Does screening for depression in primary care improve outcome?

Development of a Person-Centred Integrated Care Approach for Chronic Disease Management in Dutch Primary Care: A Mixed-Method Study

To reduce the burden of chronic diseases on society and individuals, European countries implemented chronic Disease Management Programs (DMPs) that focus on the management of a single chronic disease. However, due to the fact that the scientific evidence that DMPs reduce the burden of chronic diseases is not convincing, patients with multimorbidity may receive overlapping or conflicting treatment advice, and a single disease approach may be conflicting with the core competencies of primary care. In addition, in the Netherlands, care is shifting from DMPs to person-centred integrated care (PC-IC) approaches. This paper describes a mixed-method development of a PC-IC approach for the management of patients with one or more chronic diseases in Dutch primary care, executed from March 2019 to July 2020. In Phase 1, we conducted a scoping review and document analysis to identify key elements to construct a conceptual model for delivering PC-IC care. In Phase 2, national experts on Diabetes Mellitus type 2, cardiovascular diseases, and chronic obstructive pulmonary disease and local healthcare providers (HCP) commented on the conceptual model using online qualitative surveys. In Phase 3, patients with chronic conditions commented on the conceptual model in individual interviews, and in Phase 4 the conceptual model was presented to the local primary care cooperatives and finalized after processing their comments. Based on the scientific literature, current practice guidelines, and input from a variety of stakeholders, we developed a holistic, person-centred, integrated approach for the management of patients with (multiple) chronic diseases in primary care. Future evaluation of the PC-IC approach will show if this approach leads to more favourable outcomes and should replace the current single-disease approach in the management of chronic conditions and multimorbidity in Dutch primary care.

Identifying and managing depression through collaborative care: expanding social work's impact

While behavioral health symptoms commonly present in primary care, most primary care providers lack the time, resources, and expertise to identify and treat them on their own. To address this need, many quality improvement efforts are underway to expand teams and integrate behavioral health assessments and interventions into primary care. Due to their expertise in behavioral health, community supports, and behavioral activation, social workers are natural leaders in integrating care. This paper describes one urban academic medical center's efforts to ensure adolescent and adult patients with depressive symptoms are connected to adequate care and support. A case study is included to demonstrate the Collaborative Care Team model as described, including details regarding the role social workers play. Key quality improvement and policy considerations for scaling up and sustaining collaborative initiative are included.

Diagnostic accuracy of the Patient Health Questionnaire-9 for assessment of depression in type II diabetes mellitus and/or coronary heart disease in primary care

BACKGROUND

Depression is common among type 2 diabetes mellitus (DM2)/coronary heart disease (CHD) patients and is associated with adverse health effects. A promising strategy to reduce burden of disease is to identify patients at risk for depression in order to offer indicated prevention. This study aims to assess the diagnostic accuracy of the Patient Health Questionnaire-9 (PHQ-9) to be used as a tool to identify high risk patients.

METHODS

In this cross-sectional study, 586 consecutive DM2/CHD patients aged >18 were recruited through 23 general practices. PHQ-9 outcomes were compared to the Mini International Neuropsychiatric Interview (MINI), which was considered the reference standard. Diagnostic accuracy was evaluated for minor and major depression, comparing both sum- and algorithm based PHQ-9 scores.

RESULTS

For minor depression, the optimal cut-off score was 8 (sensitivity 71%, specificity 71% and an AUC of 0.74). For major depression, the optimal cut-off score was 10 resulting in a sensitivity of 84%, a specificity of 82%, and an AUC of 0.88. The positive predictive value of the PHQ-9 algorithm for diagnosing minor and major depression was 25% and 33%, respectively.

LIMITATIONS

Two main limitations apply. MINI Interviewers were not blinded for PHQ-9 scores and less than 10% of all invited patients could be included in the analyses. This could have resulted in biased outcomes.

CONCLUSIONS

The PHQ-9 sum score performs well in identifying patients at high risk of minor and major depression. However, the PHQ-9 showed suboptimal results for diagnostic purposes. Therefore, it is recommended to combine the use of the PHQ-9 with further diagnostics to identify depression.

Describing the relationship between cat bites and human depression using data from an electronic health record

Data mining approaches have been increasingly applied to the electronic health record and have led to the discovery of numerous clinical associations. Recent data mining studies have suggested a potential association between cat bites and human depression. To explore this possible association in more detail we first used administrative diagnosis codes to identify patients with either depression or bites, drawn from a population of 1.3 million patients. We then conducted a manual chart review in the electronic health record of all patients with a code for a bite to accurately determine which were from cats or dogs. Overall there were 750 patients with cat bites, 1,108 with dog bites, and approximately 117,000 patients with depression. Depression was found in 41.3% of patients with cat bites and 28.7% of those with dog bites. Furthermore, 85.5% of those with both cat bites and depression were women, compared to 64.5% of those with dog bites and depression. The probability of a woman being diagnosed with depression at some point in her life if she presented to our health system with a cat bite was 47.0%, compared to 24.2% of men presenting with a similar bite. The high proportion of depression in patients who had cat bites, especially among women, suggests that screening for depression could be appropriate in patients who present to a clinical provider with a cat bite. Additionally, while no causative link is known to explain this association, there is growing evidence to suggest that the relationship between cats and human mental illness, such as depression, warrants further investigation.

Mental health collaborative care and its role in primary care settings

Collaborative care models (CCMs) provide a pragmatic strategy to deliver integrated mental health and medical care for persons with mental health conditions served in primary care settings. CCMs are team-based intervention to enact system-level redesign by improving patient care through organizational leadership support, provider decision support, and clinical information systems, as well as engaging patients in their care through self-management support and linkages to community resources. The model is also a cost-efficient strategy for primary care practices to improve outcomes for a range of mental health conditions across populations and settings. CCMs can help achieve integrated care aims underhealth care reform yet organizational and financial issues may affect adoption into routine primary care. Notably, successful implementation of CCMs in routine care will require alignment of financial incentives to support systems redesign investments, reimbursements for mental health providers, and adaptation across different practice settings and infrastructure to offer all CCM components.

Integrating bipolar disorder management in primary care

There is growing realization that persons with bipolar disorder may exclusively be seen in primary (general medical) care settings, notably because of limited access to mental health care and stigma in seeking mental health treatment. At least two clinical practice guidelines for bipolar disorder recommend collaborative chronic care models (CCMs) to help integrate mental health care to better manage this illness. CCMs, which include provider guideline support, self-management support, care management, and measurement-based care, are well-established in primary care settings, and may help primary care practitioners manage bipolar disorder. However, further research is required to adapt CCMs to support complexities in diagnosing persons with bipolar disorder, and integrate decision-making processes regarding medication safety and tolerability in primary care. Additional implementation studies are also needed to adapt CCMs for persons with bipolar disorder in primary care, especially those seen in smaller practices with limited infrastructure and access to mental health care.