Can depression treatment in primary care reduce disability? A stepped care approach

Systematic review of structured care pathways in major depressive disorder and bipolar disorder

BACKGROUND

Structured care pathways (SCPs) consist of treatment algorithms that patients advance through with the goal of achieving remission or response. These SCPs facilitate the application of current evidence and adequate treatment, which potentially benefit patients with mood disorders. The aim of this systematic review was to provide an updated synthesis of SCPs for the treatment of depressive disorders and bipolar disorder (BD).

METHOD

PubMed, PsycINFO, and Embase were searched through June 2022 for peer-reviewed studies examining outcomes of SCPs. Eligibility criteria included being published in a peer-reviewed journal in the English language, reporting of intervention used in the SCP, and having quantitative outcomes. Studies Cochrane risk of bias tool was used to assess quality of RCTs.

RESULTS

Thirty-six studies including 15,032 patients were identified for qualitative synthesis. Six studies included patients with BD. The studies were highly heterogeneous in design, outcome measures, and algorithms. More than half of the studies reported superiority of SCPs over treatment as usual, suggesting that the standardized structure and consistent monitoring inherent in SCPs may be contributing to their effectiveness. We also found accumulating evidence supporting feasibility of SCPs in different settings, although dropout rates were generally higher in SCPs. The studies included were limited to being published in peer-reviewed journals in English language. The heterogeneity of studies did not allow quantitative evaluation.

CONCLUSIONS

The findings of our study suggest that SCPs are equally or more effective than treatment as usual in depression and BD. Further studies are required to ascertain their effectiveness, particularly for BD, and to identify factors that influence their feasibility and success.

The Effectiveness of Patient-Centred Medical Home-Based Models of Care versus Standard Primary Care in Chronic Disease Management: A Systematic Review and Meta-Analysis of Randomised and Non-Randomised Controlled Trials

Patient-centred care by a coordinated primary care team may be more effective than standard care in chronic disease management. We synthesised evidence to determine whether patient-centred medical home (PCMH)-based care models are more effective than standard general practitioner (GP) care in improving biomedical, hospital, and economic outcomes. MEDLINE, CINAHL, Embase, Cochrane Library, and Scopus were searched to identify randomised (RCTs) and non-randomised controlled trials that evaluated two or more principles of PCMH among primary care patients with chronic diseases. Study selection, data extraction, quality assessment using Joanna Briggs Institute (JBI) appraisal tools, and grading of evidence using Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach were conducted independently. A quantitative synthesis, where possible, was pooled using random effects models and the effect size estimates of standardised mean differences (SMDs) and odds ratios (ORs) with 95% confidence intervals were reported. Of the 13,820 citations, we identified 78 eligible RCTs and 7 quasi trials which included 60,617 patients. The findings suggested that PCMH-based care was associated with significant improvements in depression episodes (SMD -0.24; 95% CI -0.35, -0.14; I2 = 76%) and increased odds of remission (OR 1.79; 95% CI 1.46, 2.21; I2 = 0%). There were significant improvements in the health-related quality of life (SMD 0.10; 95% CI 0.04, 0.15; I2 = 51%), self-management outcomes (SMD 0.24; 95% CI 0.03, 0.44; I2 = 83%), and hospital admissions (OR 0.83; 95% CI 0.70, 0.98; I2 = 0%). In terms of biomedical outcomes, with exception to total cholesterol, PCMH-based care led to significant improvements in blood pressure, glycated haemoglobin, and low-density lipoprotein cholesterol outcomes. The incremental cost of PCMH care was identified to be small and significantly higher than standard care (SMD 0.17; 95% CI 0.08, 0.26; I2 = 82%). The quality of individual studies ranged from "fair" to "good" by meeting at least 60% of items on the quality appraisal checklist. Additionally, moderate to high heterogeneity across studies in outcomes resulted in downgrading the included studies as moderate or low grade of evidence. PCMH-based care has been found to be superior to standard GP care in chronic disease management. Results of the review have important implications that may inform patient, practice, and policy-level changes.

The Bidirectional Relationship Between Depressive Symptoms and Homebound Status Among Older Adults

OBJECTIVES

This study aimed to examine the bidirectional relationship between depressive symptoms and homebound status among older adults.

METHOD

The study sample included 7,603 community-dwelling older adults from the National Health and Aging Trends Study. A bivariate latent state-trait model of depressive symptoms and homebound status was estimated via structural equation modeling.

RESULTS

The model fit the data well (Root Mean Square Error of Approximation = .02, Comparative Fit Index = .97, Standardized Root Mean Square Residual = .06). The relationship between homebound status and depressive symptoms can be decomposed into three parts: a moderate correlation between the stable trait components (r = .56, p <.001); a contemporary association of the state components (b = .17, p <.001); and bidirectional lagged effects between the state components. Change in homebound status was as a stronger predictor of depressive symptoms (b = .19, p < .001) than change in depressive symptoms was of homebound status (b = .06, p < .001; test of difference: Δ scaled χ2(1) = 24.2, p < .001).

DISCUSSION

Homebound status and depressive symptoms form a feedback loop to influence each other. Improving the outdoor mobility of older adults may have immediate benefits for reducing depressive symptoms.

Prompt Mental Health Care (PMHC): work participation and functional status at 12 months post-treatment

BACKGROUND

Anxiety and depression are associated with substantial functional impairment. Prompt Mental Health Care (PMHC), the Norwegian adaptation of IAPT is currently piloted across Norway, as a means to improve access to evidence-based care for adults with anxiety disorders (including subthreshold cases) and minor to moderate depression. The aims of the current paper were to examine the change in work status and functional status from pre- to post-treatment and 12 months post-treatment among clients at the first 12 PMHC pilot sites, and whether degree of change differed across sociodemographic characteristics.

METHODS

A prospective cohort design was used, including working age clients receiving treatment between October 2014 and December 2016 (n = 1446, participation rate = 61%). Work status and functional status were self-reported, the latter by the Work and Social Adjustment Scale (WSAS). Changes in work status and WSAS score were examined through multilevel models based on maximum likelihood estimation. Likelihood ratio tests were performed to determine whether the interaction between time and the respective background variables were statistically significant.

RESULTS

A substantial increase in regular work participation was observed from pre- to post-treatment, which further had increased at 12 months post-treatment. The increase was driven by a corresponding reduction in proportion of clients working and receiving benefits (OR 0.38 [0.29-0.50] baseline to final treatment, OR = 0.19 [0.12-0.32] final treatment to 12-months post-treatment), while no statistically significant change was observed in proportion out of work. Large improvement (ES = - 0.89) in WSAS score was observed from pre- to post treatment. WSAS score at 12 months post-treatment remained at the post-treatment level.

CONCLUSIONS

Previous research has shown substantial symptom improvement among clients receiving treatment in PMHC. The current findings indicate that PMHC might also be able to aid adults struggling with mild to moderate anxiety and depression in returning to usual level of functioning. The degree to which the observed improvements are attributable to the treatment need nonetheless to be confirmed in a trial including a control group and with more complete follow-up data from registries.

Cost-effectiveness analysis of a randomized study of depression treatment options in primary care suggests stepped-care treatment may have economic benefits

BACKGROUND

The stepped-care pathway (SCP) model has previously been found to be clinically effective for depressive disorder in some studies, but not all. Several groups have suggested that a stepped-care approach is the most appropriate in primary care. There is relatively little information, however, regarding which specific stepped-care pathway may be best. This analysis aimed to determine cost-effectiveness of a stepped-care pathway for depression in adults in primary care versus standard care (SC), treatment-as-usual (TAU), and online cognitive behavioural therapy (CBT).

METHODS

We conducted a randomized trial with 1400 participants and 12-week follow-up to assess the impact of the four treatment options on health-related quality of life and depression severity. Costs for the groups were calculated on the basis of physician, outpatient, and inpatient services using administrative data. We then calculated the incremental cost-effectiveness ratios using this information. Cost-effectiveness acceptability curves and incremental cost-effectiveness scatterplots were created using Monte Carlo simulation with 10,000 replications. A subgroup analysis was conducted for participants who screened as depressed at baseline.

