Treatment of Depression Improves Physical Functioning in Older Adults

OBJECTIVES

To determine the effect of collaborative care management for depression on physical functioning in older adults.

DESIGN

Multisite randomized clinical trial.

SETTING

Eighteen primary care clinics from eight healthcare organizations.

PARTICIPANTS

One thousand eight hundred one patients aged 60 and older with major depressive disorder.

INTERVENTION

Patients were randomized to the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) intervention (n=906) or to a control group receiving usual care (n=895). Control patients had access to all health services available as part of usual care. Intervention patients had access for 12 months to a depression clinical specialist who coordinated depression care with their primary care physician.

MEASUREMENTS

The 12-item short form Physical Component Summary (PCS) score (range 0-100) and instrumental activities of daily living (IADLs) (range 0-7).

RESULTS

The mean patient age was 71.2, 65% were women, and 77% were white. At baseline, the mean PCS was 40.2, and the mean number of IADL dependencies was 0.7; 45% of participants rated their health as fair or poor. Intervention patients experienced significantly better physical functioning at 1 year than usual-care patients as measured using between-group differences on the PCS of 1.71 (95% confidence interval (CI)=0.96-2.46) and IADLs of -0.15 (95% CI=-0.29 to -0.01). Intervention patients were also less likely to rate their health as fair or poor (37.3% vs 52.4%, P<.001). Combining both study groups, patients whose depression improved were more likely to experience improvement in physical functioning.

CONCLUSION

The IMPACT collaborative care model for late-life depression improves physical function more than usual care.

Potentially modifiable factors associated with disability among people with diabetes

OBJECTIVE

This article seeks to identify potentially modifiable factors associated with disability among people with diabetes.

STUDY DESIGN AND SETTING

Among people with diabetes (N = 4357) in a large health maintenance organization, disease severity, psychologic and behavioral risk factors for disability were assessed. Disability was evaluated by the WHO Disability Assessment Scale (WHO-DAS-II), the SF-36 Social Functioning scale, and days of reduced household work.

RESULTS

Depression was associated with a tenfold increase in elevated WHO-DAS-II and low SF-36 Social Functioning scores, and a fourfold increase in 20+ days of reduced household work. Minor depression and the presence of three or more diabetic complications were associated with approximately a twofold increase in disability risk. Diabetic symptoms, chronic disease comorbidity, and reduced exercise were also associated with disability.

CONCLUSION

Among people with diabetes, depression, diabetic complications, and exercise are potentially modifiable factors associated with disability. This suggests that integrated, biopsychosocial approaches may be needed to understand and to ameliorate disability among people with diabetes.

Impact of comorbid panic and posttraumatic stress disorder on outcomes of collaborative care for late-life depression in primary care

OBJECTIVE

Comorbid anxiety disorders may result in worse depression treatment outcomes. The authors evaluated the effect of comorbid panic disorder and posttraumatic stress disorder (PTSD) on response to a collaborative-care intervention for late-life depression in primary care.

METHODS

A total of 1,801 older adults with depression were randomized to a collaborative-care depression treatment model versus usual care and assessed at baseline, 3, 6, and 12 months, comparing differences among participants with comorbid panic disorder (N=262) and PTSD (N=191) and those without such comorbid anxiety disorders.

RESULTS

At baseline, patients with comorbid anxiety reported higher levels of psychiatric and medical illness, greater functional impairment, and lower quality of life. Participants without comorbid anxiety who received collaborative care had early and lasting improvements in depression compared with those in usual care. Participants with comorbid panic disorder showed similar outcomes, whereas those with comorbid PTSD showed a more delayed response, requiring 12 months of intervention to show a significant effect. At 12 months, however, outcomes were comparable. Interactions of intervention status by comorbid PTSD or panic disorder were not statistically significant, suggesting that the collaborative-care model performed significantly better than usual care in depressed older adults both with and without comorbid anxiety.

CONCLUSIONS

Collaborative care is more effective than usual care for depressed older adults with and without comorbid panic disorder and PTSD, although a sustained treatment response was slower to emerge for participants with PTSD. Intensive and prolonged follow-up may be needed for depressed older adults with comorbid PTSD.

