Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial

Unmet need for recognition of common mental disorders in Australian general practice

OBJECTIVE

To determine the rate and predictors of unmet need for recognition of common mental disorders in Australian general practice.

DESIGN AND SETTING

Cross-sectional national audit of general practices throughout Australia in 1998-1999.

PARTICIPANTS

46 515 ambulatory care patients attending 386 GPs.

SCREENING TOOLS

Prevalence of common mental disorders--12 items from the 34-item SPHERE self-report questionnaire and associated classification system; prevalence of recognition of mental disorders by GPs--GPs reporting whether patients had depression, anxiety, mixed depression/anxiety, somatoform, or other psychological disorder; predictors of unmet need for recognition of mental disorders--self-report questions about demography for patients and GPs, and about practice organisation for GPs.

MAIN OUTCOME MEASURES

Reported recognition of psychological disorders by GPs; actual prevalence of disorders; and patient, GP and practice characteristics predicting the failure to recognise disorders.

RESULTS

GPs did not recognise mental disorder in 56% (11922/21210) of patients. These comprised 46% (5134/11060) of patients in the higher level of mental disorders, and (in the second level of disorders) 58% (2906/5036) of patients with predominantly psychological symptoms, and 76% (3882/5114) of those with predominantly somatic symptoms. Patients more likely to have their need for psychological assessment met had the following characteristics: middle-aged (odds ratio [OR], 1.76; 95% CI, 1.59-1.96), female (OR, 1.19; 95% CI, 1.12-1.27), Australian-born (OR, 1.16; 95% CI, 1.08-1.24), unemployed (OR, 1.75; 95% CI, 1.64-1.89), single (OR, 1.52; 95% CI, 1.41-1.61), presenting with mainly psychological symptoms (OR, 3.54; 95% CI, 3.28-3.81), and presenting for psychological reasons (OR, 4.20; 95% CI, 3.02-5.82). Characteristics of doctors associated with meeting patients' need for assessment were being aged over 35 years (OR, 1.51; 95% CI, 1.09-2.08), having an interest in mental health (OR, 1.27; 95% CI, 1.15-1.41), having had previous mental health training (OR, 1.29; 95% CI, 1.15-1.45), being in part-time practice (OR, 1.23; 95% CI, 1.09-1.39), seeing fewer than 100 patients per week (OR, 1.29; 95% CI, 1.13-1.47), working in practices with fewer than 2000 patients (OR, 1.28; 95% CI, 1.13-1.45) and working in regional centres (OR, 1.16; 95% CI, 1.05-1.28).

CONCLUSION

Unmet need for recognition of common mental disorders remains high. Predictors of unmet need include a somatic symptom profile and practitioner and organisational characteristics which impede the provision of high quality mental health services.

Effects of mental health training and clinical audit on general practitioners' management of common mental disorders

OBJECTIVE

To evaluate the effects of a seminar-based training program and clinical practice audit on general practitioners' (GPs') knowledge and management of common mental disorders.

DESIGN

Survey of GPs' knowledge before and after training, and clinical practice audit and re-audit after feedback.

PARTICIPANTS AND SETTING

GP volunteers from around Australia in 1998-1999: 1008 completed the pre-training test, 190 the post-training test, 386 the first audit (33235 patients), and 157 of these the re-audit (13280 patients), with 57 undertaking both audit and training.

INTERVENTIONS

Four-seminar, 12-hour training program focused on improving GPs' capacity to identify and manage patients with depression and anxiety; practice audit with patient- and practice-based feedback on diagnosis and treatment of common mental disorders.

MAIN OUTCOME MEASURES

Scores on pre- and post-training knowledge tests; self-rated improvements in confidence in managing patients with mental disorders after training; rates of psychological diagnoses and treatment by GPs on first audit and re-audit.

