Collaborative depression care: history, evolution and ways to enhance dissemination and sustainability

OBJECTIVE

To describe the history and evolution of the collaborative depression care model and new research aimed at enhancing dissemination.

METHOD

Four keynote speakers from the 2009 NIMH Annual Mental Health Services Meeting collaborated in this article in order to describe the history and evolution of collaborative depression care, adaptation of collaborative care to new populations and medical settings, and optimal ways to enhance dissemination of this model.

RESULTS

Extensive evidence across 37 randomized trials has shown the effectiveness of collaborative care vs. usual primary care in enhancing quality of depression care and in improving depressive outcomes for up to 2 to 5 years. Collaborative care is currently being disseminated in large health care organizations such as the Veterans Administration and Kaiser Permanente, as well as in fee-for-services systems and federally funded clinic systems of care in multiple states. New adaptations of collaborative care are being tested in pediatric and ob-gyn populations as well as in populations of patients with multiple comorbid medical illnesses. New NIMH-funded research is also testing community-based participatory research approaches to collaborative care to attempt to decrease disparities of care in underserved minority populations.

CONCLUSION

Collaborative depression care has extensive research supporting the effectiveness of this model. New research and demonstration projects have focused on adapting this model to new populations and medical settings and on studying ways to optimally disseminate this approach to care, including developing financial models to incentivize dissemination and partnerships with community populations to enhance sustainability and to decrease disparities in quality of mental health care.

Factors associated with detection and receipt of treatment for youth with depression and anxiety disorders

OBJECTIVE

Anxiety and depression are common among youth and are associated with significant morbidity. Few youth with depression are diagnosed and receive treatment for these disorders. The purpose of this study was to examine the rate of recognition and management among an insured population and the factors associated with evidence of detection among youth.

METHODS

Structured mental health interviews assessing depression and anxiety diagnoses were completed with a random sample of 581 youth (age range 11-17 years) from an integrated health care system. Administrative data on medical and pharmacy services were used to examine any evidence of detection by the medical system in the prior 12 months.

RESULTS

Fifty-one youth met criteria for an anxiety or depressive disorder. Twenty-two percent of these youth with an anxiety or depressive disorder as defined in Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition had evidence of detection or treatment. Factors associated with detection and treatment included having diagnosis of a depressive disorder (with or without an anxiety disorder), more depressive symptoms, greater functional impairment, a higher number of primary care visits in the prior year, and higher parent-reported externalizing symptoms. On multivariate analysis, having more depressive symptoms and a higher number of primary care visits were significant predictors of detection and receipt of treatment.

CONCLUSIONS

The rate of detection and treatment of anxiety and depressive disorders is very low in this age group and suggests a need for increased focus on detection, particularly in light of recent evidence suggesting decreases in diagnosis and treatment among youth following the black box warning regarding antidepressant medications.

The impact of depression on workplace functioning and disability costs

Until recently, the negative effect that major depressive disorder (MDD) has on interpersonal and workplace functioning had not been widely studied. Traditionally, the goals for treating MDD have also not focused on the commonly associated increases in healthcare utilization for somatic symptoms (ie, headache, abdominal pain) and poorly controlled comorbid medical illnesses, which lead to higher healthcare costs. This article reviews the extensive data collected during the past 10 years that have quantified the impact that MDD has on these outcomes, suggesting that patients with MDD have significant decrements in function, particularly those with comorbid general medical conditions. Also reviewed is the literature presenting evidence from randomized trials of systematic and collaborative treatment efforts that optimize treatment response and, in turn, decrease interpersonal disability, long-term healthcare costs, and the costs associated with lost productivity and absenteeism in the workplace. Such treatment models include algorithmically derived treatment alternatives and collaborative care models, which use a team approach to ensure treatment adherence and to monitor symptom response and side effects. The benefits of using disability assessment measures in conjunction with routine monitoring of depressive symptoms are also discussed.