The detection and treatment of posttraumatic distress and substance intoxication in the acute care inpatient setting

Each year, approximately 2.5 million Americans require inpatient admissions after sustaining traumatic physical injuries. Few investigations have assessed the routine detection and treatment of acute care inpatients with high levels of posttraumatic distress. A representative sample of 101 hospitalized patients with acute injuries was screened for posttraumatic stress disorder (PTSD) and depressive symptoms, as well as substance intoxication. Patients' medical records were reviewed for documentation of psychiatric symptoms and diagnoses and the initiation of early evaluation and treatment. High levels of PTSD and/or depressive symptoms were present in over 50% of patients. Although providers frequently noted symptomatic distress, few symptomatic patients received formal diagnoses, evaluations or treatment. Patients who had positive substance toxicology screens on admission infrequently received in-depth evaluation or treatment. A substantial number of injured trauma survivors have high levels of symptomatic distress that are inconsistently evaluated and treated in the acute care medical setting. Mental health interventions appear to be feasibly and effectively delivered from trauma centers. Therefore, ongoing investigation and policy initiatives informing the detection and treatment of patients with psychiatric disturbances in acute care could substantially enhance the quality of mental health care for injured survivors of individual and mass trauma.

Quality of care for primary care patients with anxiety disorders

OBJECTIVE

This study evaluated quality of care for primary care patients with anxiety disorders in university-affiliated outpatient clinics in Los Angeles, San Diego, and Seattle.

METHOD

Three hundred sixty-six primary care outpatients who were diagnosed with panic disorder, generalized anxiety disorder, social phobia, and/or posttraumatic stress disorder (with or without major depression) were surveyed about care received in the prior 3 months. Quality indicators were mental health referral, anxiety counseling, and use of appropriate antianxiety medication during the previous 3 months.

RESULTS

Approximately one-third of patients with anxiety disorders had received counseling from their primary care provider in the prior 3 months. Fewer than 10% had receiving counseling from a mental health professional that included multiple elements of cognitive behavior therapy. Approximately 40% had received appropriate antianxiety medications in the previous 3 months, although only 25% had received them at a minimally adequate dose and duration. Overall, fewer than one in three patients had received either psychotherapy or pharmacotherapy that met a criterion for quality care. In multivariate analyses, patients with comorbid depression and/or medical illness were more likely-and patients from ethnic minorities were less likely-to receive appropriate antianxiety medications.

CONCLUSIONS

Rates of quality care for anxiety disorders are moderate to low in university-affiliated primary care practices. Although an appropriate type of pharmacotherapy was frequently used, it was often of inadequate duration. Cognitive behavior therapy was markedly underused. These findings emphasize the need for practice guidelines and implementation of quality improvement programs for anxiety disorders in primary care.

Depression and diabetes symptom burden

OBJECTIVE

To examine the relationship among patient-reported diabetes symptoms, severity of depressive illness and objective measures of diabetes control and severity among a population-based sample of patients with diabetes.

METHODS

A mailed survey was sent to all patients with diabetes from nine primary care clinics of a Health Maintenance Organization. The Patient Health Questionnaire (PHQ-9) was used to diagnose major depression, the Self-Completion Patient Outcome instrument assessed diabetes symptoms and automated medical record data were used to measure diabetes treatment intensity, HbA(1c) levels, diabetes complications and medical comorbidity. Analysis of covariance (ANCOVA) was used to determine if the number of diabetes symptoms was related to having major depression and to number of depressive symptoms. Logistic regression analyses determined the relative strengths of the associations between each individual diabetic symptom and presence of major depression, HbA(1c) levels above 8.0% and two or more diabetes complications.

RESULTS

Among 4168 patients with diabetes, those with major depression (N=487) reported significantly more diabetes symptoms (mean=4.40) than participants without depression (mean=2.46) after adjusting for demographic characteristics, objective measures of diabetes severity and medical comorbidity [F(1,4029)=339.31, P<.0001]. The overall number of diabetes symptoms was related to the number of depressive symptoms (from 0 to 9) endorsed by participants [F(9,4021)=110.05, P<.0001]. Logistic regression analyses found that depression was significantly related to each of the 10 diabetes symptoms (all P<.001).

CONCLUSIONS

The depression-diabetes symptom association is stronger than the association of diabetes symptoms with measures of glycemic control and diabetes complications.

