An introduction to implementation science for the non-specialist

BACKGROUND

The movement of evidence-based practices (EBPs) into routine clinical usage is not spontaneous, but requires focused efforts. The field of implementation science has developed to facilitate the spread of EBPs, including both psychosocial and medical interventions for mental and physical health concerns.

DISCUSSION

The authors aim to introduce implementation science principles to non-specialist investigators, administrators, and policymakers seeking to become familiar with this emerging field. This introduction is based on published literature and the authors' experience as researchers in the field, as well as extensive service as implementation science grant reviewers. Implementation science is "the scientific study of methods to promote the systematic uptake of research findings and other EBPs into routine practice, and, hence, to improve the quality and effectiveness of health services." Implementation science is distinct from, but shares characteristics with, both quality improvement and dissemination methods. Implementation studies can be either assess naturalistic variability or measure change in response to planned intervention. Implementation studies typically employ mixed quantitative-qualitative designs, identifying factors that impact uptake across multiple levels, including patient, provider, clinic, facility, organization, and often the broader community and policy environment. Accordingly, implementation science requires a solid grounding in theory and the involvement of trans-disciplinary research teams. The business case for implementation science is clear: As healthcare systems work under increasingly dynamic and resource-constrained conditions, evidence-based strategies are essential in order to ensure that research investments maximize healthcare value and improve public health. Implementation science plays a critical role in supporting these efforts.

Long-Term Clinical Outcomes from a Randomized Controlled Trial of Two Implementation Strategies to Promote Collaborative Care Attendance in Community Practices

This randomized controlled implementation study compared the effectiveness of a standard versus enhanced version of the replicating effective programs (REP) implementation strategy to improve the uptake of the life goals-collaborative care model (LG-CC) for bipolar disorder. Seven community-based practices (384 patient participants) were randomized to standard (manual/training) or enhanced REP (customized manual/training/facilitation) to promote LG-CC implementation. Participants from enhanced REP sites had no significant changes in primary outcomes (improved quality of life, reduced functioning or mood symptoms) by 24 months. Further research is needed to determine whether implementation strategies can lead to sustained, improved participant outcomes in addition to program uptake.

Mortality associated with lithium and valproate treatment of US Veterans Health Administration patients with mental disorders

BackgroundThe mood stabilisers lithium and valproate might plausibly have differing associations with mortality because of differing effects on mental health and various physiological indicators.AimsTo assess associations between lithium, valproate and non-suicide mortality.MethodIntention-to-treat, propensity score-matched cohort study.ResultsLithium was associated with significantly reduced non-suicide mortality in the intent-to-treat cohort over 0-90 days (hazard ratio (HR) = 0.67, 95% CI 0.51-0.87) but not longer. In secondary analyses, a sizeable reduction in mortality was observed during active treatment with lithium across all time periods studied (for example 365-day HR = 0.62, 95% CI 0.45-0.84), but significantly increased risks were observed among patients discontinuing lithium by 180 days (HR = 1.54, 95% CI 1.01-2.37).ConclusionsPatients initiating lithium had lower non-suicide mortality over 0-90 days than patients initiating valproate and consistently lower non-suicide mortality among patients maintaining treatment, but elevated risk among patients discontinuing treatment by 180 days. Although residual confounding or selection effects cannot be excluded, this study suggests potential benefits to enhancing lithium treatment persistence and the monitoring of patients discontinuing lithium. There is a need for further research.

Reengaging veterans with serious mental illness into care: preliminary results from a national randomized trial

OBJECTIVE

This study compared effectiveness of an enhanced versus standard implementation strategy (Replicating Effective Programs [REP]) on site-level uptake of Re-Engage, a national program for veterans with serious mental illness.

METHODS

Mental health providers at 158 Veterans Affairs (VA) facilities were given REP-based manuals and training in Re-Engage, which involved identifying veterans who had not been seen in VA care for at least one year, documenting their clinical status, and coordinating further health care. After six months, facilities not responding to REP (N=88) were randomized to receive six months of facilitation (enhanced REP) or continued standard REP. Site-level uptake was defined as percentage of patients (N=1,531) with updated documentation or with whom contact was attempted.