Sociodemographic and clinical factors associated with depression in epilepsy

The impact of mood disorders on patients with epilepsy is an important and growing area of research. If clinicians are adept at recognizing which patients with epilepsy are at risk for mood disorders, treatment can be facilitated and morbidity avoided. We completed a case-control study (80 depressed subjects, 141 nondepressed subjects) to determine the sociodemographic and clinical factors associated with self-reported depression in people with epilepsy. The Patient Health Questionnaire-9 was used to determine clinically significant depression. In multivariate analyses, depressed subjects with epilepsy were significantly less likely than nondepressed subjects to be married or employed and more likely to report comorbid medical problems and active seizures in the past 6 months. Adjusted for all other variables, subjects with epilepsy reporting lamotrigine use were significantly less likely to be depressed (OR=0.4, 95% CI: 0.2-0.8) compared with those not reporting lamotrigine use.

Premature mortality from general medical illnesses among persons with bipolar disorder: a review

OBJECTIVE

Despite recent evidence that patients with bipolar disorder are at increased risk of premature mortality resulting from general medical disorders, there has been no systematic review of published studies. The authors reviewed the literature to determine whether there is evidence of increased risk of mortality from general medical causes among patients with bipolar spectrum disorders.

METHODS

MEDLINE was searched from 1959 to 2007 with a focus on bipolar disorder and medical mortality. Published studies in English with more than 100 patients were included.

RESULTS

Seventeen studies were identified involving 331,000 patients with bipolar disorder, affective psychosis, affective disorder severe enough to require inpatient psychiatric care or treatment with lithium, or schizoaffective disorder (that is, bipolar spectrum disorders) meeting the inclusion criteria. Compared with age- and sex-matched control samples without mental illness in the general population, mortality ratios for death from natural causes and from specific general medical conditions, such as cardiovascular, respiratory, cerebrovascular, and endocrine disorders, were significantly higher among patients with bipolar spectrum disorders in most studies. This finding was more consistent in larger studies with more than 2,500 patients with bipolar spectrum disorders. Cumulatively, cardiovascular disorder appeared to be the most consistent cause of excess mortality in larger studies.

CONCLUSIONS

The available evidence suggests that bipolar spectrum disorders are associated with increased premature mortality secondary to general medical illnesses. Unhealthy lifestyle, biological factors, adverse pharmacologic effects, and disparities in health care are possible underlying causes for this excess mortality.

Premature mortality from general medical illnesses among persons with bipolar disorder: a review

OBJECTIVE

Despite recent evidence that patients with bipolar disorder are at increased risk of premature mortality resulting from general medical disorders, there has been no systematic review of published studies. The authors reviewed the literature to determine whether there is evidence of increased risk of mortality from general medical causes among patients with bipolar spectrum disorders.

METHODS

MEDLINE was searched from 1959 to 2007 with a focus on bipolar disorder and medical mortality. Published studies in English with more than 100 patients were included.

RESULTS

Seventeen studies were identified involving 331,000 patients with bipolar disorder, affective psychosis, affective disorder severe enough to require inpatient psychiatric care or treatment with lithium, or schizoaffective disorder (that is, bipolar spectrum disorders) meeting the inclusion criteria. Compared with age- and sex-matched control samples without mental illness in the general population, mortality ratios for death from natural causes and from specific general medical conditions, such as cardiovascular, respiratory, cerebrovascular, and endocrine disorders, were significantly higher among patients with bipolar spectrum disorders in most studies. This finding was more consistent in larger studies with more than 2,500 patients with bipolar spectrum disorders. Cumulatively, cardiovascular disorder appeared to be the most consistent cause of excess mortality in larger studies.

CONCLUSIONS

The available evidence suggests that bipolar spectrum disorders are associated with increased premature mortality secondary to general medical illnesses. Unhealthy lifestyle, biological factors, adverse pharmacologic effects, and disparities in health care are possible underlying causes for this excess mortality.