RESULTS

GPs' knowledge of pharmacological treatments and clinical management improved after the training program (P<0.001), and 97% of GPs reported increased confidence in their management skills. GPs who undertook training had higher diagnosis rates for common mental disorders in the first audit than those who did not undertake training (36% versus 29%; P<0.001), and their diagnosis rates increased over time (36% to 39%; P<0.01), while those of GPs who did not undertake training were unchanged. Similarly, GPs who undertook training provided more mental health treatments than those who did not (30% versus 27% in the first audit [P<0.001], and 31% versus 24% at reaudit [P<0.001]). They also place greater emphasis on use of nonpharmacological treatments (24% versus 21% at first audit [P<0.001], and 25% versus 19% at re-audit [P<0.001]).

CONCLUSION

Clinical audits may heighten awareness of mental disorders, but, on their own, they do not improve mental health practice. A relatively brief but skills-based training program may contribute to better management of patients with common mental disorders by increasing GPs' confidence and competence.

Managing late-life depression in primary care practice: a case study of the Health Specialist's role

Complexities in the diagnosis and treatment of late-life depression have stimulated various strategies for assisting the primary care physician to fulfil these tasks more effectively. The role of Health Specialist was developed for this purpose in a study to reduce suicidality among older depressed patients. This role includes clinical and case management tasks which aim to provide the physician with timely, patient-specific information and recommendations. Evolution of this role and its rewards/stressors during the study's first year are described.

Pharmacological treatment of depression in older primary care patients: the PROSPECT algorithm

PROSPECT (Prevention of Suicide in Primary care Elderly-Collaborative Trial) is testing whether a trained clinician (the 'health specialist') can work in close collaboration with a primary care physician to implement a comprehensive depression management program and improve outcomes in older depressed patients. An algorithm guiding the selection and use of antidepressant medications has been developed to assist PROSPECT health specialists. This algorithm is presented and the rationale underlying the proposed treatment sequence is discussed. The PROSPECT algorithm builds upon existing guidelines after updating them and adapting them to the special circumstances of older primary care patients. Special attention has been paid to the tolerability and the target doses of the recommended antidepressant agents and to the duration of antidepressant trials. Patients who are unable to tolerate or do not respond to an antidepressant can be switched to another agent or be treated with interpersonal psychotherapy. Agents that produce only a partial response can be combined with other antidepressants or with interpersonal psychotherapy. Treatments for which empirical evidence exists are favored. However, treatments that are often poorly tolerated by elderly patients are given lower priority than treatments more likely to be tolerated. Similarly, trials that are simpler to implement in primary care are favored.

Collaborative interventions for physically injured trauma survivors: a pilot randomized effectiveness trial

Posttraumatic behavioral and emotional disturbances occur frequently among physically injured hospitalized trauma survivors. This investigation was a pilot randomized effectiveness trial of a 4-month collaborative care intervention for injured motor vehicle crash and assault victims. As surgical inpatients, intervention subjects (N=16) were assigned to a trauma support specialist who provided counseling, consulted with surgical and primary care providers, and attempted postdischarge care coordination. Control subjects (N=18) received usual posttraumatic care. For all participants, posttraumatic stress disorder (PTSD) and depressive symptoms, episodic alcohol intoxication, and functional limitations were evaluated during the hospitalization and 1 and 4 months postinjury. Study logs and field notes revealed that over 75% of intervention activity occurred in the first month after the trauma. One-month post-trauma intervention subjects when compared to controls demonstrated statistically significant decreases in PTSD symptoms as well as a reduction in depressive symptoms. However, at the 4-month assessment, intervention subjects evidenced no significant improvements in PTSD and depressive symptoms, episodic alcohol intoxication, or functional limitations. Future larger scale trials of stepped collaborative care interventions for physically injured trauma survivors are recommended.