RESULTS

For all participants, TAU was the most expensive followed by CBT, SC, and SCP. QALYs were highest in SCP, followed by SC, CBT, and TAU. In the depressed subgroup, TAU was still the most expensive, followed by SC, SCP, and CBT, while QALYs were still highest in SCP, followed by SC, CBT, and TAU. The cost-effectiveness acceptability curves suggested that SCP had a higher probability for cost-effectiveness than the other three alternatives in all participants. In the depressed subgroup, CBT was associated with the highest probability of cost-effectiveness for a willingness-to-pay cut-off of less than approximately $50,000, while SCP was the highest at a cut-off higher than $50,000. There is considerable uncertainty around the cost-effectiveness estimates.

CONCLUSIONS

Our analysis showed that even where there are no clinically significant differences in health outcomes between treatment approaches, there may be economic benefit from implementing the stepped-care model. While more work is required to identify the most clinically effective versions of a stepped-care pathway, our findings suggest that the care pathway may have potential to improve health care system value.

TRIAL REGISTRATION

NCT01975207 . The trial was prospectively registered on 4 November 2013.

Mindfulness Training Enhances Self-Regulation and Facilitates Health Behavior Change for Primary Care Patients: a Randomized Controlled Trial

BACKGROUND

Self-management of health is important for improving health outcomes among primary care patients with chronic disease. Anxiety and depressive disorders are common and interfere with self-regulation, which is required for disease self-management. An insurance-reimbursable mindfulness intervention integrated within primary care may be effective for enhancing chronic disease self-management behaviors among primary care patients with anxiety, depression, trauma, and stress-related and adjustment disorders compared with the increasingly standard practice of referring patients to outside mindfulness resources.

OBJECTIVE

Mindfulness Training for Primary Care (MTPC) is an 8-week, referral-based, insurance-reimbursable program integrated into safety-net health system patient-centered medical homes. We hypothesized that MTPC would be more effective for catalyzing chronic disease self-management action plan initiation within 2 weeks, versus a low-dose comparator (LDC) consisting of a 60-min mindfulness introduction, referral to community and digital resources, and addition to a 6-month waitlist for MTPC.

PARTICIPANTS

Primary care providers (PCPs) and mental health clinicians referred 465 patients over 12 months. All participants had a DSM-V diagnosis.

DESIGN AND INTERVENTIONS

Participants (N = 136) were randomized in a 2:1 allocation to MTPC (n = 92) or LDC (n = 44) in a randomized controlled comparative effectiveness trial. MTPC incorporates mindfulness, self-compassion, and mindfulness-oriented behavior change skills and is delivered as insurance-reimbursable visits within primary care. Participants took part in a chronic disease self-management action planning protocol at week 7.

MAIN MEASURES

Level of self-reported action plan initiation on the action plan initiation survey by week 9.

KEY RESULTS

Participants randomized to MTPC, relative to LDC, had significantly higher adjusted odds of self-management action plan initiation in an intention-to-treat analysis (OR = 2.28; 95% CI = 1.02 to 5.06, p = 0.025).

CONCLUSIONS

An 8-week dose of mindfulness training is more effective than a low-dose mindfulness comparator in facilitating chronic disease self-management behavior change among primary care patients.

Management of comorbid mental and somatic disorders in stepped care approaches in primary care: a systematic review

BACKGROUND

Stepped care models comprise a graded treatment intensity and a systematic monitoring. For an effective implementation, stepped care models have to account for the high rates of mental and somatic comorbidity in primary care.

OBJECTIVES

The aim of the systematic review was to take stock of whether present stepped care models take comorbidities into consideration. A further aim was to give an overview on treatment components and involved health care professionals.

METHODS

A systematic literature search was performed using the databases PubMed, PsycINFO, Cochrane Library and Web of Science. Selection criteria were a randomized controlled trial of a primary-care-based stepped care intervention, adult samples, publication between 2000 and 2017 and English or German language.

RESULTS

Of 1009 search results, 39 studies were eligible. One-third of the trials were conceived for depressive disorders only, one-third for depression and further somatic and/or mental comorbidity and one-third for conditions other than depression. In 39% of the studies comorbidities were explicitly integrated in treatment, mainly via transdiagnostic self-management support, interprofessional collaboration and digital approaches for treatment, monitoring and communication. Most care teams were composed of a primary care physician, a care manager and a psychiatrist and/or psychologist. Due to the heterogeneity of the addressed disorders, no meta-analysis was performed.

CONCLUSIONS

Several stepped care models in primary care already account for comorbidities, with depression being the predominant target disorder. To determine their efficacy, the identified strategies to account for comorbidities should be investigated within stepped care models for a broader range of disorders.

Telepsychiatry and other technologies for integrated care: evidence base, best practice models and competencies

Telehealth facilitates integrated, patient-centred care. Synchronous video, telepsychiatry (TP), or telebehavioural health provide outcomes as good as in-person care. It also improves access to care, leverages expertise at a distance, and is effective for education and consultation to primary care. Other technologies on an e-behavioural health spectrum are also useful, like telephone, e-mail, text, and e-consults. This paper briefly organizes these technologies into low, mid and high intensity telehealth models and reviews the evidence base for interventions to primary care, and, specifically, for TP and integrated care (IC). Technology, mobile health, and IC competencies facilitate quality care. TP is a high intensity model and it is the best-studied option. Studies of IC are preliminary, but those with collaborative and consultative care show effectiveness. Low- and mid-intensity technology options like telephone, e-mail, text, and e-consults, may provide better access for patients and more timely provider communication and education. They are also probably more cost-effective and versatile for health system workflow. Research is needed upon all technology models related to IC for adult and paediatric primary care populations. Effective healthcare delivery matches the patients' needs with the model, emphasizes clinician competencies, standardizes interventions, and evaluates outcomes.

Perioperative Inpatient Use of Selective Serotonin Reuptake Inhibitors Is Associated With a Reduced Risk of THA and TKA Revision

BACKGROUND

Depression is common in the general population, and so it is likewise common among patients undergoing THA and TKA. Depression is associated with lower perioperative patient-reported outcomes and an increased risk of postoperative complications. Antidepressants are effective in managing symptoms of depression and may potentially contribute to better functional status and better clinical outcomes after THA and TKA.

QUESTIONS/PURPOSES

We examined (1) whether perioperative depression is associated with all-cause revisions, revisions for aseptic loosening, revisions without infection, and periprosthetic joint infections (PJIs) in patients undergoing THA and TKA; and (2) whether perioperative antidepressant use reduces the risk of all-cause revisions, revisions for aseptic loosening, aseptic revisions, and PJIs in patients undergoing THA and TKA.

METHODS

This was a retrospective study of adult patients (≥ 18 years) who underwent 20,112 primary and revision THAs and TKAs from January 1, 2002, through December 31, 2009, at a large US tertiary care hospital. Data on patient and surgery characteristics and outcomes (dates and types of revisions, death) were ascertained through the institutional joint registry. Perioperative antidepressant use was assessed by searching the daily medication administration records beginning at admission and ending at discharge. A diagnosis of depression was present in 4466 (22%), and antidepressants were administered at the time of 5077 (25%) surgical procedures. Multivariable Cox proportional hazard models were used to estimate associations between antidepressant use and the risk of all-cause revisions, revisions for aseptic loosening, aseptic revisions, and PJIs.

RESULTS

Depression was associated with an increased risk of all-cause revisions (hazard ratio [HR], 1.73; 95% confidence interval [CI], 1.42-2.02; p < 0.001) and PJIs (HR, 2.23; 95% CI, 1.53-3.17; p < 0.001). Overall, perioperative antidepressant use was not associated with the risk of revision or PJI, but selective serotonin reuptake inhibitor (SSRI) users had a lower risk of all-cause revisions (HR, 0.77; 95% CI, 0.61-0.96; p = 0.001) and aseptic revisions (HR, 0.72; 95% CI, 0.56-0.93; p = 0.013).