Depression and comorbid illness in elderly primary care patients: impact on multiple domains of health status and well-being

PURPOSE

Our objective was to examine the relative association of depression severity and chronicity, other comorbid psychiatric conditions, and coexisting medical illnesses with multiple domains of health status among primary care patients with clinical depression.

METHODS

We collected cross-sectional data as part of a treatment effectiveness trial that was conducted in 8 diverse health care organizations. Patients aged 60 years and older (N = 1,801) who met diagnostic criteria for major depression or dysthymia participated in a baseline survey. A survey instrument included questions on sociodemographic characteristics, depression severity and chronicity, neuroticism, and the presence of 11 common chronic medical illnesses, as well as questions screening for panic disorder and posttraumatic stress disorder. Measures of 4 general health indicators (physical and mental component scales of the SF-12, Sheehan Disability Index, and global quality of life) were included. We conducted separate mixed-effect regression linear models predicting each of the 4 general health indicators.

RESULTS

Depression severity was significantly associated with all 4 indicators of general health after controlling for sociodemographic differences, other psychological dysfunction, and the presence of 11 chronic medical conditions. Although study participants had an average of 3.8 chronic medical illnesses, depression severity made larger independent contributions to 3 of the 4 general health indicators (mental functional status, disability, and quality of life) than the medical comorbidities.

CONCLUSIONS

Recognition and treatment of depression has the potential to improve functioning and quality of life in spite of the presence of other medical comorbidities.

Posttraumatic distress, alcohol disorders, and recurrent trauma across level 1 trauma centers

BACKGROUND

Injured survivors of individual and mass trauma receive their initial evaluation in acute care. Few investigations have comprehensively screened for posttraumatic stress disorder (PTSD) symptoms and related comorbidities across sites.

METHODS

This investigation included 269 randomly selected injury survivors hospitalized at two level 1 trauma centers. All patients were screened for PTSD, depressive, and peritraumatic dissociative symptoms during their surgical inpatient admission. Prior traumatic life events and alcohol abuse/dependence also were assessed.

RESULTS

In this study, 58% of the patients demonstrated high levels of immediate posttraumatic distress or alcohol abuse/dependence. Regression analyses identified greater prior trauma, female gender, nonwhite ethnicity, and site as significant independent predictors for high levels of posttraumatic distress.

CONCLUSIONS

High levels of posttraumatic distress, recurrent trauma, and alcohol abuse/dependence were present in more than half of acute care inpatients. Early mental health screening and intervention procedures that target both PTSD and alcohol use should be developed for acute care settings.

Common comorbidity scales were similar in their ability to predict health care costs and mortality

OBJECTIVE

To compare the ability of commonly used measures of medical comorbidity (ambulatory care groups [ACGs], Charlson comorbidity index, chronic disease score, number of prescribed medications, and number of chronic diseases) to predict mortality and health care costs over 1 year.

STUDY DESIGN AND SETTING

A prospective cohort study of community-dwelling older adults (n=3,496) attending a large primary care practice.

RESULTS

For predicting health care charges, the number of medications had the highest predictive validity (R(2)=13.6%) after adjusting for demographics. ACGs (R(2)=16.4%) and the number of medications (15.0%) had the highest predictive validity for predicting ambulatory visits. ACGs and the Charlson comorbidity index (area under the receiver operator characteristic [ROC] curve=0.695-0.767) performed better than medication-based measures (area under the ROC curve=0.662-0.679) for predicting mortality. There is relatively little difference, however, in the predictive validity across these scales.

CONCLUSION

In an outpatient setting, a simple count of medications may be the most efficient comorbidity measure for predicting utilization and health-care charges over the ensuing year. In contrast, diagnosis-based measures have greater predictive validity for 1-year mortality. Current comorbidity measures, however, have only poor to moderate predictive validity for costs or mortality over 1 year.

Relationship of depression and diabetes self-care, medication adherence, and preventive care

OBJECTIVE

We assessed whether diabetes self-care, medication adherence, and use of preventive services were associated with depressive illness.

RESEARCH DESIGN AND METHODS

In a large health maintenance organization, 4,463 patients with diabetes completed a questionnaire assessing self-care, diabetes monitoring, and depression. Automated diagnostic, laboratory, and pharmacy data were used to assess glycemic control, medication adherence, and preventive services.