A health services perspective on delivery of psychiatric services in primary care including internal medicine

Serious problems persist in the recognition and treatment of psychiatric problems in primary care despite multiple interventions directed at correcting these problems. Improved outcomes depend on improved recognition, and screening instruments need to be streamlined tremendously to be accepted by primary care providers. Publication of guidelines and physician education, although essential for improved care, are probably insufficient to implement guidelines-based care. Improvements in psychiatric outcome appear to depend on the level of intensity of the intervention employed. Continued research is needed to determine the most effective type of educational intervention and more widely applicable quality improvement processes. Broad-based changes in health service delivery focusing on the true integration of mental health services with general medical care are required to bring about meaningful, effective change. Ongoing changes in physician training programs (combined primary care/psychiatry programs) may facilitate implementation of guideline-based psychiatric care in medical settings, but the full impact of these changes is not likely to be felt for several years.

Rethinking practitioner roles in chronic illness: the specialist, primary care physician, and the practice nurse

In this article, we describe an evidence-based stepped care approach to improving the care of chronic illness in organized health care systems. We review the common principles that have been found to improve the management and outcomes of patients with major depression, asthma, diabetes, and congestive heart failure. These population-based methods to improve care of chronic illness require reorganizing the roles of specialists, primary care physicians, and nurses.

Improving depression outcomes in community primary care practice: a randomized trial of the quEST intervention. Quality Enhancement by Strategic Teaming

OBJECTIVE

To determine whether redefining primary care team roles would improve outcomes for patients beginning a new treatment episode for major depression.

DESIGN

Following stratification, 6 of 12 practices were randomly assigned to the intervention condition. Intervention effectiveness was evaluated by patient reports of 6-month change in 100-point depression symptom and functional status scales.

SETTING

Twelve community primary care practices across the country employing no onsite mental health professional.

PATIENTS

Using two-stage screening, practices enrolled 479 depressed adult patients (73.4% of those eligible); 90.2% completed six-month follow-up.

INTERVENTION

Two primary care physicians, one nurse, and one administrative staff member in each intervention practice received brief training to improve the detection and management of major depression.

MAIN RESULTS

In patients beginning a new treatment episode, the intervention improved depression symptoms by 8.2 points (95% confidence interval [CI], 0.2 to 16.1; P =.04). Within this group, the intervention improved depression symptoms by 16.2 points (95% CI, 4.5 to 27.9; P =.007), physical role functioning by 14.1 points (95% CI, 1.1 to 29.2; P =.07), and satisfaction with care (P =.02) for patients who reported antidepressant medication was an acceptable treatment at baseline. Patients already in treatment at enrollment did not benefit from the intervention.

CONCLUSIONS

In practices without onsite mental health professionals, brief interventions training primary care teams to assume redefined roles can significantly improve depression outcomes in patients beginning a new treatment episode. Such interventions should target patients who report that antidepressant medication is an acceptable treatment for their condition. More research is needed to determine how primary care teams can best sustain these redefined roles over time.

Predictors of outcome in a primary care depression trial

OBJECTIVE

Previous treatment trials have found that approximately one third of depressed patients have persistent symptoms. We examined whether depression severity, comorbid psychiatric illness, and personality factors might play a role in this lack of response.

DESIGN

Randomized trial of a stepped collaborative care intervention versus usual care.

SETTING

HMO in Seattle, Wash.

PATIENTS

Patients with major depression were stratified into severe (N = 149) and mild to moderate depression (N = 79) groups prior to randomization.

INTERVENTIONS

A multifaceted intervention targeting patient, physician, and process of care, using collaborative management by a psychiatrist and primary care physician.

MEASUREMENTS AND MAIN RESULTS

Patients with more severe depression had a higher risk for panic disorder (odds ratio [OR], 5.8), loneliness (OR, 2.6), and childhood emotional abuse (OR, 2.1). Among those with less severe depression, intervention patients showed significantly improved depression outcomes over time compared with those in usual care (z = -3.06, P<.002); however, this difference was not present in the more severely depressed groups (z = 0.61, NS). Although the group with severe depression showed differences between the intervention and control groups from baseline to 3 months that were similar to the group with less severe depression (during the acute phase of the intervention), these differences disappeared by 6 months.

CONCLUSIONS

Initial depression severity, comorbid panic disorder, and other psychosocial vulnerabilities were associated with a decreased response to the collaborative care intervention. Although the intervention was appropriate for patients with moderate depression, individuals with higher levels of depression may require a longer continuation phase of therapy in order to achieve optimal depression outcomes.

