcomes than a single disorder alone. In this exploratory subgroup analysis of a randomized trial, the authors hypothesized that providing chronic care management (CCM) for substance dependence in a primary care setting would have a beneficial effect among persons with substance dependence and major depressive disorder or posttraumatic stress disorder (PTSD).

METHODS

Adults (N=563) with alcohol dependence, drug dependence, or both were assigned to CCM or usual primary care. CCM was provided by a nurse care manager, social worker, internist, and psychiatrist. Clinical outcomes (any use of opioids or stimulants or heavy drinking and severity of depressive and anxiety symptoms) and treatment utilization (emergency department use and hospitalization) were measured at three, six, and 12 months after enrollment. Longitudinal regression models were used to compare randomized arms within the subgroups of participants with major depressive disorder or PTSD.

RESULTS

Among all participants, 79% met criteria for major depressive disorder and 36% met criteria for PTSD at baseline. No significant effect of CCM was observed within either subgroup for any outcome, including any use of opioids or stimulants or heavy drinking, depressive symptoms, anxiety symptoms, and any hospitalizations or number of nights hospitalized. Among participants with depression, those receiving CCM had fewer days in the emergency department compared with the control group, but the finding was of only borderline significance (p=.06).

CONCLUSIONS

Among patients with co-occurring substance dependence and mental disorders, CCM was not significantly more effective than usual care for improving clinical outcomes or treatment utilization.

Intervention impact on depression product appraisal and purchasing behavior by employers: a randomized trial

Background

Employers can purchase high quality depression products that provide the type, intensity and duration of depression care management shown to improve work outcomes sufficiently for many employers to achieve a return on investment. The purpose of this randomized controlled trial was to test an intervention to encourage employers to purchase a high quality depression product for their workforce.

Methods

Twenty nine organizations recruited senior health benefit professional members representing public or private employers who had not yet purchased a depression product for all 100+ workers in their company. The research team used randomization blocked by company size to assign eligible employers to: (1) a presentation encouraging employers to purchase a high quality depression product accompanied by a scientifically-derived return on investment estimate, or (2) a presentation encouraging employers to work with their most subscribed health plan to improve depression treatment quality indicators. Two hundred ninety three employers (82.3% of 356) completed baseline data immediately before learning that 140 employers had been randomized to the evidence-based (EB) depression product presentation and 153 had been randomized to the usual care (UC) depression treatment quality indicator presentation. Analysis of 250 (85.3% of 293) employers who completed web-based interviews at 12 and/or 24 months was conducted to determine presentation impact on depression product appraisal and purchasing behavior.

Results

The intervention had no impact on depression product appraisal in 232 subjects (F = 2.36, p = .07) or depression product purchasing (chisquare = 1.82, p = .44) in 250 subjects. Depression product appraisal increased in companies with greater health benefit generosity whose benefit professionals were male. Depression product purchasing behavior increased in small companies compared to large companies, companies who knew a vendor that sold depression products at baseline, companies with greater health benefit risk taking, and companies with less politicalization of health care benefit decision making.

Conclusions

Policy makers need to build innovative bridges to the employer community to convince them to purchase evidence-based benefits, even when benefits offer potential financial savings.

Trial registration

Clinical Trials Registration Number: NCT01013220.

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

BACKGROUND

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

METHODS

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

TRIAL REGISTRATION

ISRCTN16384353.

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Pharmacologic treatment of depression in the elderly

OBJECTIVE

To discuss pharmacologic treatment of depression in the elderly, including choice of antidepressants, titration of dose, monitoring of response and side effects, and treatment of unresponsive cases.

SOURCES OF INFORMATION

The 2006 Canadian Coalition for Seniors' Mental Health guideline on the assessment and treatment of depression was used as a primary source. To identify articles published since the guideline, MEDLINE was searched from 2007 to 2012 using the terms depression, treatment, drug therapy, and elderly.