RESULTS

This predominantly type 2 diabetic population had a mean HbA(1c) level of 7.8 +/- 1.6%. Three-quarters of the patients received hypoglycemic agents (oral or insulin) and reported at least weekly self-monitoring of glucose and foot checks. The mean number of HbA(1c) tests was 2.2 +/- 1.3 per year and was only slightly higher among patients with poorly controlled diabetes. Almost one-half (48.9%) had a BMI >30 kg/m(2), and 47.8% of patients exercised once a week or less. Pharmacy refill data showed a 19.5% nonadherence rate to oral hypoglycemic medicines (mean 67.4 +/- 74.1 days) in the prior year. Major depression was associated with less physical activity, unhealthy diet, and lower adherence to oral hypoglycemic, antihypertensive, and lipid-lowering medications. In contrast, preventive care of diabetes, including home-glucose tests, foot checks, screening for microalbuminuria, and retinopathy was similar among depressed and nondepressed patients.

CONCLUSIONS

In a primary care population, diabetes self-care was suboptimal across a continuum from home-based activities, such as healthy eating, exercise, and medication adherence, to use of preventive care. Major depression was mainly associated with patient-initiated behaviors that are difficult to maintain (e.g., exercise, diet, medication adherence) but not with preventive services for diabetes.

Influence of patient attachment style on self-care and outcomes in diabetes

OBJECTIVE

Difficulties collaborating with providers and important others may adversely influence self-management in patients with diabetes. We predicted that dismissing attachment style, characterized by high interpersonal self-reliance and low trust of others, would be associated with poorer self-management in patients with diabetes.

METHODS

A population-based mail survey was sent to all patients with diabetes from nine primary care clinics of a health maintenance organization. We collected data on attachment style, self-care behaviors, the patient provider relationship and depression status and accessed automated diagnostic, pharmacy, and laboratory data to measure diabetes treatment intensity, medical comorbidity, glycosylated hemoglobin levels, and diabetes complications. We used logistic regression to determine whether dismissing attachment style was associated with poorer diabetes self-care behaviors, adherence to medication, smoking status, and higher glycosylated hemoglobin.

RESULTS

In 4095 primary care patients with diabetes, prevalence rates for secure, dismissing, preoccupied, and fearful attachment styles were 44.2%, 35.8%, 7.9%, and 12.1%, respectively. When compared with secure attachment style, dismissing attachment style was associated with significantly lower levels of exercise (p =.005), foot care (p <.05), diet (p =.001), and adherence to oral hypoglycemic medications (p <.05), and with higher rates of smoking (p <.05), and these associations were mediated through the patient-provider relationship. Preoccupied attachment style, characterized by overreliance on others, was associated with a significantly lower risk of having glycosylated hemoglobin levels >8%, compared with secure attachment style.

CONCLUSION

Attachment style is significantly associated with diabetes self-management and outcomes.

The effectiveness of depression care management on diabetes-related outcomes in older patients

BACKGROUND

Depression frequently occurs in combination with diabetes mellitus, adversely affecting the course of illness.

OBJECTIVE

To determine whether enhancing care for depression improves affective and diabetic outcomes in older adults with diabetes and depression.

DESIGN

Preplanned subgroup analysis of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) randomized, controlled trial.

SETTING

18 primary care clinics from 8 health care organizations in 5 states.

PATIENTS

1801 patients 60 years of age or older with depression; 417 had coexisting diabetes mellitus.

INTERVENTION

A care manager offered education, problem-solving treatment, or support for antidepressant management by the patient's primary care physician; diabetes care was not specifically enhanced.

MEASUREMENTS

Assessments at baseline and at 3, 6, and 12 months for depression, functional impairment, and diabetes self-care behaviors. Hemoglobin A(1c) levels were obtained for 293 patients at baseline and at 6 and 12 months.

RESULTS

At 12 months, diabetic patients who were assigned to intervention had less severe depression (range, 0 to 4 on a checklist of 20 depression items; between-group difference, -0.43 [95% CI, -0.57 to -0.29]; P < 0.001) and greater improvement in overall functioning (range, 0 [none] to 10 [unable to perform activities]; between-group difference, -0.89 [CI, -1.46 to -0.32]) than did participants who received usual care. In the intervention group, weekly exercise days increased (between-group difference, 0.50 day [CI, 0.12 to 0.89 day]; P = 0.001); other self-care behaviors were not affected. At baseline, mean (+/-SD) hemoglobin A1c levels were 7.28% +/- 1.43%; follow-up values were unaffected by the intervention (P > 0.2).