CONCLUSIONS

The presence of a depression diagnosis confers an increased risk of revision and PJI among patients undergoing THA and TKA, yet the risk is lower within the subset of patients who received SSRIs during the perioperative period. Future longitudinal studies with detailed antidepressant medication histories are warranted to better understand the potential biologic effects of SSRI on the risk of revision in patients undergoing THA and TKA.

LEVEL OF EVIDENCE

Level III, therapeutic study.

An Update on Telepsychiatry and How It Can Leverage Collaborative, Stepped, and Integrated Services to Primary Care

INTRODUCTION

In this era of patient-centered care, telepsychiatry (TP; video or synchronous) provides quality care with outcomes as good as in-person care, facilitates access to care, and leverages a wide range of treatments at a distance.

METHOD

This conceptual review article explores TP as applied to newer models of care (e.g., collaborative, stepped, and integrated care).

RESULTS

The field of psychosomatic medicine (PSM) has developed clinical care models, educates interdisciplinary team members, and provides leadership to clinical teams. PSM is uniquely positioned to steer TP and implement other telebehavioral health care options (e.g., e-mail/telephone, psych/mental health apps) in the future in primary care. Together, PSM and TP provide versatility to health systems by enabling more patient points-of-entry, matching patient needs with provider skills, and helping providers work at the top of their licenses. TP and other technologies make collaborative, stepped, and integrated care less costly and more accessible.

CONCLUSION

Effective health care delivery matches the intensity of the services to the needs of a patient population or clinic, standardizes interventions, and evaluates both process and clinical outcomes. More research is indicated on the application of TP and other technologies to these service delivery models.

Collaborative Care and Related Interventions in Patients With Heart Disease: An Update and New Directions

BACKGROUND

Psychiatric disorders, such as depression, are very common in cardiac patients and are independently linked to adverse cardiac outcomes, including mortality. Collaborative care and other integrated care models have been used successfully to manage psychiatric conditions in patients with heart disease, with beneficial effects on function and other outcomes. Novel programs using remote delivery of mental health interventions and promotion of psychological well-being may play an increasingly large role in supporting cardiovascular health.

METHODS

We review prior studies of standard and expanded integrated care programs among patients with cardiac disease, examine contemporary intervention delivery methods (e.g., Internet or mobile phone) that could be adapted for these programs, and outline mental health-related interventions to promote healthy behaviors and overall recovery across all cardiac patients.

RESULTS

Standard integrated care models for mental health disorders are effective at improving mood, anxiety, and function in patients with heart disease. Novel, "blended" collaborative care models may have even greater promise in improving cardiac outcomes, and interfacing with cardiac patients via mobile applications, text messages, and video visits may provide additional benefit. A variety of newer interventions using stress management, mindfulness, or positive psychology have shown promising effects on mental health, health behaviors, and overall cardiac outcomes.

CONCLUSIONS

Further study of novel applications of collaborative care and related interventions is warranted given the potential of these programs to increase the reach and effect of mental health interventions in patients with heart disease.

Healthy IDEAS

This study evaluated an evidence-based intervention for depression delivered by case managers in three community-based service agencies to high-risk, diverse older adults. Case managers were trained to provide screening and assessment, education, referral and linkage, and behavioral activation. Outcomes addressed depression, general health status, social and physical activation, and mental health services use at baseline and 6 months. Participants (n = 94) were predominantly women (79%) and Hispanic (44%), with a mean age of 72 years. Mean Geriatric Depression Scale—15 scores differed significantly between baseline and 6 months (9.0 versus 5.5). At 6 months, significantly more participants knew how to get help for depression (68% versus 93%), reported that increasing activity helped them feel better (72% versus 89%), and reported reduced pain (16% versus 45 %). The authors conclude that nonspecialty providers can be trained to successfully implement an evidence-based self-management intervention for depression with frail, high-risk, and diverse older adults.

Investigating Factors that Bias the Reporting of Depression Symptomatology Among Older Australian Adults

OBJECTIVE

To investigate factors that may bias the reporting of major depression symptoms among older adults, specifically the presence of physical conditions, bereavement, episode onset, and episode length.

METHODS

A secondary data analysis of a nationally representative cross-sectional survey of community-dwelling older Australian adults aged 50-85 years who completed the depression module in the 2007 Australian National Survey of Mental Health and Wellbeing (N=629) was conducted. Depression symptomatology was assessed according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, criteria using the World Mental Health Composite International Diagnostic Interview.

RESULTS

Multiple indicators multiple causes modeling indicated a unidimensional factor structure of depression. Two depressive symptoms displayed measurement noninvariance (i.e., nonequivalency): worthlessness/guilt and suicidality/thoughts of death. Specifically, older adults who were bereaved were significantly less likely to report worthlessness/guilt (OR: 0.29; 95% CI: 0.16-0.50) and more likely to report suicidality/thoughts of death (OR: 4.67; 95% CI: 2.84-7.68), compared with older adults who were not bereaved. Examination of latent mean differences revealed that older adults with physical conditions displayed significantly greater depression severity compared with older adults without physical conditions.

CONCLUSION

The presence of physical conditions and episode onset and length do not appear to differentially influence reporting of depression symptoms among older Australian adults, suggesting these factors do not bias prevalence estimates of depression. Reporting of worthlessness/guilt and suicidality/thoughts of death may be biased toward older adults who are bereaved; however, these did not influence overall depression severity.

Validation of the Policy Advocacy Engagement Scale for frontline healthcare professionals

BACKGROUND

Nurses, social workers, and medical residents are ethically mandated to engage in policy advocacy to promote the health and well-being of patients and increase access to care. Yet, no instrument exists to measure their level of engagement in policy advocacy.

RESEARCH OBJECTIVE

To describe the development and validation of the Policy Advocacy Engagement Scale, designed to measure frontline healthcare professionals' engagement in policy advocacy with respect to a broad range of issues, including patients' ethical rights, quality of care, culturally competent care, preventive care, affordability/accessibility of care, mental healthcare, and community-based care.

RESEARCH DESIGN

Cross-sectional data were gathered to estimate the content and construct validity, internal consistency, and test-retest reliability of the Policy Advocacy Engagement Scale. Participants and context: In all, 97 nurses, 94 social workers, and 104 medical residents (N = 295) were recruited from eight acute-care hospitals in Los Angeles County. Ethical considerations: Informed consent was obtained via Qualtrics and covered purposes, risks and benefits; voluntary participation; confidentiality; and compensation. Institutional Review Board approval was obtained from the University of Southern California and all hospitals.

FINDINGS

Results supported the validity of the concept and the instrument. In confirmatory factor analysis, seven items loaded onto one component with indices indicating adequate model fit. A Pearson correlation coefficient of .36 supported the scale's test-retest stability. Cronbach's α of .93 indicated strong internal consistency.

DISCUSSION

The Policy Advocacy Engagement Scale demonstrated satisfactory psychometric properties in this initial test. Findings should be considered within the context of the study's limitations, which include a low response rate and limited geographic scope.

CONCLUSION

The Policy Advocacy Engagement Scale appears to be the first validated scale to measure frontline healthcare professionals' engagement in policy advocacy. With it, researchers can analyze variations in professionals' levels of policy advocacy engagement, understand what factors are associated with it, and remedy barriers that might exist to their provision of it.

Integrated primary care for patients with mental and physical multimorbidity: cluster randomised controlled trial of collaborative care for patients with depression comorbid with diabetes or cardiovascular disease

OBJECTIVE

To test the effectiveness of an integrated collaborative care model for people with depression and long term physical conditions.

DESIGN

Cluster randomised controlled trial.

SETTING

36 general practices in the north west of England.

PARTICIPANTS

387 patients with a record of diabetes or heart disease, or both, who had depressive symptoms (≥ 10 on patient health questionaire-9 (PHQ-9)) for at least two weeks. Mean age was 58.5 (SD 11.7). Participants reported a mean of 6.2 (SD 3.0) long term conditions other than diabetes or heart disease; 240 (62%) were men; 360 (90%) completed the trial.