MAIN MESSAGE

The goal of treatment should be remission of symptoms. Improvement of symptoms can be monitored by identifying patient goals or by use of a clinical tool such as the Patient Health Questionnaire-9. Treatment should be considered in 3 phases: an acute treatment phase to achieve remission of symptoms, a continuation phase to prevent recurrence of the same episode of illness (relapse), and a maintenance (prophylaxis) phase to prevent future episodes (recurrence). Initial dosing should be half of the usual adult starting dose and be titrated regularly until the patient responds, until the maximum dose is reached, or until side effects limit further increases. Common side effects of medications include falls, nausea, dizziness, headaches, and, less commonly, hyponatremia and QT interval changes. Strategies for switching or augmenting antidepressants are discussed. Older patients should be treated for at least a year from when clinical improvement is noted, and those with recurrent depression or severe symptoms should continue treatment indefinitely. Treatment of specific situations such as severe depression or depression with psychosis is discussed, including the use of electroconvulsive therapy. Criteria for referral to geriatric psychiatry are provided; however, many family physicians do not have easy access to this resource or to other nonpharmacologic clinical strategies.

CONCLUSION

The effectiveness of pharmacologic treatment of depression is not substantially affected by age. Identification of depression, choice of appropriate treatment, titration of medications, monitoring of side effects, and adequate duration of treatment will improve outcomes for older patients.

There are no randomized controlled trials that support the United States Preventive Services Task Force Guideline on screening for depression in primary care: a systematic review

BACKGROUND

The United States Preventive Services Task Force (USPSTF) recommends screening adults for depression in primary care settings when staff-assisted depression management programs are available. This recommendation, however, is based on evidence from depression management programs conducted with patients already identified as depressed, even though screening is intended to identify depressed patients not already recognized or treated. The objective of this systematic review was to evaluate whether there is evidence from randomized controlled trials (RCTs) that depression screening benefits patients in primary care, using an explicit definition of screening.

METHODS

We re-evaluated RCTs included in the 2009 USPSTF evidence review on depression screening, including only trials that compared depression outcomes between screened and non-screened patients and met the following three criteria: determined patient eligibility and randomized prior to screening; excluded patients already diagnosed with a recent episode of depression or already being treated for depression; and provided the same level of depression treatment services to patients identified as depressed in the screening and non-screening trial arms. We also reviewed studies included in a recent Cochrane systematic review, but not the USPSTF review; conducted a focused search to update the USPSTF review; and reviewed trial registries.

RESULTS

Of the nine RCTs included in the USPSTF review, four fulfilled none of three criteria for a test of depression screening, four fulfilled one of three criteria, and one fulfilled two of three criteria. There were two additional RCTs included only in the Cochrane review, and each fulfilled one of three criteria. No eligible RCTs were found via the updated review.

CONCLUSIONS

The USPSTF recommendation to screen adults for depression in primary care settings when staff-assisted depression management programs are available is not supported by evidence from any RCTs that are directly relevant to the recommendation. The USPSTF should re-evaluate this recommendation. Please see related article: http://www.biomedcentral.com/1741-7015/12/14 REGISTRATION: PROSPERO (#CRD42013004276).

The case for chronic disease management for addiction

Chronic disease (care) management (CDM) is a patient-centered model of care that involves longitudinal care delivery; integrated, and coordinated primary medical and specialty care; patient and clinician education; explicit evidence-based care plans; and expert care availability. The model, incorporating mental health and specialty addiction care, holds promise for improving care for patients with substance dependence who often receive no care or fragmented ineffective care. We describe a CDM model for substance dependence and discuss a conceptual framework, the extensive current evidence for component elements, and a promising strategy to reorganize primary and specialty health care to facilitate access for people with substance dependence. The CDM model goes beyond integrated case management by a professional, colocation of services, and integrated medical and addiction care-elements that individually can improve outcomes. Supporting evidence is presented that: 1) substance dependence is a chronic disease requiring longitudinal care, although most patients with addictions receive no treatment (eg, detoxification only) or short-term interventions, and 2) for other chronic diseases requiring longitudinal care (eg, diabetes, congestive heart failure), CDM has been proven effective.