RESULTS

Rate of Re-Engage uptake was greater for enhanced REP sites compared with standard REP sites (41% versus 31%, p=.01). Total REP facilitation time was 7.3 hours per site for six months.

CONCLUSIONS

Added facilitation improved short-term uptake of a national mental health program.

Enhancing outreach for persons with serious mental illness: 12-month results from a cluster randomized trial of an adaptive implementation strategy

Background

Few implementation strategies have been empirically tested for their effectiveness in improving uptake of evidence-based treatments or programs. This study compared the effectiveness of an immediate versus delayed enhanced implementation strategy (Enhanced Replicating Effective Programs (REP)) for providers at Veterans Health Administration (VA) outpatient facilities (sites) on improved uptake of an outreach program (Re-Engage) among sites not initially responding to a standard implementation strategy.

Methods

One mental health provider from each U.S. VA site (N = 158) was initially given a REP-based package and training program in Re-Engage. The Re-Engage program involved giving each site provider a list of patients with serious mental illness who had not been seen at their facility for at least a year, requesting that providers contact these patients, assessing patient clinical status, and where appropriate, facilitating appointments to VA health services. At month 6, sites considered non-responsive (N = 89, total of 3,075 patients), defined as providers updating documentation for less than <80% of patients on their list, were randomized to two adaptive implementation interventions: Enhanced REP (provider coaching; N = 40 sites) for 6 months followed by Standard REP for 6 months; versus continued Standard REP (N = 49 sites) for 6 months followed by 6 months of Enhanced REP for sites still not responding. Outcomes included patient-level Re-Engage implementation and utilization.

Results

Patients from sites that were randomized to receive Enhanced REP immediately compared to Standard REP were more likely to have a completed contact (adjusted OR = 2.13; 95% CI: 1.09–4.19, P = 0.02). There were no differences in patient-level utilization between Enhanced and Standard REP sites.

Conclusions

Enhanced REP was associated with greater Re-Engage program uptake (completed contacts) among sites not responding to a standard implementation strategy. Further research is needed to determine whether national implementation of Facilitation results in tangible changes in patient-level outcomes.

Trial registration

ISRCTN: ISRCTN21059161

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-014-0163-3) contains supplementary material, which is available to authorized users.

Suicide risk in Veterans Health Administration patients with mental health diagnoses initiating lithium or valproate: a historical prospective cohort study

BACKGROUND

Lithium has been reported in some, but not all, studies to be associated with reduced risks of suicide death or suicidal behavior. The objective of this nonrandomized cohort study was to examine whether lithium was associated with reduced risk of suicide death in comparison to the commonly-used alternative treatment, valproate.

METHODS

A propensity score-matched cohort study was conducted of Veterans Health Administration patients (n=21,194/treatment) initiating lithium or valproate from 1999-2008.

RESULTS

Matching produced lithium and valproate treatment groups that were highly similar in all 934 propensity score covariates, including indicators of recent suicidal behavior, but recent suicidal ideation was not able to be included. In the few individuals with recently diagnosed suicidal ideation, a significant imbalance existed with suicidal ideation more prevalent at baseline among individuals initiating lithium than valproate (odds ratio (OR) 1.30, 95% CI 1.09, 1.54; p=0.003). No significant differences in suicide death were observed over 0-365 days in A) the primary intent-to-treat analysis (lithium/valproate conditional odds ratio (cOR) 1.22, 95% CI 0.82, 1.81; p=0.32); B) during receipt of initial lithium or valproate treatment (cOR 0.86, 95% CI 0.46, 1.61; p=0.63); or C) after such treatment had been discontinued/modified (OR 1.51, 95% CI 0.91, 2.50; p=0.11). Significantly increased risks of suicide death were observed after the discontinuation/modification of lithium, compared to valproate, treatment over the first 180 days (OR 2.72, 95% CI 1.21, 6.11; p=0.015).