Collaborative care for adolescent depression: a pilot study

OBJECTIVE

The main objectives of this study were to explore the preliminary outcomes and assess the feasibility and acceptability of a collaborative care intervention designed to improve treatment and outcomes of depression among youth seen in primary care settings.

METHODS

We conducted a pilot intervention study at three clinics in a university affiliated primary care clinic network. The intervention model was designed to support the provision of depression treatment by primary care providers using methods adapted from the IMPACT study developed for the improvement of depression among older adults. Specific components include the provision of regular case management by a nurse depression care manager (DCM), enhanced patient and parent education about depression and its treatment, encouragement of patient self-management with a choice of starting medications or therapy or both, and oversight of the DCM by a mental health specialist. Study participants were assessed regularly by the DCM for 6 months and completed written self-report assessments at baseline, 3, and 6 months after starting the intervention.

RESULTS

40 youth (12-18 years) with major and minor depression enrolled in the intervention. Study participants were predominantly female (90%). The baseline Patient Health Questionnaire (PHQ-9) score was 14.2 (SD=4.5). Patients were similarly divided among initiating medications (n=12), therapy (n=15), or combination therapy (n=8). Five patients withdrew prior to initiating treatment. The mean number of in person and telephone contacts with the DCM was 9 (range=5 to 17). Eighty-seven percent of youth completed the 6-month intervention. At 6 month follow-up, 74% of youth had a 50% or more reduction in depressive symptoms as measured by the PHQ-9. Parents, youth and physicians indicated high levels of satisfaction with the intervention on written surveys and in qualitative exit interviews.

CONCLUSION

The collaborative care model is feasible and highly acceptable to adolescents and parents as demonstrated both by self-report and by engagement in the intervention. It is also associated with improved depressive outcomes at similar levels to adult interventions. Future studies should evaluate these models in a randomized controlled trial.

Adolescents' and parents' agreement on posttraumatic stress disorder symptoms and functioning after adolescent injury

Few investigations have simultaneously assessed concordance between youth and parent ratings of posttraumatic stress disorder (PTSD) symptoms and functioning. Randomly sampled adolescent injury survivors ages 12-18 and their parents were assessed on the inpatient ward and again at 2, 5, and 12-months postinjury (N = 99). Adolescent PTSD symptoms and functioning were rated by both adolescents and parents. Parent PTSD was also assessed; 27% of parents endorsed symptoms consistent with a diagnosis of PTSD over the course of the year after adolescent injury. The PTSD positive parents demonstrated significantly greater discordance in ratings of adolescent PTSD symptoms, family cohesion, and mental health functioning. These findings suggest caution in clinical and policy applications of parental ratings of adolescent symptomatic and functional outcomes after injury.

Depression and diabetes: a potentially lethal combination

OBJECTIVE

To assess whether Medicare fee-for-service beneficiaries with depression and diabetes had a higher mortality rate over a 2-year period compared with beneficiaries with diabetes alone.

DESIGN

Evidence of depression was based on a physician diagnosis or self-reported prescription of an antidepressant in the year prior to screening, or a score of > or = 3 on the Patient Health Questionnaire two-item questionnaire. Mortality was assessed bi-monthly by checking Medicare claims and eligibility files or from information from telephone contact with the participant's family. Cox proportional hazard regression models were used to calculate adjusted hazard ratios of death in depressed versus nondepressed beneficiaries with diabetes.

PARTICIPANTS

A total of 10,704 beneficiaries with diabetes enrolled in a disease management program were surveyed with a health assessment questionnaire and followed over a two-year period.

MAIN RESULTS

Comorbid depression in Medicare beneficiaries with diabetes participating in a disease management program was associated with an increased risk for all-cause mortality over a two-year period of approximately 36% to 38%, depending on the definition of depression that was used. No significant increase in rates of cause-specific mortality from macrovascular disease were found in depressed versus nondepressed beneficiaries.