INTERVENTIONS

Collaborative care included patient preference for behavioural activation, cognitive restructuring, graded exposure, and/or lifestyle advice, management of drug treatment, and prevention of relapse. Up to eight sessions of psychological treatment were delivered by specially trained psychological wellbeing practitioners employed by Improving Access to Psychological Therapy services in the English National Health Service; integration of care was enhanced by two treatment sessions delivered jointly with the practice nurse. Usual care was standard clinical practice provided by general practitioners and practice nurses.

MAIN OUTCOME MEASURES

The primary outcome was reduction in symptoms of depression on the self reported symptom checklist-13 depression scale (SCL-D13) at four months after baseline assessment. Secondary outcomes included anxiety symptoms (generalised anxiety disorder 7), self management (health education impact questionnaire), disability (Sheehan disability scale), and global quality of life (WHOQOL-BREF).

RESULTS

19 general practices were randomised to collaborative care and 20 to usual care; three practices withdrew from the trial before patients were recruited. 191 patients were recruited from practices allocated to collaborative care, and 196 from practices allocated to usual care. After adjustment for baseline depression score, mean depressive scores were 0.23 SCL-D13 points lower (95% confidence interval -0.41 to -0.05) in the collaborative care arm, equal to an adjusted standardised effect size of 0.30. Patients in the intervention arm also reported being better self managers, rated their care as more patient centred, and were more satisfied with their care. There were no significant differences between groups in quality of life, disease specific quality of life, self efficacy, disability, and social support.

CONCLUSIONS

Collaborative care that incorporates brief low intensity psychological therapy delivered in partnership with practice nurses in primary care can reduce depression and improve self management of chronic disease in people with mental and physical multimorbidity. The size of the treatment effects were modest and were less than the prespecified effect but were achieved in a trial run in routine settings with a deprived population with high levels of mental and physical multimorbidity.

TRIAL REGISTRATION

ISRCTN80309252.

Rationale and Methods of a Trial to Evaluate a Depression Telemonitoring Program that Includes a Patient-Selected Support Person

OBJECTIVE

To test the effectiveness of an automated telemonitoring program for patients with depression that includes feedback to clinicians and support for a family member or friend serving as a non-professional caregiver.

METHODS

Prior to being randomized to receive one year of either the Care Partners for Depression (CP-D) intervention or usual care alone, depressed patients from primary care clinics serving primarily low-income populations in rural and urban Michigan select a supportive adult from outside their home (their "Care Partner;" CP) to assist them in their depression self-management. In the CP-D arm, patients receive weekly automated telephone calls that provide monitoring and self-management guidance, CPs receive emailed guidance on supporting the patient's self-management based on patient-reported information, and primary care providers receive notifications about any urgent issues. At Baseline, Month 6, and Month 12, we assess depressive symptom severity (primary outcome) and several secondary outcomes.

CONCLUSION

To date, this is the only mHealth intervention for any psychiatric condition that involves a patient-selected support person. If it proves effective and cost-efficient, a new sustainable intervention would be available to patients with significant depressive symptoms, providing new management alternatives for patients who are medically underserved or socially isolated.

Risk factors for incidence and persistence of disability in chronic major depression and alcohol use disorders: longitudinal analyses of a population-based study

BACKGROUND

Major depression and alcohol use disorders are risk factors for incidence of disability. However, it is still unclear whether a chronic course of these health conditions is also prospectively associated with incidence of disability. The aim of the present study was, first, to confirm whether chronic major depression (MD) and alcohol use disorders (AUD) are, respectively, risk factors for persistence and incidence of disability in the general population; and then to analyze the role of help-seeking behavior in the course of disability among respondents with chronic MD and chronic AUD.

METHOD

Data from two assessments in the National Epidemiologic Survey on Alcohol and Related Conditions were analyzed. Disability was measured by eight domains of the Short Form 12 Health Survey version 2 (SF-12). Generalized estimating equations and logistic regression models were run to estimate risk factors for persistence and incidence of disability, respectively.

RESULTS

Analyses conducted on data from the US general population showed that chronic MD was the strongest risk factor for incidence and persistence of disability in the social functioning, emotional role and mental health domains. Chronic AUD were risk factors for incidence and persistence of disability in the vitality, social functioning, and emotional role domains. Within the group of chronic MD, physical comorbidity and help-seeking were associated with persistent disability in most of the SF-12 domains. Help-seeking behavior was also associated with incidence of problems in the mental health domain for the depression group. Regarding the AUD group, comorbidity with physical health problems was a strong risk factor for persistence of disability in all SF-12 domains. Help-seeking behavior was not related to either persistence or incidence of disability in the chronic alcohol group.

CONCLUSIONS

Chronic MD and chronic AUD are independent risk factors for persistence and incidence of disability in the US general population. People with chronic MD seek help for their problems when they experience persistent disability, whereas people with chronic AUD might not seek any help even if they are suffering from persistent disability.

Differences in quality of life outcomes among depressed spinal cord injury trial participants

OBJECTIVE

To assess the role that treatment response plays in a randomized controlled trial of an antidepressant among people with spinal cord injury (SCI) diagnosed with major depressive disorder (MDD) in explaining quality of life (QOL), assessed both globally as life satisfaction and in terms of physical and mental health-related QOL.

DESIGN

Multivariable analyses were conducted, controlling for demographic, neurologic, and participatory factors and perceived functional limitations.

SETTING

Rehabilitation centers.

PARTICIPANTS

Of the 133 persons who were randomized into the Project to Improve Symptoms and Mood after Spinal Cord Injury randomized controlled trial, 124 participated in this study. All participants were between the ages of 18 and 64 years, at least 1 month post-SCI, met the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, criteria for MDD, and completed the core measures used in this study.

INTERVENTIONS

Not applicable.

MAIN OUTCOME MEASURES

The Satisfaction with Life Scale and the physical and mental component summary scores of the Medical Outcomes Study 12-Item Short-Form Health Survey.

RESULTS

Reduction in depressive symptoms over the course of a 12-week trial was predictive of increased QOL, which was measured as life satisfaction and mental well-being, within the context of other explanatory factors. However, reduction in symptoms did not explain differences in physical well-being among those with MDD. Perceived functional disability explained all 3 indices of QOL.

CONCLUSIONS

Greater recognition has been given to QOL outcomes as endpoints of clinical trials because these often reflect participants' reported outcomes. Our findings support the association of QOL to the reduction of depression symptoms among trial participants. This association differs depending on how QOL is defined and measured, with stronger relations observed with life satisfaction and mental well-being among those diagnosed with MDD. The lack of association between depression and physical well-being may be explained by participants' subjective interpretation of physical well-being after SCI and their expectations and perceptions of improved physical health-related QOL based on the use of assistive technology. Consistent with our findings, pain is likely to play a role in decreasing physical QOL among those with incomplete injuries. Practicing caution is suggested in using physical well-being as an endpoint in trials among people with SCI.

Improving care for depression in obstetrics and gynecology: a randomized controlled trial

OBJECTIVE

To evaluate an evidence-based collaborative depression care intervention adapted to obstetrics and gynecology clinics compared with usual care.

METHODS

A two-site, randomized controlled trial included screen-positive women (Patient Health Questionnaire-9 score of at least 10) who met criteria for major depression, dysthymia, or both (Mini-International Neuropsychiatric Interview). Women were randomized to 12 months of collaborative depression management or usual care; 6-month, 12-month, and 18-month outcomes were compared. The primary outcomes were change from baseline to 12 months in depression symptoms and functional status. Secondary outcomes included at least 50% decrease and remission in depressive symptoms, global improvement, treatment satisfaction, and quality of care.

RESULTS

Participants were, on average, 39 years old, 44% were nonwhite, and 56% had posttraumatic stress disorder. Intervention (n=102) compared with usual care (n=103) patients had greater improvement in depressive symptoms at 12 months (P<.001) and 18 months (P=.004). The intervention group compared with usual care group had improved functioning over the course of 18 months (P<.05), were more likely to have at least 50% decrease in depressive symptoms at 12 months (relative risk [RR] 1.74, 95% confidence interval [CI] 1.11-2.73), greater likelihood of at least four specialty mental health visits (6-month RR 2.70, 95% CI 1.73-4.20; 12-month RR 2.53, 95% CI 1.63-3.94), adequate dose of antidepressant (6-month RR 1.64, 95% CI 1.03-2.60; 12-month RR 1.71, 95% CI 1.08-2.73), and greater satisfaction with care (6-month RR 1.70, 95% CI 1.19-2.44; 12-month RR 2.26, 95% CI 1.52-3.36).