Mental health treatment associated with community-based depression screening: considerations for planning multidisciplinary collaborative care

BACKGROUND

Depression places a large economic burden on the US health care system. Routine screening has been recognized as a fundamental step in the effective treatment of depression, but should be undertaken only when support systems are available to ensure proper diagnosis, treatment, and follow-up.

OBJECTIVE

To estimate differences in prescribing new antidepressants and referral to stress management, psychotherapy, and other mental health (OMH) counseling at physician visits when documented depression screening was and was not performed.

METHODS

Cross-sectional physician visit data for adults from the 2005-2007 National Ambulatory Medical Care Survey were used. The final analytical sample included 55,143 visits, representing a national population estimate of 1,741,080,686 physician visits. Four dependent variables were considered: (1) order for new antidepressant(s), and referral to (2) stress management, (3) psycho therapy, or (4) OMH counseling. Bivariable and multivariable associations between depression screening and each measure of depression follow-up care were evaluated using the design-based F statistic and multivariable logistic regression models.

RESULTS

New antidepressant prescribing increased significantly (2.12% of visits without depression screening vs 10.61% with depression screening resulted in a new prescription of an antidepressant). Referral to stress management was the behavioral treatment with the greatest absolute change (3.31% of visits without depression screening vs 33.10% of visits with depression screening resulted in a referral to stress management). After controlling for background sociodemographic characteristics, the adjusted odds ratio of a new antidepressant order remained significantly higher at visits involving depression screening (AOR 5.36; 99.9% CI 2.92-9.82), as did referrals for all behavioral health care services (ie, stress management, psychotherapy, and OMH counseling).

CONCLUSIONS

At the national level, depression screening was associated with increased new antidepressant prescribing and referral for behavioral health care. It is critical for policy planners to recognize changes in follow-up depression care when implementing screening programs to ensure adequate capacity. Pharmacists are poised to assume a role in collaborative depression care, particularly with antidepressant medication therapy management.

Innovation in health economic modelling of service improvements for longer-term depression: demonstration in a local health community

BACKGROUND

The purpose of the analysis was to develop a health economic model to estimate the costs and health benefits of alternative National Health Service (NHS) service configurations for people with longer-term depression.

METHOD

Modelling methods were used to develop a conceptual and health economic model of the current configuration of services in Sheffield, England for people with longer-term depression. Data and assumptions were synthesised to estimate cost per Quality Adjusted Life Years (QALYs).

RESULTS

Three service changes were developed and resulted in increased QALYs at increased cost. Versus current care, the incremental cost-effectiveness ratio (ICER) for a self-referral service was £11,378 per QALY. The ICER was £2,227 per QALY for the dropout reduction service and £223 per QALY for an increase in non-therapy services. These results were robust when compared to current cost-effectiveness thresholds and accounting for uncertainty.

CONCLUSIONS

Cost-effective service improvements for longer-term depression have been identified. Also identified were limitations of the current evidence for the long term impact of services.

[Integral Care Guide for Early Detection and Diagnosis of Depressive Episodes and Recurrent Depressive Disorder in Adults. Integral Attention of Adults with a Diagnosis of Depressive Episodes and Recurrent Depressive Disorder: Part I: Risk Factors, Screening, Suicide Risk Diagnosis and Assessment in Patients with a Depression Diagnosis]

INTRODUCTION

Depression is an important cause of morbidity and disability in the world; however, it is under-diagnosed at all care levels.

OBJECTIVE

The purpose here is to present recommendations based on the evidence gathered to answer a series of clinical questions concerning risk factors, screening, suicide risk diagnosis and evaluation in patients undergoing a depressive episode and recurrent depressive disorder. Emphasis has been made upon the approach used at the primary care level so as to grant adult diagnosed patients the health care guidelines based on the best and more updated evidence available thus achieving minimum quality standards.

METHODOLOGY

A practical clinical guide was elaborated according to standards of the Methodological Guide of the Ministry of Social Protection. Recommendation from guides NICE90 and CANMAT were adopted and updated so as to answer the questions posed while de novo questions were developed.