CONCLUSION

Among a large Medicare cohort of fee-for-service beneficiaries with diabetes, comorbid depression was associated with an increase in all-cause mortality over a two-year period. Future research will be required to determine whether the increase in mortality associated with depression is due to potential behavioral mediators (i.e., smoking, poor adherence to diet) or physiologic abnormalities (i.e., hypothalamic-pituitary axis dysregulation) associated with depression.

Association between posttraumatic stress and depressive symptoms and functional outcomes in adolescents followed up longitudinally after injury hospitalization

OBJECTIVE

To assess the association between early posttraumatic stress disorder (PTSD) and depressive symptoms and functional and quality-of-life outcomes among injured youth.

DESIGN

Prospective cohort study.

SETTING

Combined pediatric-adult level I trauma center.

PARTICIPANTS

Randomly sampled adolescent injury survivors aged 12 to 18 years (N = 108) were recruited from surgical inpatient units.

MAIN EXPOSURES

Posttraumatic stress disorder and depressive symptom levels in the days and weeks immediately following injury. We also collected relevant adolescent demographic, injury, and clinical characteristics.

MAIN OUTCOME MEASURE

Multiple domains of adolescent functional impairment were assessed with the 87-item Child Health Questionnaire (CHQ-87) at 2, 5, and 12 months after injury.

RESULTS

The investigation attained greater than 80% adolescent follow-up at each assessment after injury. Mixed-model regression was used to assess the association between baseline levels of PTSD and depressive symptoms and subsequent functional outcomes longitudinally. High baseline PTSD symptom levels were associated with significant impairments in CHQ-87 Role/Social Behavioral, Role/Social Physical, Bodily Pain, General Behavior, Mental Health, and General Health Perceptions subscales. High baseline depressive symptoms were associated with significant impairments in CHQ-87 Physical Function, Role/Social Emotional, Bodily Pain, Mental Health, Self-esteem, and Family Cohesion subscales.

CONCLUSIONS

Early PTSD and depressive symptoms are associated with a broad spectrum of adolescent functional impairment during the year after physical injury. Coordinated investigative and policy efforts that refine mental health screening and intervention procedures have the potential to improve the functioning and well-being of injured youth treated in the acute care medical setting.

One extra month of depression: the effects of caregiving on depression outcomes in the IMPACT trial

BACKGROUND

Depression occurs in 5-10% of older adults and there are nearly 6 million informal caregivers aged 65 or older. Prior research has focused on vulnerability to psychological distress in caregivers. Research has not addressed the caregiving burden of depressed elderly patients or how that burden affects depression treatment outcomes.

AIMS

To describe the self-reported caregiving burden in a large, representative cohort of depressed elderly patients and compare depression treatment outcomes between caregivers and non-caregivers.

METHODS

Univariate and multiple regression analyses were performed comparing 24-month depression outcomes (measured as depression free days) in those providing care at any time over the 24-month trial to those who never reported a caregiving burden.

RESULTS

At 3, 6, 12, 18, and 24 months, nearly 10% of cohabitating elderly depressed patients provided care for basic activities such as bathing or dressing while nearly 20% reported providing care for other activities such as making phone calls or taking medication. Over 24 months, after adjusting for marital status, intervention status, and number of medical comorbidities, those reporting any caregiving burden had over 30 more days with depression compared to those with no caregiving burden. The IMPACT collaborative care model did not modify the effect of caregiving on depression outcomes.

CONCLUSION

Caregiving is common in depressed older adults and appears to affect response to depression treatment. In the future, interventions for depressed older adults should consider and specifically address caregiving activities in addition to specific depression treatment.

Anxiety and depression screening for youth in a primary care population

OBJECTIVE

Prior studies have shown a low rate of accurate identification by primary care physicians of mental health disorders in youth. This study tested the psychometric properties of 2 brief mental health screening questionnaires, the Mood and Feelings Questionnaire, short form, (MFQ-SF) and Childhood Anxiety Sensitivity Index (ASI), in a large sample of youth.