CONCLUSION

Collaborative depression care adapted to women's health settings improved depressive and functional outcomes and quality of depression care.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, www.clinicaltrials.gov, NCT01096316.

LEVEL OF EVIDENCE

I.

Improving depression treatment for women: integrating a collaborative care depression intervention into OB-GYN care

BACKGROUND

Women have higher rates of depression and often experience depression symptoms during critical reproductive periods, including adolescence, pregnancy, postpartum, and menopause. Collaborative care intervention models for mood disorders in patients receiving care in an OB-GYN clinic setting have not been evaluated. Study design and methodology for a randomized controlled trial of collaborative care depression management versus usual care in OB-GYN clinics and the details of the adapted collaborative care intervention and model implementation are described in this paper.

METHODS

Women over age 18 years with clinically significant symptoms of depression, as measured by a Patient Health Questionnaire-9 (PHQ-9) score ≥10 and a clinical diagnosis of major depression or dysthymia, were randomized to the study intervention or to usual care and were followed for 18 months. The primary outcome assessed was change over time in the SCL-20 depression scale between baseline and 12 months.

BASELINE RESULTS

Two hundred five women were randomized: 57% white, 20% African American, 9% Asian or Pacific Islander, 7% Hispanic, and 6% Native American. Mean age was 39 years. 4.6% were pregnant and 7.5% were within 12 months postpartum. The majority were single (52%), and 95% had at least the equivalent of a high school diploma. Almost all patients met DSM IV criteria for major depression (99%) and approximately 33% met criteria for dysthymia.

CONCLUSIONS

An OB-GYN collaborative care team, including a social worker, a psychiatrist, and an OB-GYN physician, who met weekly and used an electronic tracking system for patients was the essential element of the proposed depression care treatment model described here. Further study of models that improve quality of depression care that are adapted to the unique OB-GYN setting is needed.

The use and performance of productivity scales to evaluate presenteeism in mood disorders

OBJECTIVE

Mood disorders are associated with a high societal cost, mainly due to presenteeism. The objective of this study was to review the use of 10 instruments that rate presenteeism in mood disorders and to provide recommendations regarding the appropriateness of instruments in different study settings.

METHODS

A systematic review of the literature was conducted to identify scales used to measure presenteeism, including the World Health Organization Health and Work Performance Questionnaire, the Lam Employment Absence and Productivity Scale, the Sheehan Disability Scale, the Work Limitation Questionnaire, and Work Productivity and Activity Impairment questionnaire. Study characteristics and major results (by symptom level, by treatment arm, correlation to other scales, and use of monetization) were data extracted.

RESULTS

Twenty-nine studies were identified. The Sheehan Disability Scale, the Work Limitation Questionnaire, and Health and Work Performance Questionnaire were the most commonly used instruments. The majority (60%) of scales demonstrated higher presenteeism in individuals with mood disorders than in individuals without. The Lam Employment Absence and Productivity Scale, the Sheehan Disability Scale, and the Work Limitation Questionnaire showed that presenteeism increased with increasing severity of disease. Few studies reported results on presenteeism by treatment, with only small between-treatment differences observed. Good correlations between presenteeism instruments and clinical or quality-of-life scales were reported. Three studies converted results from presenteeism scales into monetary units.

CONCLUSIONS

Limited experiential evidence exists comparing the performance of presenteeism scales in mood disorders. Therefore, recommendations for inclusion of a presenteeism tool must be driven by instrument properties (ease of administration, amenability to monetization) and the study type. Future research should focus on the responsiveness of the instrument and on how mood disorders impact self-reported assessment.

Development of the Global Disability Scale (Glo.Di.S): preliminary results

BACKGROUND

The assessment of functioning and disability is an important part of the clinical evaluation, since it measures disease burden and reflects the effectiveness of therapeutic planning and interventions. The aim of the current study was to develop such a self-report instrument on the basis of a review of the literature, and compatible with the WHO approach.

MATERIAL AND METHODS

The review of the literature led to the development of the Global Disability Scale (Glo.Di.S) with 25 items assessing different aspects of disability. The study sample included 728 persons from vulnerable populations (homeless, jobless, very low income, single parent families etc.; (29.12% males and 70.88% females; aged 55.96 ± 15.22 years). The protocol included also the STAI and the CES-D. The statistical analysis included factor analysis item analysis and ANCOVA.

RESULTS

The factor analysis revealed the presence of 4 factors explaining 71% of total variance (Everyday functioning, Social and interpersonal functioning, Severity and Mental disability). Chronbach's alpha for the whole scale was 0.95 and for subscales were 0.74-0.94.

DISCUSSION

The results of the current study suggest that the Glo.Di.S. has the potential to serve as a reliable and valid tool for assessing functioning and disability. Further research is needed to prove that it could be useful across countries, populations and diseases, and whether it provides data that are culturally meaningful and comparable. It can be used in surveys and in clinical research settings and it can generate information of use in evaluating health needs and the effectiveness of interventions to reduce disability and improve health.

Implementation of the veterans health administration national pain management strategy

Since its introduction in 1998, the VHA National Pain Management Strategy has introduced and implemented a series of plans for promoting systems improvements in pain care. We present the milestones of VHA efforts in pain management as reflected by the work of the Strategy. This includes the development of the Strategy and its current structure as well as a review of important initiatives such as "pain as the fifth vital sign" and the stepped care model of pain management.

Long-term effectiveness of collaborative depression care in older primary care patients with and without PTSD symptoms

OBJECTIVE

Depressed patients with comorbid post-traumatic stress disorder (PTSD) are more functionally impaired and may take longer to respond to depression treatment than patients without PTSD. This study examined the long-term effects of PTSD on depression severity, treatment response, and health care costs among older adults.

METHODS

Patients were recruited from 18 primary care clinics in five states. A total of 1801 patients aged 60 years or older with major depression or dysthymia were randomized to Improving Mood Promoting Access to Collaborative Treatment (IMPACT) collaborative care or usual care. The study included 191 (10.6%) subjects who screened positive for PTSD. Depression severity, assessed by the Hopkins Depression Symptom Checklist, was used to estimate depression-free days (DFDs) over 24 months. Total health care costs included inpatient, outpatient, and pharmacy costs.

RESULTS

Depressed patients with PTSD had higher depression severity than patients without PTSD symptoms at baseline. Over 2 years, intervention patients with PTSD symptoms had relatively the same benefits from collaborative care (99 more DFDs than usual care patients) as patients without PTSD (108 more DFDs than usual care) (p = 0.85). Total health care costs did not differ significantly for depressed patients with and without PTSD symptoms.

CONCLUSION

Depressed older adults with PTSD symptoms were more depressed at baseline, but collaborative care (compared to usual care) produced similar improvements in depression severity in both groups. This reduction of depression symptoms was observed for up to 12 months after the intervention ended, suggesting that long-term improvements in depression are possible with collaborative care in patients with and without PTSD symptoms.

Progress monitoring and feedback in psychiatric care reduces depressive symptoms

BACKGROUND

To date, the monitoring of patient progress using standardized assessments has been neglected in hospital-based psychiatric care. Findings in outpatient psychotherapy have demonstrated clinically significant benefits for providing feedback to the sizeable minority of patients who were otherwise unlikely to experience positive outcome (Lambert, 2007). However, a similar system for presenting feedback on patient progress has not yet been assessed for group therapy within psychiatric inpatient settings. The current study aimed to develop and evaluate the effectiveness of a feedback system suitable for use in psychiatric services.

METHODS

In a nonrandomized trial, 1308 consecutive inpatients and day patients, whose diagnoses were primarily depressive and anxiety disorders, completed the World Health Organization's Wellbeing Index (WHO-5) routinely during a ten-day cognitive behavioral therapy group. The first cohort (n=461) received treatment as usual. The second cohort (n=439) completed monitoring measures without feedback, and for patients in the third cohort (n=408), feedback on progress was provided to both clinicians and patients midway through the treatment period.