Treatment preferences among depressed primary care patients

OBJECTIVE

To understand patient factors that may affect the probability of receiving appropriate depression treatment, we examined treatment preferences and their predictors among depressed primary care patients.

DESIGN

Patient questionnaires and interviews.

SETTING

Forty-six primary care clinics in 7 geographic regions of the United States.

PARTICIPANTS

One thousand one hundred eighty-seven English- and Spanish-speaking primary care patients with current depressive symptoms.

MEASUREMENTS AND MAIN RESULTS

Depressive symptoms and diagnoses were determined by the Composite International Diagnostic Interview (CIDI) and the Center for Epidemiological Studies Depression Scale (CES-D). Treatment preferences and characteristics were assessed using a self-administered questionnaire and a telephone interview. Nine hundred eight-one (83%) patients desired treatment for depression. Those who preferred treatment were wealthier (odds ratio [OR], 3.7; 95% confidence interval [95% CI], 1.8 to 7.9; P =.001) and had greater knowledge about antidepressant medication ( OR, 2.6; 95% CI, 1.6 to 4.4; P

CONCLUSIONS

Despite low rates of treatment for depression, most depressed primary care patients desire treatment, especially counseling. Preferences for depression treatment vary by ethnicity, gender, income, and knowledge about treatments.

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Key Words

• depression
• primary care
• patient preferences
• treatment preferences

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MESH Headings

• Adolescent
• Adult
• Depression/classification
• Depression/diagnosis
• Depression/therapy
• Female
• Humans
• Interviews as Topic
• Male
• Middle Aged
• Patient Acceptance of Health Care
• Patient Satisfaction
• Primary Health Care
• Socioeconomic Factors
• Surveys and Questionnaires

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Grants

• R01 HS008349 AHRQ HHS
• K12 MH00990-01-01 NIMH NIH HHS
• HS08349-02 AHRQ HHS

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Affiliation(s)

M Dwight-Johnson Department of Psychiatry, University of Southern California, Los Angeles, Calif, USA.
C D Sherbourne
D Liao
K B Wells

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Psychiatric comorbidity in chronic epilepsy: identification, consequences, and treatment of major depression

The purpose of this article is to review the topic of interictal psychiatric comorbidity among adult patients with chronic epilepsy, focusing specifically on those studies that have used contemporary psychiatric nosology. Five specific issues are addressed: (a) the risk and predominant type(s) of psychiatric comorbidity in chronic epilepsy, (b) adequacy of recognition and treatment of psychiatric comorbidity, (c) the additional burdens that comorbid psychiatric disorders impose upon patients with chronic epilepsy, (d) the etiology of these disorders, and (e) strategies for treatment. Current appreciation for these issues in epilepsy is contrasted to related fields (e.g., primary care, psychiatry, and epidemiology), where considerable attention has been devoted to the identification, consequences, and treatment of psychiatric comorbidity. The issue of psychiatric comorbidity in epilepsy is reviewed with the aim of identifying a clinical and research agenda that will advance understanding of at least one important psychiatric condition associated with epilepsy-namely, major depression.

Responses to nervous breakdowns in America over a 40-year period. Mental health policy implications

The 1957 and 1976 Americans View Their Mental Health surveys from the Institute of Social Research were partially replicated in the 1996 General Social Survey (GSS) to examine the policy implications of people's responses to feeling an impending nervous breakdown. Questions about problems in modern living were added to the GSS to provide a profile of the public's view of mental health problems. Results were compared for 1957, 1976, and 1996. In 1957, 19% of respondents had experienced an impending nervous breakdown; in 1996, 26% had had this experience. Between 1957 and 1996, participants increased their use of informal social supports, decreased their use of physicians, and increased their use of nonmedical mental health professionals. These findings support policies that strengthen informal support seeking and access to effective psychosocial treatments rather than current mental health reimbursement practices, which emphasize the role of primary care physicians.