CONCLUSIONS

In this somewhat distinct sample (a predominantly male Veteran sample with a broad range of psychiatric diagnoses), no significant differences in associations with suicide death were observed between lithium and valproate treatment over 365 days. The only significant difference was observed over 0-180 days: an increased risk of suicide death, among individuals discontinuing or modifying lithium, compared to valproate, treatment. This difference could reflect risks either related to lithium discontinuation or higher baseline risks among lithium recipients (i.e., confounding) that became more evident when treatment stopped. Our findings therefore support educating patients and providers about possible suicide-related risks of discontinuing lithium even shortly after treatment initiation, and the close monitoring of patients after lithium discontinuation, if feasible. If our findings include residual confounding biasing against lithium, however, as suggested by the differences observed in diagnosed suicidal ideation, then the degree of beneficial reduction in suicide death risk associated with active lithium treatment would be underestimated. Further research is urgently needed, given the lack of interventions against suicide and the uncertainties concerning the degree to which lithium may reduce suicide risk during active treatment, increase risk upon discontinuation, or both.

Randomized controlled trial of a health plan-level mood disorders psychosocial intervention for solo or small practices

BACKGROUND

Mood disorders represent the most expensive mental disorders for employer-based commercial health plans. Collaborative care models are effective in treating chronic physical and mental illnesses at little to no net healthcare cost, but to date have primarily been implemented by larger healthcare organizations in facility-based models. The majority of practices providing commercially insured care are far too small to implement such models. Health plan-level collaborative care treatment can address this unmet need. The goal of this study is to implement at the national commercial health plan level a collaborative care model to improve outcomes for persons with mood disorders.

METHODS/DESIGN

A randomized controlled trial of a collaborative care model versus usual care will be conducted among beneficiaries of a large national health plan from across the country seen by primary care or behavioral health practices. At discharge 344 patients identified by health plan claims as hospitalized for unipolar depression or bipolar disorder will be randomized to receive collaborative care (patient phone-based self-management support, care management, and guideline dissemination to practices delivered by a plan-level care manager) or usual care from their provider. Primary outcomes are changes in mood symptoms and mental health-related quality of life at 12 months. Secondary outcomes include rehospitalization, receipt of guideline-concordant care, and work productivity.

DISCUSSION

This study will determine whether a collaborative care model for mood disorders delivered at the national health plan level improves outcomes compared to usual care, and will inform a business case for collaborative care models for these settings that can reach patients wherever they receive treatment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02041962; registered January 3, 2014.

Weight loss after participation in a national VA weight management program among veterans with or without PTSD

OBJECTIVE

This evaluation compared the effectiveness of MOVE!, a U.S. Veterans Health Administration (VHA) weight management program, among veterans with posttraumatic stress disorder (PTSD), other mental conditions, or no mental health diagnoses.

METHODS

VHA administrative data from 2008 to 2012 were used to estimate adjusted six- and 12-month weight change and ≥5% weight loss among 20,819 veterans with "intense and sustained" MOVE! participation (14% of 148,963 MOVE! participants, regardless of mental health status).

RESULTS

Compared with veterans with no mental health diagnoses, veterans with PTSD lost significantly less weight at six and 12 months (p<.05) and were less likely to lose ≥5% body weight at six months (OR=.89, p<.05). At six months, those with other mental conditions lost significantly less weight than those with no mental health diagnoses (p<.05).

CONCLUSIONS

MOVE! may need adaptation to increase overall engagement and enhance weight loss for veterans with mental conditions, especially PTSD.

Protocol: Adaptive Implementation of Effective Programs Trial (ADEPT): cluster randomized SMART trial comparing a standard versus enhanced implementation strategy to improve outcomes of a mood disorders program

BACKGROUND

Despite the availability of psychosocial evidence-based practices (EBPs), treatment and outcomes for persons with mental disorders remain suboptimal. Replicating Effective Programs (REP), an effective implementation strategy, still resulted in less than half of sites using an EBP. The primary aim of this cluster randomized trial is to determine, among sites not initially responding to REP, the effect of adaptive implementation strategies that begin with an External Facilitator (EF) or with an External Facilitator plus an Internal Facilitator (IF) on improved EBP use and patient outcomes in 12 months.