LIMITATIONS

Because patients had good glycemic control at baseline, power to detect small but clinically important improvements in glycemic control was limited.

CONCLUSIONS

Collaborative care improves affective and functional status in older patients with depression and diabetes; however, among patients with good glycemic control, such care minimally affects diabetes-specific outcomes.

Quality of care for medicaid-covered youth treated with antidepressant therapy

BACKGROUND

Although antidepressant use has increased in pediatric populations, few studies have addressed the quality of follow-up care or duration of treatment for depressed youth.

OBJECTIVE

To evaluate the quality of care for antidepressant-treated youth, using the Health Plan Employer Data and Information Set guidelines (>or=3 visits in the 3 months after a new antidepressant prescription fill and continuation of antidepressant use at 3 and 6 months) as a benchmark.

DESIGN

Administrative records were examined for 1205 Medicaid-covered youth (aged 5-18 years) who presented with a "new episode" of depression in 1998. Statistics were generated to describe the number of follow-up visits and duration of treatment within 6 months of first prescription fill.

RESULTS

A total of 507 (42.1%) youth with new episodes of depression were treated with antidepressants. Selective serotonin reuptake inhibitors accounted for 80.9% of prescriptions. Twenty-eight percent (28.1%) of youth with an antidepressant fill had 3 or more follow-up visits in the subsequent 3 months; however, an additional 29.2% had no further provider visits. Selective serotonin reuptake inhibitors were continued by 46.6% of treated youth at 3 months and by 26.3% at 6 months.

CONCLUSIONS

Many antidepressant-treated youth do not receive adequate follow-up or duration of treatment. Future studies should address reasons for poor follow-up and methods to improve monitoring for these youth.

A randomized effectiveness trial of stepped collaborative care for acutely injured trauma survivors

CONTEXT

Although posttraumatic stress disorder (PTSD) and alcohol abuse frequently occur among acutely injured trauma survivors, few real-world interventions have targeted these disorders.

OBJECTIVE

We tested the effectiveness of a multifaceted collaborative care (CC) intervention for PTSD and alcohol abuse.

DESIGN

Randomized effectiveness trial.

PARTICIPANTS

We recruited a population-based sample of 120 male and female injured surgical inpatients 18 or older at a level I trauma center.

INTERVENTION

Patients were randomly assigned to the CC intervention (n = 59) or the usual care (UC) control condition (n = 61). The CC patients received stepped care that consisted of (1) continuous postinjury case management, (2) motivational interviews targeting alcohol abuse/dependence, and (3) evidence-based pharmacotherapy and/or cognitive behavioral therapy for patients with persistent PTSD at 3 months after injury.

MAIN OUTCOME MEASURES

We used the PTSD symptomatic criteria (PTSD Checklist) at baseline and 1, 3, 6, and 12 months after injury, and alcohol abuse/dependence (Composite International Diagnostic Interview) at baseline and 6 and 12 months after injury.

RESULTS

Random-coefficient regression analyses demonstrated that over time, CC patients were significantly less symptomatic compared with UC patients with regard to PTSD (P =.01) and alcohol abuse/dependence (P =.048). The CC group demonstrated no difference (-0.07%; 95% confidence interval [CI], -4.2% to 4.3%) in the adjusted rates of change in PTSD from baseline to 12 months, whereas the UC group had a 6% increase (95% CI, 3.1%-9.3%) during the year. The CC group showed on average a decrease in the rate of alcohol abuse/dependence of -24.2% (95% CI, -19.9% to -28.6%), whereas the UC group had on average a 12.9% increase (95% CI, 8.2%-17.7%) during the year.

CONCLUSIONS

Early mental health care interventions can be feasibly and effectively delivered from trauma centers. Future investigations that refine routine acute care treatment procedures may improve the quality of mental health care for Americans injured in the wake of individual and mass trauma.