RESULTS

Recommendations 1-22 corresponding to screening, suicide risk and depression diagnosis were presented. The corresponding degree of recommendation is included.

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.

Incremental benefits and cost of coordinated anxiety learning and management for anxiety treatment in primary care

BACKGROUND

Improving the quality of mental health care requires integrating successful research interventions into 'real-world' practice settings. Coordinated Anxiety Learning and Management (CALM) is a treatment-delivery model for anxiety disorders encountered in primary care. CALM offers cognitive behavioral therapy (CBT), medication, or both; non-expert care managers assisting primary care clinicians with adherence promotion and medication optimization; computer-assisted CBT delivery; and outcome monitoring. This study describes incremental benefits, costs and net benefits of CALM versus usual care (UC).

METHOD

The CALM randomized, controlled effectiveness trial was conducted in 17 primary care clinics in four US cities from 2006 to 2009. Of 1062 eligible patients, 1004 English- or Spanish-speaking patients aged 18-75 years with panic disorder (PD), generalized anxiety disorder (GAD), social anxiety disorder (SAD) and/or post-traumatic stress disorder (PTSD) with or without major depression were randomized. Anxiety-free days (AFDs), quality-adjusted life years (QALYs) and expenditures for out-patient visits, emergency room (ER) visits, in-patient stays and psychiatric medications were estimated based on blinded telephone assessments at baseline, 6, 12 and 18 months.

RESULTS

Over 18 months, CALM participants, on average, experienced 57.1 more AFDs [95% confidence interval (CI) 31-83] and $245 additional medical expenses (95% CI $-733 to $1223). The mean incremental net benefit (INB) of CALM versus UC was positive when an AFD was valued ≥$4. For QALYs based on the Short-Form Health Survey-12 (SF-12) and the EuroQol EQ-5D, the mean INB was positive at ≥$5000.

CONCLUSIONS

Compared with UC, CALM provides significant benefits with modest increases in health-care expenditures.

Chronic and recurrent depression in primary care: socio-demographic features, morbidity, and costs

Background. Major depression is often chronic or recurrent and is usually treated within primary care. Little is known about the associated morbidity and costs. Objectives. To determine socio-demographic characteristics of people with chronic or recurrent depression in primary care and associated morbidity, service use, and costs. Method. 558 participants were recruited from 42 GP practices in the UK. All participants had a history of chronic major depression, recurrent major depression, or dysthymia. Participants completed questionnaires including the BDI-II, Work and Social Adjustment Scale, Euroquol, and Client Service Receipt Inventory documenting use of primary care, mental health, and other services. Results. The sample was characterised by high levels of depression, functional impairment, and high service use and costs. The majority (74%) had been treated with an anti-depressant, while few had seen a counsellor (15%) or a psychologist (3%) in the preceding three months. The group with chronic major depression was most depressed and impaired with highest service use, whilst those with dysthymia were least depressed, impaired, and costly to support but still had high morbidity and associated costs. Conclusion. This is a patient group with very significant morbidity and high costs. Effective interventions to reduce both are required.

Supported self-management: a simple, effective way to improve depression care

OBJECTIVES

To introduce supported self-management (SSM) for depression, examine it through the use of a quality assessment framework, and show its potential for enhancing the Canadian health care system.

METHOD

SSM is examined in terms of quality criteria: relevance, effectiveness, appropriateness, efficiency, safety, acceptability, and sustainability. Critical research is highlighted, and a case study is presented to illustrate the use of SSM with depressed patients.

RESULTS

SSM is defined by access to a self-management guide (workbook or website) plus encouragement and coaching by health care provider, family member, or other supporter. It has high relevance to depression care in Canada, high cost-effectiveness, high appropriateness for most people with depression, and high safety. Acceptability of this intervention is more problematic: many providers remain doubtful of its acceptability to their poorly motivated patients. Sustainability of SSM as a component of mental health care will require ongoing knowledge exchange among policy-makers, health care providers, and researchers.