RESULTS

Feedback was effective in reducing depressive symptoms (F(1,649)=6.29, p<.05) for those patients at risk of poor outcome, but not effective in improving wellbeing (F(1,569)=1.14, p>.05).

LIMITATIONS

The current findings may be generalized to patient samples that exhibit largely depressive disorders, however rigorous follow-up is warranted.

CONCLUSIONS

Similar to outpatient settings, feedback appears to be beneficial for improving symptom outcomes but further time may be required for wellbeing to be affected.

[Major depression in primary care and clinical impacts of treatment strategies: a literature review]

Major or clinical depression represents a frequent mental illness that is often associated with a high level of morbidity and mortality. Yet, major depression remains under-diagnosed and under-treated. On the level of treatment, it would appear desirable for reasons of better prognosis, to aim more than the simple reduction of depressive symptoms and target their remission resolutely and the fastest return to the individual's optimal functioning. This article presents a systematic review of the literature relating to the clinical impacts of treatment strategies aiming at the improvement of services offered to people who suffer of clinical depression and who consult in primary care. The authors summarize results drawn from 41 studies that include a measurement of the clinical impacts (reduction of symptoms, response, remission and functioning) of various treatment strategies. It appears that using complex treatment strategies favour positive outcomes. The authors propose various paths of research to further increase current knowledge.

Depression and occupational disability in five diagnostic groups: A review of recent research

PURPOSE

To compare the methodologies and results of research across five diagnostic groups in which there was expected to be a high prevalence of depression and occupational disability.

METHOD

A review of research published since 1994 was carried out concerning depression and occupational disability in five diagnostic groups: Major depressive disorder (MDD), spinal cord injuries (SCI), traumatic brain injuries (TBI), chronic back pain (CP) and myocardial infarction/coronary artery bypass grafting (MI/CABG).

RESULTS

Prospective longitudinal designs were mostly undertaken in MDD studies. Diagnostic interview schedules were utilized in most MDD studies whereas self-report inventories that tend to confound somatic and depressive symptoms were mostly used in CP, SCI, TBI and MI/CABG studies. In longitudinal MDD studies both depression and occupational disability were related to access to enhanced primary care treatment. On the other hand, CP research reported different results concerning the strength of depressive symptoms, cognitive and psychosocial factors in predicting occupational disability. Different trends across diagnostic groups were evident in relation to depression, occupational disability, co-morbidity, socio-demographic factors and psychosocial resources.

CONCLUSIONS

Co-morbid, socio-demographic and psychosocial factors provide a framework from which to identify those at greater risk of depression and occupational disability. However, more CP, SCI, TBI and MI/CABG studies with diagnostic schedules, prospective designs and longer follow-up are required.

Persistent depression and anxiety in the United States: prevalence and quality of care

OBJECTIVE

Although effective treatments exist, individuals with depressive and anxiety disorders can remain ill for years. Little is known regarding mental health status and treatment use in this population. This study provided national estimates of the prevalence of persistent depression and anxiety, as well as estimates of illness severity, treatment use, and quality of care in this population.

METHODS

Data were from a prospective, community-based cohort study of 1,642 adults with probable major depression, dysthymia, panic disorder, or generalized anxiety disorder who were part of a U.S. probability sample. Telephone surveys were conducted during 1997-1998 and again an average of 32 months later. Surveys assessed diagnosis, quality of life, treatment satisfaction, medical conditions, suicidal ideation, insurance, medications, and treatment use.

RESULTS

At follow-up, 59% no longer met criteria for a disorder. The estimated national prevalence of a persistent depressive or anxiety disorder was 4.7%. In this subgroup, 87% had a chronic comorbid medical disorder. During the past year, 88% had seen a primary care practitioner, and 22% had seen a mental health specialist. Between baseline and follow-up, the percentage using appropriate medication increased (21% to 29%), but there was no significant change in use of appropriate counseling (23% to 19%). Only 12% were receiving both appropriate medication and counseling at follow-up. Treatment was less likely for men and people with less education. Suicidal ideation was present in 51% at follow-up.

CONCLUSIONS

Strategies are needed to increase treatment use and intensity for people with persistent depressive and anxiety disorders. This may require improved access to mental health specialists.

Disability from depression: the public health challenge to primary care

Epidemiologists have identified that depression will soon be the leading cause of disability throughout the world. To inform public health campaigns to reduce this problem, this paper summarizes current scientific knowledge about optimizing the potential of primary care settings to reduce disability by providing effective treatment for depression. To meet this challenge, primary care practices need to be re-engineered: 1) to conduct systematic screening programs to identify depressed patients, 2) to provide depressed patients initial evidence-based treatment, and 3) to monitor treatment adherence and symptom response in treated patients over 2 years. While additional research is needed in developing countries, preliminary evidence indicates that primary care practices re-engineered to improve depression management can make a substantial contribution to reducing depression-associated disability.

Improving efficiency and access to mental health care: combining integrated care and advanced access

OBJECTIVE

To provide an example of implementation of a new program that enhances access to mental health care in primary care.

METHOD

A general and specialized mental health service was redesigned to introduce open access to comprehensive mental health care in a primary care clinic. Key variables measured before and after implementation of the clinic included numbers of completed referrals, waiting time for appointments and clinic productivity. Workload and pre/post-implementation waiting time data were gathered through a computerized electronic monitoring system.

RESULTS

Waiting time for new appointments was shortened from a mean of 33 days to 19 min. Clinician productivity and evaluations of new referrals more than doubled. These improvements have been sustained for 4 years.

CONCLUSION

Moving mental health services into primary care, initiating open access and increasing use of technological aids led to dramatic improvements in access to mental health care and efficient use of resources. Implementation and sustainability of the program were enhanced by using a quality improvement approach.

Finding the ideal place for a psychotherapeutic intervention in a stepped care approach--a brief overview of the literature and preliminary results from the Project PREDICT

AIMS

To provide an overview over empirical evidence regarding stepped care approaches that include psychotherapies. To present own preliminary study results in alcohol dependent patients.

METHODS

Publications were searched in the databases Medline, PsycINFO and the internet search engine Google Scholar. Inclusion criteria were psychosocial treatment and psychiatric disorders. Our own study consists of two steps. In step 1 patients receive anti-craving medication or placebo and Medical Management (MM). After a relapse to heavy drinking patients can step up and after randomization they either continue with the same treatment or they receive additional alcoholism specific psychotherapy (ASP).

RESULTS

Evidence suggests that stepped care might be efficacious in patients with obsessive-compulsive behavior and depression. There is no evidence for efficacy in problem drinkers. Results of our own study show that the completer rate in MM alone is higher than in ASP with MM, but there are no significant differences concerning age, sex and disease severity between completer and non-completer in both study arms.

CONCLUSIONS

Further research with regard to stepped care in alcohol dependent patients is needed. An introduction of the psychotherapy at earlier stages might be sensible.

Building an evidence base on mental health interventions for children affected by armed conflict

This paper reviews what is currently known from research about the effectiveness of interventions to address mental health problems in children and adolescents affected by armed conflict. The focus will be on interventions delivered in conflict affected countries either during active humanitarian emergencies or during the post conflict period. The paper will discuss two main paradigms of intervention dominating the field: psychosocial approaches and clinical/psychiatric approaches. The paper reviews some of the basic literature, theories and issues involved in assessment, programme planning, monitoring and evaluation of both approaches. In order to explore these issues in depth, the paper will draw from the author's field experiences with research in the Russian Federation and in northern Uganda. The paper also presents a brief review of a handful of other published evaluations of mental health interventions for war affected children. We will close with a discussion of what future research is needed to build an evidence base regarding mental health interventions for children affected by armed conflict as well as the ethical and feasibility issues associated with carrying out this work.

Major depression in individuals with chronic medical disorders: prevalence, correlates and association with health resource utilization, lost productivity and functional disability

OBJECTIVE

The objective of this study was to determine the prevalence and odds of major depression and the incremental effect of major depression on utilization, lost productivity and functional disability in individuals with common chronic medical disorders.