Behavioral and clinical factors associated with depression among individuals with diabetes

OBJECTIVE

The goal of this study was to determine the behavioral and clinical characteristics of diabetes that are associated with depression after controlling for potentially confounding variables.

RESEARCH DESIGN AND METHODS

A population-based mail survey was sent to patients with diabetes from nine primary care clinics of a health maintenance organization. The Patient Health Questionnaire was used to diagnose depression, and automated diagnostic, pharmacy, and laboratory data were used to measure diabetes treatment intensity, HbA(1c) levels, and diabetes complications.

RESULTS

Independent factors that were associated with a significantly higher likelihood of meeting criteria for major depression included younger age, female sex, less education, being unmarried, BMI > or = >30 kg/m(2), smoking, higher nondiabetic medical comorbidity, higher numbers of diabetes complications in men, treatment with insulin, and higher HbA(1c) levels in patients <65 years of age. Independent factors associated with a significantly higher likelihood of meeting criteria for minor depression included younger age, less education, non-Caucasian status, BMI > or = 30 kg/m(2), smoking, longer duration of diabetes, and a higher number of complications in older (> or = 65 years) patients.

CONCLUSIONS

Smoking and obesity were associated with a higher likelihood of meeting criteria for major and minor depression. Diabetes complications and elevated HbA(1c) were associated with major depression among demographic subgroups: complications among men and HbA(1c) among individuals <65 years of age. Older patients with a higher number of complications had an increased likelihood of minor depression.

Depression and pain comorbidity: a literature review

Because depression and painful symptoms commonly occur together, we conducted a literature review to determine the prevalence of both conditions and the effects of comorbidity on diagnosis, clinical outcomes, and treatment. The prevalences of pain in depressed cohorts and depression in pain cohorts are higher than when these conditions are individually examined. The presence of pain negatively affects the recognition and treatment of depression. When pain is moderate to severe, impairs function, and/or is refractory to treatment, it is associated with more depressive symptoms and worse depression outcomes (eg, lower quality of life, decreased work function, and increased health care utilization). Similarly, depression in patients with pain is associated with more pain complaints and greater impairment. Depression and pain share biological pathways and neurotransmitters, which has implications for the treatment of both concurrently. A model that incorporates assessment and treatment of depression and pain simultaneously is necessary for improved outcomes.

Somatic, posttraumatic stress, and depressive symptoms among injured patients treated in trauma surgery

Few investigations have examined the course of somatic complaints among acutely injured trauma survivors. Posttraumatic stress disorder (PTSD), depressive, and somatic symptoms were assessed in trauma surgery inpatients (N=73) interviewed while hospitalized and again 12 months after their injury. Somatic symptoms occurred frequently and were significantly greater in patients with higher levels of PTSD and depressive symptoms, even after the analyses were adjusted for injury severity and medical comorbidity. These findings, when considered in conjunction with data documenting the heterogeneity of treatment providers visited after traumatic injury, suggest that the development of early screening and intervention procedures should incorporate assessments of physical symptoms.

Effect of improving depression care on pain and functional outcomes among older adults with arthritis: a randomized controlled trial

CONTEXT

Depression and arthritis are disabling and common health problems in late life. Depression is also a risk factor for poor health outcomes among arthritis patients.

OBJECTIVE

To determine whether enhancing care for depression improves pain and functional outcomes in older adults with depression and arthritis.

DESIGN, SETTING, AND PARTICIPANTS

Preplanned subgroup analyses of Improving Mood-Promoting Access to Collaborative Treatment (IMPACT), a randomized controlled trial of 1801 depressed older adults (> or =60 years), which was performed at 18 primary care clinics from 8 health care organizations in 5 states across the United States from July 1999 to August 2001. A total of 1001 (56%) reported coexisting arthritis at baseline.

INTERVENTION

Antidepressant medications and/or 6 to 8 sessions of psychotherapy (Problem-Solving Treatment in Primary Care).

MAIN OUTCOME MEASURES

Depression, pain intensity (scale of 0 to 10), interference with daily activities due to arthritis (scale of 0 to 10), general health status, and overall quality-of-life outcomes assessed at baseline, 3, 6, and 12 months.