CONCLUSION

The introduction of SSM represents a unique opportunity to enhance the delivery of depression care in Canada. Actively engaging the distressed individual in changing depressive patterns can improve outcomes without mobilizing substantial new resources. Over time, we will learn more about making SSM compatible with constraints on provider time, increasing access to self-management tools, and evaluating the benefit to everyday clinical work.

Depression treatment in patients with general medical conditions: results from the CO-MED trial

PURPOSE

We studied the effect of 3 antidepressant treatments on outcomes (depressive severity, medication tolerability, and psychosocial functioning) in depressed patients having comorbid general medical conditions in the Combining Medications to Enhance Depression Outcomes (CO-MED) trial.

METHODS

Adult outpatients who had chronic and/or recurrent major depressive disorder (MDD) with and without general medical conditions were randomly assigned in 1:1:1 ratio to 28 weeks of single-blind, placebo-controlled antidepressant treatment with (1) escitalopram plus placebo, (2) bupropion-SR plus escitalopram, or (3) venlafaxine-XR plus mirtazapine. At weeks 12 and 28, we compared response and tolerability between participants with 0, 1, 2, and 3 or more general medical conditions.

RESULTS

Of the 665 evaluable patients, 49.5% reported having no treated general medical conditions, 23.8% reported having 1, 14.8% reported having 2, and 11.9% reported having at least 3. We found only minimal differences in antidepressant treatment response between these groups having different numbers of conditions; patients with 3 or more conditions reported higher rates of impairment in social and occupational functioning at week 12 but not at week 28. Additionally, we found no significant differences between the 3 antidepressant treatments across these groups.

CONCLUSIONS

Patients with general medical conditions can be safely and effectively treated for MDD with antidepressants with no additional adverse effect or tolerability burden relative to their counterparts without such conditions. Combination therapy is not associated with an increased treatment response beyond that found with traditional monotherapy in patients with MDD, regardless of the presence and number of general medical conditions.

A primary care focus on the treatment of patients with major depressive disorder

Major depressive disorder (MDD) is a common psychiatric illness affecting nearly 20% of adults in the United States at least once during their lifetime. MDD is frequently diagnosed and treated in the primary care setting. Management of the disease may be complicated by patients and family members feeling stigmatized by the diagnosis and not understanding that depression is a treatable medical illness, which, in turn, fosters low rates of adherence to treatment recommendations. Incomplete or delayed response to treatment, adverse events associated with antidepressants and medical or psychiatric comorbidities also interfere with optimal depression management. This article presents an overview of diagnostic and treatment guidelines for MDD and focuses on challenges encountered by primary care physicians. The role of antidepressant medications, psychotherapy and nonpharmacologic interventions for the treatment of patients with MDD is described, and factors influencing treatment selection, such as adverse event profiles and patient characteristics, are examined.

Does integrated care improve treatment for depression? A systematic review

Care management-based interventions promoting integrated care by combining primary care with mental health services in a coordinated and colocated manner are increasingly popular; yet, the benefits of specific approaches are not well established. We conducted a systematic review of integrated care trials in US primary care settings to assess whether the level of integration of provider roles or care process affects clinical outcomes. Although most trials showed positive effects, the degree of integration was not significantly related to depression outcomes. Integrated care appears to improve depression management in primary care patients, but questions remain about its specific form and implementation.

Does integrated care improve treatment for depression? A systematic review

Care management-based interventions promoting integrated care by combining primary care with mental health services in a coordinated and colocated manner are increasingly popular; yet, the benefits of specific approaches are not well established. We conducted a systematic review of integrated care trials in US primary care settings to assess whether the level of integration of provider roles or care process affects clinical outcomes. Although most trials showed positive effects, the degree of integration was not significantly related to depression outcomes. Integrated care appears to improve depression management in primary care patients, but questions remain about its specific form and implementation.

New Zealand general practice nurses' roles in mental health care

AIM

To examine the roles of nurses in general practice interdisciplinary teams caring for people with mild to moderate mental health conditions.

BACKGROUND

Supporting mental health and well-being is an important aspect of primary care. Until now nurses in general practice settings have had variable roles in providing mental health care. The New Zealand Primary Mental Health Initiatives are 26 government-funded, time-limited projects using different service delivery models.