METHODS

In a sample of 1375 youth aged 11 to 17 (779 with asthma, 596 randomly selected controls) enrolled in a health maintenance organization, the psychometric properties (optimum cutoffs on receiver operator characteristic (ROC) curves, sensitivity, specificity, positive and negative predictive values) of 2 brief anxiety and depression screens were compared with a gold standard-structured psychiatric interview.

RESULTS

Both the MFQ-SF and ASI performed well on ROC analysis for screening youth for 1 or more Diagnostic and Statistical Manual of Mental Disorders-IV (DSM-IV) anxiety or depressive disorders. The MFQ-SF performed better on ROC analysis than the ASI for youth with major depression (area under the curve of 0.84 vs 0.77). For screening youth with anxiety disorders, ROC curves showed that both the MFQ-SF and ASI only performed in the fair range (area under the curve of 0.76).

CONCLUSION

The MFQ-SF and ASI are 2 relatively brief questionnaires that performed well for screening youth for 1 or more DSM-IV anxiety or depressive disorders. The MFQ-SF performed better than the ASI for screening youth with major depression. Use of these instruments could increase the accuracy of identification of mental health disorders in youth by primary care physicians.

Bullying and school safety

OBJECTIVE

To identify an association between involvement in bullying and problems in school.

STUDY DESIGN

This was a cross-sectional study of 5391 students in grades 7, 9, and 11 in an urban public school district. The main outcome measure was involvement in bullying. Secondary outcomes included attendance, grade point average, psychosocial distress, and perceived acceptability of carrying guns to school.

RESULTS

Of the 5391 children surveyed, 26% were involved in bullying either as victim, bully, or both (bully-victim). All 3 groups were significantly more likely than bystanders to feel unsafe at school and sad most days. Victims and bully-victims were more likely to say they are "no good." Victims were more likely to feel that they "do not belong" in their school. The odds of being a victim (vs a bystander) were 10% lower for every 1 point increase in grade point average. Bully-victims were more likely to say that it is "not wrong" to take a gun to school.

CONCLUSIONS

Associations between involvement in bullying and academic achievement, psychological distress, and the belief that it is not wrong to take a gun to school reinforce the notion that school environment is interrelated with mental health and school success.

The effect of comorbid anxiety and depressive disorders on health care utilization and costs among adolescents with asthma

OBJECTIVE

To assess whether youth with asthma and comorbid anxiety and depressive disorders have higher health care utilization and costs than youth with asthma alone.

METHODS

A telephone survey was conducted among 767 adolescents (aged 11 to 17 years) with asthma. Diagnostic and Statistical Manual-4th Version (DSM-IV) anxiety and depressive disorders were assessed via the Diagnostic Interview Schedule for Children. Health care utilization and costs in the 12 months pre- and 6 months post-interview were obtained from computerized health plan records. Multivariate analyses were used to determine the impact of comorbid depression and anxiety on medical utilization and costs.

RESULTS

Unadjusted analyses showed that compared to youth with asthma alone, youth with comorbid anxiety/depressive disorders had more primary care visits, emergency department visits, outpatient mental health specialty visits, other outpatient visits and pharmacy fills. After controlling for asthma severity and covariates, total health care costs were approximately 51% higher for youth with depression with or without an anxiety disorder but not for youth with an anxiety disorder alone. Most of the increase in health care costs was attributable to nonasthma and non-mental health-related increases in primary care and laboratory/radiology expenditures.

CONCLUSIONS

Youth with asthma and comorbid depressive disorders have significantly higher health care utilization and costs. Most of these costs are due to increases in non-mental health and nonasthma expenses. Further study is warranted to evaluate whether improved mental health treatment and resulting increases in mental health costs would be balanced by savings in medical costs.

The prevalence of DSM-IV anxiety and depressive disorders in youth with asthma compared with controls

PURPOSE

To determine the prevalence of anxiety and depressive disorders in youth with asthma compared with a control sample of youth and to determine the sociodemographic and clinical characteristics associated with having one or more anxiety/depressive disorders among youth with asthma.