METHOD

Data on 30,801 adults from the 1999 National Health Interview Survey were analyzed. The 12-month prevalence and age/sex-adjusted odds of major depression were calculated for adults with hypertension (HTN), diabetes mellitus (DM), coronary artery disease (CAD), congestive heart failure (CHF), stroke or cerebrovascular accident (CVA), chronic obstructive pulmonary disease (COPD) and end-stage renal disease (ESRD). The association between chronic condition status (with and without major depression) and utilization, lost productivity and functional disability was determined by controlling for covariates.

RESULTS

The 12-month prevalence and age/sex-adjusted odds of major depression by chronic conditions were as follows: CHF, 7.9% [odds ratio (OR)=1.96]; HTN, 8.0% (OR=2.00); DM, 9.3% (OR=1.96); CAD, 9.3% (OR=2.30); CVA, 11.4% (OR=3.15); COPD, 15.4% (OR=3.21); ESRD, 17.0% (OR=3.56); any chronic condition, 8.8% (OR=2.61). Compared to adults without chronic conditions, those with chronic conditions plus major depression had greater odds of > or = 1 ambulatory visit [OR=1.50; 95% confidence interval (95% CI)=1.28, 1.77]; > or = 1 emergency room visit (OR=1.94; 95% CI=1.55, 2.45); and > or = 1 day in bed due to illness (OR=1.60; 95% CI=1.28, 2.00); and functional disability (OR=2.48; 95% CI=1.96, 3.15).

CONCLUSION

The 12-month prevalence and odds of major depression are high in individuals with chronic medical conditions, and major depression is associated with significant increases in utilization, lost productivity and functional disability.

Improving quality of care for mental illness in an uninsured, low-income primary care population

OBJECTIVE

We assessed if an ongoing, multifaceted quality improvement program improved mental health care in a low-income, uninsured primary care clinic.

METHODS

We reviewed the charts of 500 consecutive patients in 1999 and 500 consecutive patients in 2004 to compare the number of mental health visits; the percentage of patients with more than three follow-up visits; the percentage with > or = 1 visit with a prescribing provider and the percentage with a psychiatric medication prescribed. We also assessed whether patients with more than one charted mental illness received more care than patients with one mental illness.

RESULTS

Compared to 1999, patients in 2004 had significantly more visits in the first 120 days (acute phase) of treatment (3.16 vs. 4.81, P<.001) and more visits in up to 9 months post acute phase (3.76 vs. 4.88, P>.012). A higher percentage of patients in the acute phase (28.9% vs. 49.5%, P<.001) had three follow-up visits, saw a medical provider and received a prescription. Patients with multiple charted mental illnesses had more visits than patients with one mental illness in 2004 but not in 1999 (P<.001).

CONCLUSIONS

An ongoing, multifaceted intervention improved the quality of mental health care in a primary care population with a high prevalence of mental illness.

PTSD in urban primary care: high prevalence and low physician recognition

BACKGROUND

Posttraumatic stress disorder (PTSD) is associated with medical and psychological morbidity. The prevalence of PTSD in urban primary care has not been well described.

OBJECTIVE

To measure the prevalence of PTSD in primary care patients overall and among those with selected conditions (chronic pain, depression, anxiety, heavy drinking, substance dependence (SD), irritable bowel syndrome (IBS), and immigrant status).

DESIGN

Cross-sectional study.

PARTICIPANTS

English-speaking patients aged 18-65 years old, awaiting primary care appointments in an urban academic medical center, were eligible for enrollment to determine PTSD prevalence (N = 509). Additional eligible participants (n = 98) with IBS or SD were subsequently enrolled.

MEASUREMENTS

PTSD (past year) and trauma exposure were measured with Composite International Diagnostic Interview. We calculated the prevalence of PTSD associated with depression, anxiety, heavy drinking, SD, IBS, and chronic pain. Only the analyses on heavy drinking, SD, and IBS used all 607 participants.

RESULTS

Among the 509 adults in primary care, 23% (95% CI, 19-26%) had PTSD, of whom 11% had it noted in the medical record. The prevalence of PTSD, adjusted for age, gender, race, and marital and socioeconomic statuses, was higher in participants with, compared to those without, the following conditions: chronic pain (23 vs 12%, p = .003), major depression (35 vs 11%, p < .0001), anxiety disorders (42 vs 14%, p < .0001), and IBS (34 vs 18%, p = .01) and lower in immigrants (13 vs 21%, p = .05).

CONCLUSIONS

The prevalence of PTSD in the urban primary care setting, and particularly among certain high-risk conditions, compels a critical examination of optimal approaches for screening, intervention, and referral to PTSD treatment.

Comorbid depression and health-related quality of life in patients with coronary artery disease

OBJECTIVE

This article reviews recent studies relating to the impact of depression and its treatment on the health-related quality of life (HRQOL) of patients with coronary artery disease (CAD).

METHODS

Articles for the primary review were identified via MEDLINE and PsycINFO (1995-2006).

RESULTS

Evidence suggests that depression has an aversive impact on the HRQOL of patients with stable CAD as well as on patients hospitalized for acute myocardial infarction and coronary artery bypass graft surgery. Unfortunately, there are few depression treatment studies in patients with CAD that make use of standardized HRQOL measures, but the limited evidence suggests that successful treatment has positive implications for HRQOL in these patients. The mechanisms through which depression impacts on HRQOL require further study but are likely to be behavioral.

CONCLUSIONS

Depressive symptoms significantly undermine HRQOL in patients with CAD despite successful medical and surgical management. Although successful treatment of depression has not been shown to reduce mortality rates in patients with CAD, further study may find that the HRQOL benefits of such treatment are equally valuable.

Systematic review of multifaceted interventions to improve depression care

OBJECTIVE

Depression is a prevalent high-impact illness with poor outcomes in primary care settings. We performed a systematic review to determine to what extent multifaceted interventions improve depression outcomes in primary care and to define key elements, patients who are likely to benefit and resources required for these interventions.

METHOD

We searched Medline, HealthSTAR, CINAHL, PsycINFO and a specialized registry of depression trials from 1966 to February 2006; reviewed bibliographies of pertinent articles; and consulted experts. Searches were limited to the English language. We included 28 randomized controlled trials that: (a) involved primary care patients receiving acute-phase treatment; (b) tested a multicomponent intervention involving a patient-directed component; and (c) reported effects on depression severity. Pairs of investigators independently abstracted information regarding (a) setting and subjects, (b) components of the intervention and (c) outcomes.

RESULTS

Twenty of 28 interventions improved depression outcomes over 3-12 months (an 18.4% median absolute increase in patients with 50% improvement in symptoms; range, 8.3-46%). Sustained improvements at 24-57 months were demonstrated in three studies addressing acute-phase and continuation-phase treatments. All interventions involved care management and required additional resources or staff reassignment to implement; interventions were delivered exclusively or predominantly by telephone in 16 studies. The most commonly used intervention features were: patient education and self-management, monitoring of depressive symptoms and treatment adherence, decision support for medication management, a patient registry and mental health supervision of care managers. Other intervention features were highly variable.

CONCLUSION

There is strong evidence supporting the short-term benefits of care management for depression; critical elements for successful programs are emerging.

[Perception of quality of life and social adjustment of patients with recurrent depression]

INTRODUCTION

Depression is the most commonly present psychiatric entity in clinical practice, accompanied by significant impairment of both social and professional functioning. In addition, depression frequently develops as complication of other psychiatric disorders and various somatic diseases.

OBJECTIVE

To investigate subjective perception of quality of life and social adjustment, severity of depressive symptoms as well as level of correlation of severity of depressive symptoms and quality of life and social adjustment of patients with recurrent depression in comparison to the group of patients with diabetes and healthy subjects.