METHODS/DESIGN

This study employs a sequential multiple assignment randomized trial (SMART) design to build an adaptive implementation strategy. The EBP to be implemented is life goals (LG) for patients with mood disorders across 80 community-based outpatient clinics (N = 1,600 patients) from different U.S. regions. Sites not initially responding to REP (defined as < 50% patients receiving ≥ 3 EBP sessions) will be randomized to receive additional support from an EF or both EF/IF. Additionally, sites randomized to EF and still not responsive will be randomized to continue with EF alone or to receive EF/IF. The EF provides technical expertise in adapting LG in routine practice, whereas the on-site IF has direct reporting relationships to site leadership to support LG use in routine practice. The primary outcome is mental health-related quality of life; secondary outcomes include receipt of LG sessions, mood symptoms, implementation costs, and organizational change.

DISCUSSION

This study design will determine whether an off-site EF alone versus the addition of an on-site IF improves EBP uptake and patient outcomes among sites that do not respond initially to REP. It will also examine the value of delaying the provision of EF/IF for sites that continue to not respond despite EF.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02151331.

SMI life goals: description of a randomized trial of a collaborative care model to improve outcomes for persons with serious mental illness

BACKGROUND

Persons with serious mental illnesses (SMI) are more likely to die earlier than the general population, primarily due to increased medical burden, particularly from cardiovascular disease (CVD). Life Goals Collaborative Care (LG-CC) is designed to improve health outcomes in SMI through self-management, care management, and provider support. This single-blind randomized controlled effectiveness study will determine whether patients with SMI receiving LG-CC compared to usual care (UC) experience improved physical health in 12 months.

METHODS

Patients diagnosed with SMI and at least one CVD risk factor receiving care at a VA mental health clinic were randomized to LG-CC or UC. LG-CC included five self-management sessions covering mental health symptom management reinforced through health behavior change, care coordination and health monitoring via a registry, and provider feedback. The primary outcome is change in physical health-related quality of life score (VR-12) from baseline to 12 months. Secondary outcomes include changes in mental health-related quality of life, CVD risk factors (blood pressure, BMI), and physical activity from baseline to 12 months later.

RESULTS

Out of 304 enrolled, 139 were randomized to LG-CC and 145 to UC. Among patients completing baseline assessments (N = 284); the mean age was 55.2 (SD = 10.9; range 28-75 years), 15.6% were women, the majority (62%) were diagnosed with depression, and the majority (63%) were diagnosed with hypertension or were overweight (BMI mean ± SD = 33.3 ± 6.3). Baseline VR-12 physical health component score was below population norms (50.0 ± SD = 10) at 33.4 ± 11.0.

CONCLUSIONS

Findings from this trial may inform initiatives to improve physical health for SMI patient populations.

Long-term benzodiazepine use in patients with major depressive disorder in China

PURPOSE

There have been no data about long-term benzodiazepine (BZD) use and its correlates in patients with major depressive disorder (MDD) in China. This study aimed to examine the prevalence of long-term BZD use (more than three months) and its demographic and clinical correlates in Chinese patients with MDD.

DESIGN AND METHODS

A total of 1,192 patients with MDD were examined in 10 mental health centers in China. Patients' socio-demographic and clinical characteristics and prescriptions for psychotropic drugs were recorded using a standardized form.

FINDINGS

A large portion of patients (36.2%) received long-term BZD treatment. Univariate analyses revealed that long-term BZD users were older, poorer, and had more impaired occupational functioning than patients not taking BZDs. Long-term BZD users had fewer psychotic symptoms and took less antipsychotic drugs. In multivariate analyses, long-term BZD use was independently associated with older age and more severe impaired occupational functioning; long-term BZD users were less likely to receive antipsychotic medications and traditional antidepressants (tricyclic antidepressants, tetracyclic antidepressant, and monoamine oxidase inhibitors).

PRACTICE IMPLICATIONS

Long-term BZD use was common in patients with MDD in China. A host of demographic and clinical factors were independently associated with long-term BZD use.