METHODS

An analysis was undertaken of a qualitative data set of interviews, which included commentary about nurses mental health work collected from the different project stakeholders throughout a 29-month external evaluation.

FINDINGS

Two main groups of roles for nurses within the general practice interdisciplinary team were identified: specialist mental health nurses working in newly created roles and practice nurses working in existing roles. Barriers exist to the development of the latter roles.

CONCLUSIONS

Mental health care is a key role in general practice as this is where people frequently present. Internationally, nurses represent a large workforce with the potential to provide effective mental health care. This study found that attitudinal, structural and professional barriers are restricting New Zealand practice nurse role development in the care of those with mild to moderate mental health conditions. There is potential to develop their role within a structured pathway by workforce development and recognition of the value of interdisciplinary care. Given the shortage of mental health professionals this will be an important aspect of the improvement of primary mental health care.

Relational barriers to depression help-seeking in primary care

OBJECTIVE

To identify attitudinal and interpersonal barriers to depression care-seeking and disclosure in primary care and in so doing, evaluate the primary care paradigm for depression care in the United States.

METHODS

Fifteen qualitative focus group interviews in three cities. Study participants were English-speaking men and women aged 25-64 with first-hand knowledge of depression. Transcripts were analyzed iteratively for recurring themes.

RESULTS

Participants expressed reservations about the ability of primary care physicians (PCPs) to meet their mental health needs. Specific barriers included problems with PCP competence and openness as well as patient-physician trust. While many reflected positively on their primary care experiences, some doubted PCPs' knowledge of mental health disorders and believed mental health concerns fell outside the bounds of primary care. Low-income participants in particular shared stories about the essentiality, and ultimate fragility, of patient-PCP trust.

CONCLUSION

Patients with depression may be deterred from care-seeking or disclosure by relational barriers including perceptions of PCPs' mental health-related capabilities and interests.

PRACTICE IMPLICATIONS

PCPs should continue to develop their depression management skills while supporting vigorous efforts to inform the public that primary care is a safe and appropriate venue for treatment of common mental health conditions.

A Web-based clinical decision support system for depression care management

OBJECTIVE

To inform the design of future informatics systems that support the chronic care model.

STUDY DESIGN

We describe the development and functionality of a decision support system for the chronic care model of depression treatment, known as collaborative care. Dissemination of evidence-based collaborative care models has been slow, and fidelity to the evidence base has been poor during implementation initiatives. Implementation could be facilitated by a decision support system for depression care managers, the cornerstone of the collaborative care model. The Net Decision Support System (https://www.netdss.net/) is a free Web-based system that was developed to support depression care manager activities and to facilitate the dissemination of collaborative care models that maintain high fidelity to the evidence base.

METHODS

The NetDSS was based on intervention materials used for a randomized trial of depression care management that improved clinical outcomes compared with usual care. The NetDSS was developed jointly by a cross-functional design team of psychiatrists, depression care managers, information technology specialists, technical writers, and researchers.

RESULTS

The NetDSS has the following functional capabilities: patient registry, patient encounter scheduler, trial management, clinical decision support, progress note generator, and workload and outcomes report generator. The NetDSS guides the care manager through a self-documenting patient encounter using evidence-based scripts and self-scoring instruments. The NetDSS has been used to provide evidence-based depression care management to more than 1700 primary care patients.

CONCLUSION

Intervention protocols can be successfully converted to Web-based decision support systems that facilitate the implementation of evidence-based chronic care models into routine care with high fidelity.

Evaluation of a system of structured, pro-active care for chronic depression in primary care: a randomised controlled trial

BACKGROUND

People with chronic depression are frequently lost from effective care, with resulting psychological, physical and social morbidity and considerable social and financial societal costs. This randomised controlled trial will evaluate whether regular structured practice nurse reviews lead to better mental health and social outcomes for these patients and will assess the cost-effectiveness of the structured reviews compared to usual care.The hypothesis is that structured, pro-active care of patients with chronic depression in primary care will lead to a cost-effective improvement in medical and social outcomes when compared with usual general practitioner (GP) care.