METHOD

The study included 45 subjects of both sexes, ranging from 18 to 60 years of age, divided in three groups of 15 subjects each. The experimental group comprised the patients diagnosed with recurrent depression in remission (DSM-IV), one control group was consisted of patients diagnosed with Type 2 Diabetes mellitus and another one comprised healthy subjects. The instruments of assessment were: The Beck Depression Inventory-BDI, The Social Adaptation Self -evaluation scale -SASS, The Psychological General Well-Being Scale-WBQ. RESULTS Significant difference of both BDI and WBQ scales was found between the experimental and the control group of healthy subjects (ANOVA, Mann Whitney; p < 0.01), as well as between two control groups (p < or = 0.02). The level of inverse correlation of mean score values of BDI and SASS scales was significant in the control group of patients with diabetes while such levels of BDI and WBQ scales (Spearman correlation coefficient, p < 0.01) were found in all groups of our study.

CONCLUSION

In the group of patients with recurrent depression, significant decline of quality of life and significantly higher severity of depressive symptoms were present in comparison to the group of healthy subjects as well as significant level of inverse correlation of severity of depressive symptoms and quality of life.

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.

Inadequate follow-up care for depression and its impact on antidepressant treatment duration among veterans with and without diabetes mellitus in the Veterans Health Administration

OBJECTIVE

Our objective was to describe the adequacy of follow-up care for depression and its association with antidepressant treatment duration among veterans with and without diabetes mellitus (DM).

METHOD

This was a retrospective study (1997-2005) of 2178 veterans (33% with DM) in a Midwestern Veterans Health Administration facility who had a new episode of unipolar depression. Adequate follow-up care was defined by a health care visit within 7 and 14 days, and >/=3 visits following antidepressant treatment initiation. Adequate treatment duration was defined by a medication possession ratio of >/=80%. Multivariate logistic regression was used to calculate odds ratios (ORs) adjusted for demographic, clinical and health care utilization characteristics.

RESULTS

Only 27% received >/=3 follow-up visits within 12 weeks, and <23% received follow-up within 2 weeks of antidepressant initiation. Subjects with DM were 1.36-fold more likely [95% confidence interval (95% CI)=1.05-1.75] to have received >/=3 visits but were similarly likely to have received follow-up within 7 days (OR=1.02; 95% CI=0.74-1.41) or 14 days (OR=1.08; 95% CI=0.83-1.40) of antidepressant initiation. Adequate follow-up care was the most important predictor of adequate treatment duration (OR=2.10; 95% CI=1.54-2.88).

CONCLUSION

DM had little influence on the adequacy of follow-up care for depression, with few exceptions. Follow-up care for depression is underutilized and has a significant impact on antidepressant treatment duration. Strategies to more effectively manage depression treatment are required.

Cognitive behavioural therapy increases re-employment of job seeking worker's compensation clients

INTRODUCTION

The aim of this study was to determine whether cognitive behavioural therapy (CBT) would enhance employment outcomes in worker's compensation clients who were seeking employment.

METHODS

Participants were randomly assigned to a standard job search assistance group that met for 4 hours/week for four weeks, or to a group that received standard job search assistance for 4 hours/week for the first two weeks and CBT for 4 hours/week for the next two weeks. Depression, Anxiety and Stress scores were measured prior to and on completion of the intervention, and employment outcomes were assessed at four- and ten-week follow-up.

RESULTS

Affective states decreased and employment was found more rapidly after CBT than after standard job search assistance.

CONCLUSION

These findings indicate that CBT has a useful role in the rehabilitation of people on worker's compensation who are seeking employment.

Cognitive impairment and depression outcomes in the IMPACT study

INTRODUCTION

It is unclear whether cognitive impairment affects acute and long-term treatment response in geriatric depression. In addition, little is known about the long-term outcome of depression among older individuals who experience cognitive decline during a course of treatment for depression. The authors examined both of these issues using data from the IMPACT trial.

METHODS

The sample consisted of 1,684 participants in the IMPACT study who had baseline and two-year follow-up data. Subjects were randomized to one year of active intervention with a depression care manager or usual care. After one year, all subjects had usual care for another year. Data were collected for two years. The authors used the Six-Item Cognitive Screener to examine acute and long-term effects on depression outcome of baseline cognitive impairment and of cognitive decline. Depression measures included the HSCL-20 and an estimation of depression-free days. Outcomes were determined using both linear regression and repeated-measures analyses.

RESULTS

Depressed subjects in the active intervention group had better depression outcomes at one year regardless of baseline cognitive impairment. Cognitively impaired subjects within each treatment group had similar outcomes to subjects without cognitive impairment. Subjects who experienced decline in cognitive score over two years had worse 24-month depression outcomes compared with subjects whose cognitive score did not change.

CONCLUSIONS

Cognitively impaired depressed patients can experience significant improvement in depression with appropriate acute and continuation-phase management. Older depressed adults experiencing ongoing cognitive decline may be at higher risk for poor depression outcomes and may require more careful clinical monitoring and management of both cognitive and affective symptoms.

How Much Does Quality Mental Health Care Profit Employers?

OBJECTIVE

Employers provide most American mental health benefits and are increasingly cost conscious. However, commonplace anxiety and depressive disorders have enormous economic and workplace performance costs.

METHODS

We performed multiple literature searches on several areas of pertinent research (and on key articles) covering the past 5 years.

RESULTS

Substantial research exists about anxiety and depression costs, such as performance and productivity, absenteeism, presenteeism, disability, physical disability exacerbation, mental health treatment, increased medical care costs, exacerbating of physical illness, and studies of mental health care limitations and cost-offset. Research addressing the potential value of higher quality mental health care is limited.

CONCLUSIONS

Commonplace anxiety and depressive disorders are costly in the workplace. Employers and researchers remain largely unaware of the value of quality care and psychiatric skills. Effective solutions involve the increased use of psychiatric skills and appropriate treatment.

The influence of patient preference on depression treatment in primary care

BACKGROUND

The chronic illness model encourages consideration of patients' treatment preferences. Moreover, research suggests that matching treatment to preference might affect outcomes for patients with depression.

PURPOSE

This investigation explored factors associated with treatment preference matching and the effects of matching on depression treatment outcomes.

METHODS

Treatment preferences were assessed among primary care patients with depression participating in a large randomized trial of depression management. Patients were offered antidepressant medication and/or counseling based on preference and several other factors. Depression was assessed at 3 and 9 months.

RESULTS

Participants who preferred medication were older, were in worse physical health, and were more likely to already be taking antidepressants. Participants who preferred both medication and counseling evidenced greater agreement with the statement that depression is a medical illness. Overall, 72% of participants were matched with their preferred treatment; matched participants demonstrated more rapid improvement in depression symptomatology than unmatched participants.

CONCLUSIONS

Obtaining preferred treatment appears to contribute to improved treatment outcome. Continued attempts to assess for and accommodate treatment preferences might result in better response to depression treatment.

Depression and early retirement: prospective population based study in middle aged men

BACKGROUND

Mental depression is an important health problem in many countries. It reduces productivity at work and is the fastest increasing reason for early retirement.

METHODS

This study followed up a Finnish cohort of 1726 men from 1984 to 2000. Depression was assessed at baseline by HPL depression score. Pension records were obtained from the national pension registers. Cox's regression analysis was used to estimate the associations of depression with the risk of all disability pensions combined, separately for different causes of disability, and non-illness based pension.

RESULTS

During the follow up, 839 men (48.6%) received a disability pension. A total of 142 men (16.9% of all disability pensions) retired because of mental disorder and of these, 75 (52.8%) because of depression. After adjustment for the potential confounders, men in the highest third of depression score had an increased risk of non-illness based pension (RR 1.86 95% CI 1.37 to 2.51) and disability pension attributable to mental disorders (RR 2.74, 95% CI 1.68 to 4.46), chronic somatic diseases (RR 1.68, 95% CI 1.05 to 2.71), cardiovascular diseases (RR 1.61, 95% CI 1.12 to 2.32). The mean age of retirement for men with a high and low depression score was 57.6 years (SD 3.87) and 59.1 years (SD 3.65) (p<0.001) respectively.

CONCLUSIONS

A high depression score predicted disability attributable to any cause, especially mental disorders, and non-illness based pensions. Depressed people retired on average 1.5 years younger than those without depression. Further studies are needed to elucidate the pathways of how mental depression leads people to seek retirement pension.