Diagnostic accuracy of the Composite International Diagnostic Interview (CIDI 3.0) PTSD module among female Vietnam-era veterans

The World Health Organization (WHO) Composite International Diagnostic Interview (CIDI) posttraumatic stress disorder (PTSD) module is widely used in epidemiological studies of PTSD, yet relatively few data attest to the instrument's diagnostic utility. The current study evaluated the diagnostic utility of the CIDI 3.0 PTSD module with U. S. women Vietnam-era veterans. The CIDI and the Clinician-Administered PTSD Scale (CAPS) were independently administered to a stratified sample of 160 women, oversampled for current PTSD. Both lifetime PTSD and recent (past year) PTSD were assessed within a 3-week interval. Forty-five percent of the sample met criteria for a CAPS diagnosis of lifetime PTSD, and 21.9% of the sample met criteria for a CAPS diagnosis of past-year PTSD. Using CAPS as the diagnostic criterion, the CIDI correctly classified 78.8% of cases for lifetime PTSD (κ = .56) and 82.0% of past year PTSD cases (κ = .51). Estimates of diagnostic performance for the CIDI were sensitivity of .61 and specificity of .91 for lifetime PTSD and sensitivity of .71 and specificity of .85 for past-year PTSD. Results suggest that the CIDI has good utility for identifying PTSD, though it is a somewhat conservative indicator of lifetime PTSD as compared to the CAPS.

Collaborative care outcomes for pediatric behavioral health problems: a cluster randomized trial

OBJECTIVE

To assess the efficacy of collaborative care for behavior problems, attention-deficit/hyperactivity disorder (ADHD), and anxiety in pediatric primary care (Doctor Office Collaborative Care; DOCC).

METHODS

Children and their caregivers participated from 8 pediatric practices that were cluster randomized to DOCC (n = 160) or enhanced usual care (EUC; n = 161). In DOCC, a care manager delivered a personalized, evidence-based intervention. EUC patients received psychoeducation and a facilitated specialty care referral. Care processes measures were collected after the 6-month intervention period. Family outcome measures included the Vanderbilt ADHD Diagnostic Parent Rating Scale, Parenting Stress Index-Short Form, Individualized Goal Attainment Ratings, and Clinical Global Impression-Improvement Scale. Most measures were collected at baseline, and 6-, 12-, and 18-month assessments. Provider outcome measures examined perceived treatment change, efficacy, and obstacles, and practice climate.

RESULTS

DOCC (versus EUC) was associated with higher rates of treatment initiation (99.4% vs 54.2%; P < .001) and completion (76.6% vs 11.6%, P < .001), improvement in behavior problems, hyperactivity, and internalizing problems (P < .05 to .01), and parental stress (P < .05-.001), remission in behavior and internalizing problems (P < .01, .05), goal improvement (P < .05 to .001), treatment response (P < .05), and consumer satisfaction (P < .05). DOCC pediatricians reported greater perceived practice change, efficacy, and skill use to treat ADHD (P < .05 to .01).

CONCLUSIONS

Implementing a collaborative care intervention for behavior problems in community pediatric practices is feasible and broadly effective, supporting the utility of integrated behavioral health care services.

HealthViEWS: mortality study of female US Vietnam era veterans, 1965-2010

We conducted a retrospective study among 4,734 women who served in the US military in Vietnam (Vietnam cohort), 2,062 women who served in countries near Vietnam (near-Vietnam cohort), and 5,313 nondeployed US military women (US cohort) to evaluate the associations of mortality outcomes with Vietnam War service. Veterans were identified from military records and followed for 40 years through December 31, 2010. Information on underlying causes of death was obtained from death certificates and the National Death Index. Based on 2,743 deaths, all 3 veteran cohorts had lower mortality risk from all causes combined and from several major causes, such as diabetes mellitus, heart disease, chronic obstructive pulmonary disease, and nervous system disease relative to comparable US women. However, excess deaths from motor vehicle accidents were observed in the Vietnam cohort (standardized mortality ratio = 3.67, 95% confidence interval (CI): 2.30, 5.56) and in the US cohort (standardized mortality ratio = 1.91, 95% CI: 1.02, 3.27). More than two-thirds of women in the study were military nurses. Nurses in the Vietnam cohort had a 2-fold higher risk of pancreatic cancer death (adjusted relative risk = 2.07, 95% CI: 1.00, 4.25) and an almost 5-fold higher risk of brain cancer death compared with nurses in the US cohort (adjusted relative risk = 4.61, 95% CI: 1.27, 16.83). Findings of all-cause and motor vehicle accident deaths among female Vietnam veterans were consistent with patterns of postwar mortality risk among other war veterans.