METHODS

A telephone interview was offered to all youth aged 11-17 years with asthma (N = 781) and a random sample of similar aged controls (N = 598) enrolled in a Health Maintenance Organization. The C-DISC-4.0 was used to diagnose anxiety and depressive disorders and reliable and valid questionnaires were used to assess severity of anxiety and depressive symptoms. Automated diagnostic, pharmacy and health use data were used to measure asthma treatment intensity, asthma severity and nonasthmatic medical comorbidity. One parent was interviewed to assess sociodemographic variables, child/adolescent psychiatric symptoms and to confirm the asthma diagnosis.

RESULTS

In all, 16.3% of youth with asthma compared with 8.6% of youth without asthma met DSM-IV criteria for one or more anxiety and depressive disorders (OR = 1.92, 95% CI = 1.13-3.28). Independent factors associated with a significantly higher likelihood of meeting criteria for one or more anxiety or depressive disorders included female gender [OR = 1.96 (95% CI = 1.27, 3.03)], living in a single-parent household, [OR = 1.96 (95% CI = 1.26, 3.07)], more parent-reported externalizing behaviors [OR = 1.03 (95% CI = 1.01, 1.05)], more recent diagnosis of asthma [OR = 0.94 (95% CI = 0.89, 0.98)], and more impairment on the asthma physical health scale [OR = 0.95 (95% CI = 0.94, 0.96)].

CONCLUSIONS

Youth with asthma have an almost twofold higher prevalence of comorbid DSM-IV anxiety and depressive disorders compared with control youth. Clinical factors associated with meeting criteria for one or more anxiety and depressive included more recent asthma diagnosis, more impairment on the asthma physical health scale, and increased externalizing behaviors.

Pediatric primary care providers and adolescent depression: a qualitative study of barriers to treatment and the effect of the black box warning

PURPOSE

The recent black box warning on antidepressants has drawn attention to controversies regarding the treatment of adolescent depression in primary care settings, but little is known about how providers decide to treat depressed youth and what resources are employed.

METHODS

We conducted focus groups with 35 providers and staff in nine community-based pediatric practices in rural and urban settings of western Washington State. Discussion topics included perceived barriers to the treatment of depression in youth, how providers addressed these barriers, and the impact of the recent Federal Drug Administration (FDA) black-box warning. Focus groups were audiotaped and professionally transcribed. Qualitative content analysis was conducted using Atlas ti software and differences in coding were resolved via discussion by three independent reviewers.

RESULTS

Based on analysis of interviews, a conceptual model was developed detailing factors influencing primary care providers' (PCP) decisions about depression treatment. The three key themes that influenced doctors' decisions about treating depression were lack of availability of mental health resources in the community, feeling responsible for helping based on long-standing relationships with patients and families, and patient and family beliefs and preferences regarding treatment. Most of the approaches to address barriers were not systemized and were physician dependent. Most providers expressed concern about recent antidepressant warnings, but many continued to treat and none had developed new strategies for closer monitoring of youth initiating treatment with antidepressants.

CONCLUSION

The decision of when and how PCPs decide to treat adolescent depression is strongly influenced by PCP perceptions of their role in treatment, availability of other treatment resources, and family and patient preferences and resources. Few practices have developed changes in the approach to practice needed to meet FDA black-box recommendations regarding close monitoring of response to medications.

Anxiety and depressive disorders are associated with smoking in adolescents with asthma

PURPOSE

To evaluate the association between mental health indicators (including meeting criteria for one or more DSM-IV [Diagnostic and Statistical Manual of Mental Disorders-fourth edition] anxiety or depressive disorders) and susceptibility to smoking or current smoking among youth with asthma and to evaluate the impact of smoking on asthma symptoms and self-management.