RESULTS

In addition to reduction in depressive symptoms, the intervention group compared with the usual care group at 12 months had lower mean (SE) scores for pain intensity (5.62 [0.16] vs 6.15 [0.16]; between-group difference, -0.53; 95% confidence interval [CI], -0.92 to -0.14; P =.009), interference with daily activities due to arthritis (4.40 [0.18] vs 4.99 [0.17]; between-group difference, -0.59; 95% CI, -1.00 to -0.19; P =.004), and interference with daily activities due to pain (2.92 [0.07] vs 3.17 [0.07]; between-group difference, -0.26; 95% CI, -0.41 to -0.10; P =.002). Overall health and quality of life were also enhanced among intervention patients relative to control patients at 12 months.

CONCLUSIONS

In a large and diverse population of older adults with arthritis (mostly osteoarthritis) and comorbid depression, benefits of improved depression care extended beyond reduced depressive symptoms and included decreased pain as well as improved functional status and quality of life.

Effect on disability outcomes of a depression relapse prevention program

OBJECTIVE

This report evaluates the effects of a depression relapse prevention program on disability outcomes among patients treated for depression at high risk for relapse.

MATERIALS AND METHODS

Primary care patients initiating antidepressant treatment for depression were assessed 6 to 8 weeks after the initial prescription. Patients responding to initial treatment but at high risk for relapse were randomized to usual care or a relapse prevention intervention (N= 386). The 12-month relapse prevention program included systematic patient education, two psycho-educational visits with a depression prevention specialist, shared decision-making regarding maintenance pharmacotherapy, and ongoing monitoring of medication adherence and depressive symptoms via telephone and mail. Disability outcomes were assessed via blinded telephone assessments at 3, 6, 9, and 12 months using SF-36 and Sheehan Disability scales.

RESULTS

Usual care patients and relapse prevention program patients had high rates of use of maintenance pharmacotherapy. Both relapse prevention and usual care patients showed improved functioning over the 12-month follow-up period. One of the three disability measures (the SF-36 Social Function scale) showed a significant intervention effect because of continuing improvement at 9 and 12 month follow-up, whereas the Sheehan Disability Scale showed a nonsignificant trend toward greater improvements in disability among relapse prevention patients than among usual care controls.

CONCLUSIONS

Moderate effects of a relapse prevention intervention on depressive symptoms were associated with modest and variable effects on disability outcomes. Inconsistent effects of the intervention for disability outcomes may be because of the high rates of maintenance pharmacotherapy among usual care patients, relatively mild levels of depressive symptoms among both intervention and control patients at baseline, the absence of a specific relapse prevention effect of the intervention, and the resultant modest differences in depressive symptoms between intervention and control patients in this trial.

Managed Care and Primary Physician Satisfaction

BACKGROUND

We examined whether physician compensation, financial incentives, and care management tools were associated with primary physician job and referral satisfaction. Our study was guided by a conceptual model of physician satisfaction derived from published evidence.

METHODS

A cross-sectional survey was performed of 495 primary physicians (family practitioners, general practitioners, general internists) in the Seattle metropolitan area in 1997.

RESULTS

Bivariate analyses revealed that salary compensation, productivity bonuses, and withholds for referrals were associated with job and referral dissatisfaction. However, after controlling for physician, practice, and office characteristics, only the association between salary payment and job dissatisfaction remained significant. Practice in offices with more physicians had the strongest association with physician job dissatisfaction.

CONCLUSIONS

Although managed care features are correlated with physician job and referral dissatisfaction, the source of dissatisfaction may originate from being an employed physician in a large medical group with more physicians, which may be more likely to impose bureaucratic controls that limit physician autonomy.

Behavioural factors associated with symptom outcomes in a primary care-based depression prevention intervention trial

BACKGROUND

A randomized trial of a primary care-based intervention to prevent depression relapse resulted in improved adherence to long-term antidepressant medication and depression outcomes. We evaluated the effects of this intervention on behavioural processes and identified process predictors of improved depressive symptoms.

METHOD

Patients at high risk for depression recurrence or relapse following successful acute phase treatment (N=386) were randomly assigned to receive a low intensity 12-month intervention or continued usual care. The intervention combined education about depression, shared decision-making regarding use of maintenance pharmacotherapy and cognitive-behavioural strategies to promote self-management. Baseline, 3, 6, 9 and 12-month interviews assessed patients' self-care practices, self-efficacy for managing depression and depressive symptoms.