A comparison of cognitive-behavioral therapy, antidepressants, their combination and standard treatment for Chinese patients with moderate-severe major depressive disorders

BACKGROUND

No study has examined the effect of cognitive-behavioral therapy (CBT) on moderate-severe major depressive disorders (MDD) in China. The objective of this study was to evaluate the effect of CBT, antidepressants alone (MED), combined CBT and antidepressants (COMB) and standard treatment (ST; i.e., receiving psycho-educational intervention and/or medication treatment determined by treating psychiatrists) on depressive symptoms and social functioning in Chinese patients with moderate-severe MDD.

METHOD

A total of 180 patients diagnosed with MDD according to ICD-10 were randomly allocated to one of the four treatment regimens for a period of 6 months. Depressive symptoms were measured using the Hamilton Rating Scale for Depression (HAMD) and the Quick Inventory of Depressive Symptomatology-Self-Report (C-QIDS-SR). Remission threshold was defined as a C-QIDS-SR total score of <5. Social functioning was evaluated with the Work and Social Adjustment Scale (WSAS). All outcome measures were evaluated at entry, and at 3- and 6-months follow-up.

RESULTS

At the 6-months assessment, the remission rates in the whole sample (n=96), the MED, the CBT, the COMB and the ST groups were 54.2%, 48%, 75%, 53.5% and 50%, respectively. Following the treatment periods, there was no significant difference in any of the study outcomes between the four groups. However, the CBT showed the greatest effect in the HAMD total score with the effect size=0.94, whereas the ST has only a moderate effect size in the WSAS total score (effect size=0.47).

CONCLUSIONS

The findings support the feasibility and effectiveness of CBT as a psychosocial intervention for Chinese patients with moderate-severe MDD. We also found that single treatment using MED or CBT performed equally well as the combined CBT-antidepressant treatment in controlling the remission. The study provided important knowledge to inform the mental health care planning in China.

Enhanced fidelity to treatment for bipolar disorder: results from a randomized controlled implementation trial

OBJECTIVE

The authors compared fidelity to bipolar disorder treatment at community practices that received a standard or enhanced version of a novel implementation intervention called Replicating Effective Programs (REP).

METHODS

Five community practices in Michigan and Colorado were assigned at random to receive enhanced (N=3) or standard (N=2) REP to help implement Life Goals Collaborative Care (LGCC), a psychosocial intervention consisting of four self-management support group sessions, ongoing care management contacts by phone, and dissemination of guidelines to providers. Standard REP includes an intervention package consisting of an outline, a treatment manual and implementation guide, a standard training program, and as-needed technical assistance. Enhanced REP added customization of the treatment manual and ongoing, proactive technical assistance from internal and external facilitators. Multiple and logistic regression analyses determined the impact of enhanced versus standard REP on patient-level fidelity.

RESULTS

The participants (N=384) had a mean age of 42 years; 67% were women, and 30% were nonwhite. Participants attended an average of three group sessions and had an average of four care management contacts. After adjustment for patient factors, enhanced REP was associated with 2.6 (p<.001) times more total sessions and contacts than standard REP, which was driven by 2.5 (p<.01) times more care management contacts. Women and participants with a history of homelessness had fewer total sessions and contacts.

CONCLUSIONS

Enhanced REP was associated with improved LGCC fidelity, primarily for care management contacts. Additional customization of interventions such as LGCC may be needed to ensure adequate treatment fidelity for vulnerable populations.

Overcoming roadblocks: current and emerging reimbursement strategies for integrated mental health services in primary care

The Chronic Care Model (CCM) has been shown to improve medical and psychiatric outcomes for persons with mental disorders in primary care settings, and has been proposed as a model to integrate mental health care in the patient-centered medical home under healthcare reform. However, the CCM has not been widely implemented in primary care settings, primarily because of a lack of a comprehensive reimbursement strategy to compensate providers for day-to-day provision of its core components, including care management and provider decision support. Drawing upon the existing literature and regulatory guidelines, we provide a critical analysis of challenges and opportunities in reimbursing CCM components under the current fee-for-service system, and describe an emerging financial model involving bundled payments to support core CCM components to integrate mental health treatment into primary care settings. Ultimately, for the CCM to be used and sustained over time to integrate physical and mental health care, effective reimbursement models will need to be negotiated across payers and providers. Such payments should provide sufficient support for primary care providers to implement practice redesigns around core CCM components, including care management, measurement-based care, and mental health specialist consultation.