METHODS/DESIGN

Participants were recruited from 42 general practices throughout the United Kingdom. Eligible participants had to have a history of chronic major depression, recurrent major depression or chronic dsythymia confirmed using the Composite International Diagnostic Interview (CIDI). They also needed to score 14 or above on the Beck Depression Inventory (BDI-II) at recruitment.Once consented, participants were randomised to treatment as usual from their general practice (controls) or the practice nurse led intervention. The intervention includes a specially prepared education booklet and a comprehensive baseline assessment of participants' mood and any associated physical and psycho-social factors, followed by regular 3 monthly reviews by the nurse over the 2 year study period. At these appointments intervention participants' mood will be reviewed, together with their current pharmacological and psychological treatments and any relevant social factors, with the nurse suggesting possible amendments according to evidence based guidelines. This is a chronic disease management model, similar to that used for other long-term conditions in primary care.The primary outcome is the BDI-II, measured at baseline and 6 monthly by self-complete postal questionnaire. Secondary outcomes collected by self-complete questionnaire at baseline and 2 years include social functioning, quality of life and data for the economic analyses. Health service data will be collected from GP notes for the 24 months before recruitment and the 24 months of the study.

DISCUSSION

558 participants were recruited, 282 to the intervention and 276 to the control arm. The majority were recruited via practice database searches using relevant READ codes.

TRIAL REGISTRATION

ISRCTN36610074.

Agomelatine in the treatment of major depressive disorder: potential for clinical effectiveness

To demonstrate the clinical effectiveness of an antidepressant drug requires evidence beyond short- and long-term efficacy, including a favourable adverse-effect profile and sustained treatment adherence. Under these conditions, patients should experience enhanced social and functional outcomes. The novel antidepressant agomelatine, a melatonergic MT(1)/MT(2) receptor agonist with serotonin 5-HT(2C) receptor antagonist activity, displays antidepressant efficacy with a favourable adverse-effect profile that is associated with good patient adherence. Specifically, agomelatine has demonstrated significant short-term (6-8 weeks) and sustained (6 months) antidepressant efficacy relative to placebo, as well as evidence of relapse prevention (up to 10 months). In head-to-head comparative studies with venlafaxine and sertraline, there was evidence of early (at 1-2 weeks) and sustained (at 6 months) advantages for agomelatine. In addition to evidence of early efficacy, agomelatine also restored disturbed sleep-wake patterns early in treatment. There was no evidence of antidepressant-induced sexual dysfunction, weight gain or discontinuation-emergent symptoms. Agomelatine has demonstrated a range of properties that suggest it could offer advantages over current treatments for major depressive disorder, although further comparative trials are still required, as is evidence from real-world clinical practice.

Collaborative care for depressed patients with chronic medical conditions: a randomized trial in Puerto Rico

OBJECTIVE

This study examined whether a collaborative care model for depression would improve clinical and functional outcomes for depressed patients with chronic general medical conditions in primary care practices in Puerto Rico.

METHODS

A total of 179 primary care patients with major depression and chronic general medical conditions were randomly assigned to receive collaborative care or usual care. The collaborative care intervention involved enhanced collaboration among physicians, mental health specialists, and care managers paired with depression-specific treatment guidelines, patient education, and follow-up. In usual care, study personnel informed the patient and provider of the diagnosis and encouraged patients to discuss treatment options with their provider. Depression severity was assessed with the Hopkins Symptom Checklist; social functioning was assessed with the 36-item Short Form.

RESULTS

Compared with usual care, collaborative care significantly reduced depressive symptoms and improved social functioning in the six months after randomization. Integration of collaborative care in primary care practices considerably increased depressed patients' use of mental health services.

CONCLUSIONS

Collaborative care significantly improved clinical symptoms and functional status of depressed patients with coexisting chronic general medical conditions receiving treatment for depression in primary care practices in Puerto Rico. These findings highlight the promise of the collaborative care model for strengthening the relationship between mental health and primary care services in Puerto Rico.