METHODS

We conducted telephone interviews with a population-based sample of 11- to 17-year-old youth and their parents (n = 769). Interview content included questions on smoking behaviors, asthma symptoms and treatment, externalizing behavior, and a structured psychiatric interview to assess DSM-IV anxiety and depressive disorders.

RESULTS

Five percent of youth were smokers and 10.6% indicated that they were "susceptible to smoking." Smoking was more common among youth with mental health disorders. Anxiety/depressive disorders were present in 14.5% of nonsmokers, 19.8% of susceptible nonsmokers, and 37.8% of smokers. After controlling for important covariates, youth with more than one anxiety and depressive disorder were at over twofold increased risk for being a smoker. Similarly, for each one-point increase in externalizing disorder symptoms, youth had a 10% increase in likelihood of being a smoker and a 4% increase in risk for "susceptibility to smoking." Youth who were smokers reported more asthma symptoms, reduced functioning due to asthma, less use of controller medicines, and more use of rescue medications.

CONCLUSIONS

Comorbid mental health disorders are associated with increased risk of smoking in youth with asthma. Smoking is associated with increased asthma symptom burden and decreased controller medication use. Interventions for youth with asthma should consider screening for and targeting these behavioral concerns.

Impact of anxiety and depression on functional impairment in adolescents with asthma

OBJECTIVE

This study aimed to assess the association of anxiety and depression with psychosocial and asthma-related functional impairment in a large-population-based sample of adolescents with asthma.

METHOD

The sample consisted of 767 youths ages 11 to 17 with a documented diagnosis of, and active treatment for, asthma. Telephone interviews were completed with each youth and one parent to assess asthma-related symptoms and self-report of psychosocial and asthma-related functional status. Structured diagnostic interviews (Computerized Diagnostic Interview Schedule for Children) were administered to determine psychiatric diagnoses. Weighted multiple linear regression models were employed to identify variables that were independently and significantly associated with levels of functioning.

RESULTS

One hundred twenty-five youths (16.2%) met DSM-IV criteria for one or more anxiety and depressive disorders in the last 12 months. After controlling for demographic variables, greater severity of self-reported depressive and anxiety symptoms and presence of one or more DSM-IV anxiety or depressive diagnosis were associated with psychosocial and asthma-related functional status. The mental health factors were more strongly associated with measures of asthma and psychological functional outcomes than the modified Health Plan Employer Data and Information Set asthma risk measure.

CONCLUSIONS

Increased awareness of the need to assess and effectively treat psychiatric symptoms in youth with asthma may reduce the functional burden associated with asthma.

The association of depression and anxiety with medical symptom burden in patients with chronic medical illness

BACKGROUND

Primary care patients with anxiety and depression often describe multiple physical symptoms, but no systematic review has studied the effect of anxiety and depressive comorbidity in patients with chronic medical illnesses.

METHODS

MEDLINE databases were searched from 1966 through 2006 using the combined search terms diabetes, coronary artery disease (CAD), congestive heart failure (CHF), asthma, COPD, osteoarthritis (OA), rheumatoid arthritis (RA), with depression, anxiety and symptoms. Cross-sectional and longitudinal studies with >100 patients were included as were all randomized controlled trials that measure the impact of improving anxiety and depressive symptoms on medical symptom outcomes.

RESULTS

Thirty-one studies involving 16,922 patients met our inclusion criteria. Patients with chronic medical illness and comorbid depression or anxiety compared to those with chronic medical illness alone reported significantly higher numbers of medical symptoms when controlling for severity of medical disorder. Across the four categories of common medical disorders examined (diabetes, pulmonary disease, heart disease, arthritis), somatic symptoms were at least as strongly associated with depression and anxiety as were objective physiologic measures. Two treatment studies also showed that improvement in depression outcome was associated with decreased somatic symptoms without improvement in physiologic measures.

CONCLUSIONS

Accurate diagnosis of comorbid depressive and anxiety disorders in patients with chronic medical illness is essential in understanding the cause and in optimizing the management of somatic symptom burden.