Characteristics of unrecognised bipolar disorder in patients treated for major depressive disorder in China: general versus psychiatric hospitals

OBJECTIVES

Bipolar disorder is often misdiagnosed as major depressive disorder. Such misdiagnosis partly depends on the type of treatment setting. This study compared general hospital psychiatric units with psychiatric hospitals in China with respect to basic demographic and clinical characteristics of patients with unrecognised bipolar disorder who are treated for major depressive disorder.

METHODS

Patients treated for major depressive disorder were consecutively examined in 13 health centres (6 general hospital psychiatric units and 7 psychiatric hospitals) in China. Their socio-demographic and clinical features were recorded using a standardised protocol and data collection procedure. The DSM-IV diagnoses were established using the Mini-International Neuropsychiatric Interview.

RESULTS

Of the 1487 patients included in the study, 309 (20.8%) were diagnosed with bipolar disorder. There was no significant difference between general hospital psychiatric units and psychiatric hospitals in the ratio of all types of unrecognised bipolar disorders (χ2 = 0.008, degrees of freedom = 1, p = 0.9) and bipolar II disorders (χ2 = 3.1, degrees of freedom = 1, p = 0.08). The proportions of unrecognised bipolar I disorders (χ2 = 4.1, degrees of freedom = 1, p = 0.04) differed significantly between the 2 types of study site. Multivariate analyses showed that patients with bipolar I disorders with more seasonal depressive episodes were more likely to receive treatment in general hospital psychiatric units (odds ratio = 3.3, 95% confidence interval = 1.1-9.8).

CONCLUSION

Patients with bipolar I disorders receiving treatment in general hospital psychiatric units had different clinical characteristics compared to their counterparts treated in psychiatric hospitals in China.

Cluster randomized adaptive implementation trial comparing a standard versus enhanced implementation intervention to improve uptake of an effective re-engagement program for patients with serious mental illness

Background

Persons with serious mental illness (SMI) are disproportionately burdened by premature mortality. This disparity is exacerbated by poor continuity of care with the health system. The Veterans Health Administration (VA) developed Re-Engage, an effective population-based outreach program to identify veterans with SMI lost to care and to reconnect them with VA services. However, such programs often encounter barriers getting implemented into routine care. Adaptive designs are needed when the implementation intervention requires augmentation within sites that do not initially respond to an initial implementation intervention. This protocol describes the methods used in an adaptive implementation design study that aims to compare the effectiveness of a standard implementation strategy (Replicating Effective Programs, or REP) with REP enhanced with External Facilitation (enhanced REP) to promote the uptake of Re-Engage.

Methods/Design

This study employs a four-phase, two-arm, longitudinal, clustered randomized trial design. VA sites (n = 158) across the United States with a designated Re-Engage provider, at least one Veteran with SMI lost to care, and who received standard REP during a six-month run-in phase. Subsequently, 88 sites with inadequate uptake were stratified at the cluster level by geographic region (n = 4) and VA regional service network (n = 20) and randomized to REP (n = 49) vs. enhanced REP (n = 39) in phase two. The primary outcome was the percentage of veterans on each facility outreach list documented on an electronic web registry. The intervention was at the site and network level and consisted of standard REP versus REP enhanced by external phone facilitation consults. At 12 months, enhanced REP sites returned to standard REP and 36 sites with inadequate participation received enhanced REP for six months in phase three. Secondary implementation outcomes included the percentage of veterans contacted directly by site providers and the percentage re-engaged in VA health services.

Discussion

Adaptive implementation designs consisting of a sequence of decision rules that are tailored based on a site’s uptake of an effective program may produce more relevant, rapid, and generalizable results by more quickly validating or rejecting new implementation strategies, thus enhancing the efficiency and sustainability of implementation research and potentially leading to the rollout of more cost-efficient implementation strategies.

Trial registration

Current Controlled Trials ISRCTN21059161.

Gender differences in demographic and clinical features and prescribing patterns of psychotropic medications in patients with major depressive disorder in China

PURPOSE

Little is known about gender differences associated with major depressive disorder (MDD) in China. This study examined gender differences associated with other demographic and clinical characteristics and psychotropic drug treatment in Chinese patients with MDD.