RESULTS

Intervention patients had significantly greater self-efficacy for managing depression (P<0.01) and were more likely to keep track of depressive symptoms (P<0.0001), monitor early warning signs (P<0.0001), and plan for coping with high risk situations (P<0.0001) at all time points compared to usual care control patients. Self-efficacy for managing depression (P<0.0001), keeping track of depressive symptoms (P=0.05), monitoring for early warning signs (P=0.01), engaging in pleasant activities (P<0.0001) and engaging in social activities (P<0.0001) positively predicted improvements in depression symptom scores.

CONCLUSIONS

A brief intervention designed to target cognitive-behavioural factors and promote adherence to pharmacotherapy in order to prevent depression relapse was highly successful in changing several behaviours related to controlling depression. Improvements in self-efficacy and several self-management behaviours that were targets of the intervention were significantly related to improvements in depression outcome.

Identifying Depressed Patients With a High Risk of Comorbid Anxiety in Primary Care

BACKGROUND: Depressive and anxiety disorders are highly prevalent in the primary care setting. There is evidence that patients with depression and comorbid anxiety are more severely impaired than patients with depression alone and require aggressive mental health treatment. The goal of this study was to assess the impact of comorbid anxiety in a primary care population of depressed patients. METHOD: 342 subjects diagnosed with a DSM-IV-defined major depressive episode, dysthymia, or both were asked 2 questions about the presence of comorbid anxiety symptoms (history of panic attacks and/or flashbacks). Patient groups included depression only (N = 119), depression and panic attacks (N = 51), depression and flashbacks (N = 97), and depression and both panic attacks and flashbacks (N = 75). Groups were compared on demographics, mental health histories, and health-related quality-of-life variables. Data were gathered from January 1998 to March 1999. RESULTS: Those patients with depression, panic attacks, and flashback symptoms as compared with those with depression alone were more likely to be younger, unmarried, and female. The group with depression, panic attacks, and flashbacks was also more likely to have more depressive symptoms, more impaired health status, worse disability, and a more complicated and persistent history of mental illness. Regression analysis revealed that the greatest impact on disability, presence of depressive symptoms, and mental health outcomes was associated with panic attacks. CONCLUSION: By asking 2 questions about comorbid anxiety symptoms, primary care providers evaluating depressed patients may be able to identify a group of significantly impaired patients at high risk of anxiety disorders who might benefit from collaboration with or referral to a mental health specialist.

Improving primary care treatment of depression among patients with diabetes mellitus: the design of the pathways study

This paper describes the methodology of a population based study of primary care patients with diabetes mellitus enrolled in a health maintenance organization. The first goal was to determine the prevalence and impact of depression in patients with diabetes. The second goal was to randomize approximately 300 patients with diabetes and major depression and/or dysthymia in a trial to test the effectiveness of a collaborative care intervention in improving quality of care and health outcomes among patients with diabetes and depression.

Cost-effectiveness of collaborative care for depression in a primary care veteran population

OBJECTIVE

This study examined the incremental cost-effectiveness of a collaborative care intervention for depression compared with consult-liaison care.

METHODS

A total of 354 patients in a Department of Veterans Affairs (VA) primary care clinic who met the criteria for major depression or dysthymia were randomly assigned to one of the two care models. Under the collaborative care model, a mental health team provided a treatment plan to primary care providers, telephoned patients to encourage adherence, reviewed treatment results, and suggested modifications. Outcomes were assessed at three and nine months by telephone interviews. Health care use and costs were also assessed.

RESULTS

A significantly greater number of collaborative care patients were treated for depression and given prescriptions for antidepressants. The collaborative care patients experienced an average of 14.6 additional depression-free days over the nine months. The mean incremental cost of the intervention per patient was $237 US dollars for depression treatment and $519 US dollars for total outpatient costs. A majority of the additional expenditures were accounted for by the intervention. The incremental cost-effectiveness ratio was $24 US dollars per depression-free day for depression treatment costs and $33 US dollars for total outpatient cost.

CONCLUSIONS

Better coordination and communication under collaborative care was associated with a greater number of patients being treated for depression and with moderate increases in days free of depression and in treatment cost. Additional resources are needed for effective collaborative care models for depression treatment in primary care.