Managed care and patient ratings of the quality of specialty care among patients with pain or depressive symptoms

BACKGROUND

Managed care efforts to regulate access to specialists and reduce costs may lower quality of care. Few studies have examined whether managed care is associated with patient perceptions of the quality of care provided by physician and non-physician specialists. Aim is to determine whether associations exist between managed care controls and patient ratings of the quality of specialty care among primary care patients with pain and depressive symptoms who received specialty care for those conditions.

METHODS

A prospective cohort study design was conducted in the offices of 261 primary physicians in private practice in Seattle in 1997. Patients (N = 17,187) were screened in waiting rooms, yielding a sample of 1,514 patients with pain only, 575 patients with depressive symptoms only, and 761 patients with pain and depressive symptoms. Patients (n = 1,995) completed a 6-month follow-up survey. Of these, 691 patients received specialty care for pain, and 356 patients saw mental health specialists. For each patient, managed care was measured by the intensity of managed care controls in the patient's health plan and primary care office. Quality of specialty care at follow-up was measured by patient rating of care provided by the specialists. Outcomes were pain interference and bothersomeness, Symptom Checklist for Depression, and restricted activity days.

RESULTS

The intensity of managed care controls in health plans and primary care offices was generally not associated with patient ratings of the quality of specialty care. However, pain patients in more-managed primary care offices had lower ratings of the quality of specialty care from physician specialists and ancillary providers.

CONCLUSION

For primary care patients with pain or depressive symptoms and who see specialists, managed care controls may influence ratings of specialty care for patients with pain but not patients with depressive symptoms.

Arthritis pain and disability: response to collaborative depression care

OBJECTIVE

Collaborative care for depression decreases arthritis pain and disability among older adults, above and beyond mood improvement. This study investigates whether depression management is effective for improving arthritis outcomes across a range of pain severity and activity interference.

METHODS

A multi-site randomized-controlled trial (Improving Mood, Providing Access to Collaborative Treatment - IMPACT) identified 1001 participants with both depression and arthritis (mostly osteoarthritis). Depression care managers provided 12 months of systematic depression care [antidepressant pharmacotherapy, and/or problem-solving treatment (PST)] for intervention participants in primary care settings. Control patients received care as usual. Baseline and 12-month interviews assessed arthritis pain severity and activity interference as well as depression, analgesic use, overall functional impairment and coexisting medical conditions.

RESULTS

Baseline pain severity showed significant interactions with the intervention on 12-month pain severity (t=2.28, df=68, P=.03) and disability outcomes (t=2.03, df=177, P=.04). Interaction effects of the intervention with baseline activity interference on 12-month pain severity showed a similar trend, but were not statistically significant (t=1.87, df=944, P=.06).

CONCLUSIONS

Systematic depression management was more effective than usual care in decreasing pain severity among arthritis patients with lower initial pain severity, but did not have greater benefits than usual care on pain among patients with higher initial pain severity.

Panic episodes among patients with diabetes

OBJECTIVE

The objective of this study was to examine the prevalence of panic episodes in persons with diabetes and the demographic, behavioral and clinical characteristics associated with panic symptoms in persons with diabetes.

METHOD

A survey mailed to 4385 patients with diabetes assessed recent experiences of panic episodes, depression, diabetes symptoms, quality of life, disability, smoking status and body mass index. Automated medical record data were used to measure diabetes treatment, hemoglobin A1c (Hb(A1c)) levels, diabetes complications and medical comorbidity.

RESULTS

One hundred ninety-three (4.4%) participants reported recent panic episodes, among whom 54.5% also met criteria for major depression. After accounting for the effects of depression, panic episodes were associated with higher Hb(A1c) values, increased diabetic complications and symptoms, greater disability and lower self-rated health and functioning.

CONCLUSION

Panic is strongly associated with decrements in disease status and functioning. Since panic is often comorbid with depression, efforts to address psychological disorders among persons with diabetes may need to pay increased attention to anxiety and mood disorders.