METHODS

A total of 1178 patients with MDD from 13 psychiatric hospitals or psychiatric units of general hospitals in China nationwide were enrolled. Cross-sectional data including patients' demographic and clinical characteristics and prescriptions of psychotropic medications were recorded using a standardized protocol and data collection procedure.

RESULTS

The sample consisted of 793 female and 385 male patients. Univariate analyses revealed that male patients were younger than female patients, had a younger age of onset of depression, had less lifetime depressive episodes and had more bipolar features (i.e. patients who screened positive for hypomanic symptoms on the 32-item Hypomania Checklist, but did not meet the diagnostic criteria for DSM-IV bipolar disorders as measured by the Mini International Neuropsychiatric Interview). Also, men were more likely to be employed than women and less likely to have depressive episodes following stressful life events. In multivariate analyses, being employed, having bipolar features and not having depressive episodes following stressful life events were independently associated with being a male patient with major depressive disorder. There was no difference in use of psychotropic medications by gender.

CONCLUSIONS

Most gender differences in MDD patients in this study are not consistent with findings of Western studies suggesting that gender differences in MDD may be determined by both biological and sociocultural differences among ethnically different patient populations.

Collaborative chronic care models for mental health conditions: cumulative meta-analysis and metaregression to guide future research and implementation

OBJECTIVE

Prior meta-analysis indicates that collaborative chronic care models (CCMs) improve mental and physical health outcomes for individuals with mental disorders. This study aimed to investigate the stability of evidence over time and identify patient and intervention factors associated with CCM effects to facilitate implementation and sustainability of CCMs in clinical practice.

METHODS

We reviewed 53 CCM trials that analyzed depression, mental quality of life (QOL), or physical QOL outcomes. Cumulative meta-analysis and metaregression were supplemented by descriptive investigations across and within trials.

RESULTS

Most trials targeted depression in the primary care setting, and cumulative meta-analysis indicated that effect sizes favoring CCM quickly achieved significance for depression outcomes, and more recently achieved significance for mental and physical QOL. Four of 6 CCM elements (patient self-management support, clinical information systems, system redesign, and provider decision support) were common among reviewed trials, whereas 2 elements (health care organization support and linkages to community resources) were rare. No single CCM element was statistically associated with the success of the model. Similarly, metaregression did not identify specific factors associated with CCM effectiveness. Nonetheless, results within individual trials suggest that increased illness severity predicts CCM outcomes.

CONCLUSIONS

Significant CCM trials have been derived primarily from 4 original CCM elements. Nonetheless, implementing and sustaining this established model will require health care organization support. Although CCMs have typically been tested as population-based interventions, evidence supports stepped care application to more severely ill individuals. Future priorities include developing implementation strategies to support adoption and sustainability of the model in clinical settings while maximizing fit of this multicomponent framework to local contextual factors.

Pain conditions among veterans with schizophrenia or bipolar disorder

OBJECTIVE

The purpose of this study was to assess the rates of chronic, noncancer pain conditions in patients with schizophrenia or bipolar disorder within the Veterans Health Administration (VHA) System.

METHOD

This cross-sectional study used administrative data extracted from VHA treatment records of all individuals receiving VHA services in fiscal year 2008 (N=5,195,551). The associations between severe psychiatric disorders (schizophrenia and bipolar disorder) and chronic pain (arthritis, back pain, chronic pain, migraine, headache, psychogenic and neuropathic) were evaluated using a series of logistic regression analyses.

RESULTS

Veterans with schizophrenia [odds ratio (OR)=1.21] and bipolar disorder (OR=2.17) were significantly more likely to have chronic pain overall relative to veterans without these psychiatric conditions. These associations were slightly lower than for the association between depression and pain in this sample (OR=2.61). The highest associations between specific psychiatric diagnosis and pain condition were found with chronic pain, headache and psychogenic pain.

CONCLUSIONS

Noncancer pain conditions occur in elevated rates among patients with schizophrenia and bipolar disorder. Future research could further examine possible barriers to adequate pain treatment among people with serious mental illness, as well as the extent to which chronic pain might impact mental health recovery.