Recommendation from the community preventive services task force for use of collaborative care for the management of depressive disorders

Association of collaborative care intervention features with depression and metabolic outcomes in the INDEPENDENT study: A mixed methods study

AIMS

The INtegrating DEPrEssioN and Diabetes treatmENT (INDEPENDENT) trial tested a collaborative care model including electronic clinical decision support (CDS) for treating diabetes and depression in India. We aimed to assess which features of this clinically and cost-effective intervention were associated with improvements in diabetes and depression measures.

METHODS

Post-hoc analysis of the INDEPENDENT trial data (189 intervention participants) was conducted to determine each intervention feature's effect: 1. Collaborative case reviews between expert psychiatrists and the care team; 2. Patient care-coordinator contacts; and 3. Clinicians' CDS prompt modifications. Primary outcome was baseline-to-12-months improvements in diabetes control, blood pressure, cholesterol, and depression. Implementer interviews revealed barriers and facilitators of intervention success. Joint displays integrated mixed methods' results.

RESULTS

High baseline HbA1c≥ 74.9 mmol/mol (9%) was associated with 5.72 fewer care-coordinator contacts than those with better baseline HbA1c (76.8 mmol/mol, 9.18%, p < 0.001). Prompt modification proportions varied from 38.3% (diabetes) to 1.3% (LDL). Interviews found that providers' and participants' visit frequencies were preference dependent. Qualitative data elucidated patient-level factors that influenced number of clinical contacts and prompt modifications explaining their lack of association with clinical outcomes.

CONCLUSION

Our mixed methods approach underlines the importance of the complementarity of different intervention features. Qualitative findings further illuminate reasons for variations in fidelity from the core model.

Exploring Effective Approaches: Integrating Mental Health Services into HIV Clinics in Northern Uganda

Background

Integrating mental health services into HIV clinics is recognized as a promising strategy. However, the literature reveals gaps, particularly in the unique context of Northern Uganda, where factors such as historical conflict, stigma, and limited resources pose potential barriers.

Material and Methods

This qualitative study, conducted between October and November 2023, employed a phenomenological design. The study involved primary healthcare facilities across diverse urban and rural settings, focusing on healthcare providers, village health teams, and service users. A purposive sampling approach ensured diverse demographics and perspectives. In-depth interviews and focus group discussions were conducted, with healthcare providers and service users participating individually, and village health teams engaged in group discussions. Thematic analysis was employed during data analysis.

Results

Findings revealed a predominance of females among healthcare providers (18 of 30) and service users (16 of 25), as well as in VHTs. Average ages were 33.4 (healthcare providers), 38.5 (service users), and 35.1 (VHTs). Most healthcare providers (15) held diplomas, while 12 service users and 4 VHTs had certificates. The majority of healthcare providers (n=20) and 4 VHTs had 6-10 years of experience. Thematic analysis highlighted three key themes: benefits of integrated mental health services, implementation challenges, and the role of community engagement and cultural sensitivity.

Conclusion

This study contributes valuable insights into the integration of mental health services into HIV clinics in Northern Uganda. The perceived benefits, challenges, and importance of cultural sensitivity and community engagement should guide future interventions, fostering a holistic approach that enhances the overall well-being of individuals living with HIV/AIDS in the region. Policymakers can use this information to advocate for resource allocation, training programs, and policy changes that support the integration of mental health services into HIV clinics in a way that addresses the identified challenges.

Missing link: a qualitative analysis of community-based organisations' contributions to partnered collaborative care to treat late-life depression

OBJECTIVE

Extending collaborative care, a model integrating mental health services into primary care, to include community-based organisations (CBOs) may improve older patient health outcomes by increasing access to care and addressing patients' social needs; however, little is known about how CBOs contribute to such partnered depression care. We explored how six primary care clinic and CBO partnerships came together to provide late-life depression care through the Care Partners funded in 2014.

DESIGN

43 key informant interviews and 15 focus groups were conducted with care managers, administrators and primary care providers partnering to provide late-life depression care. Data were coded and analysed iteratively using qualitative thematic analysis.

SETTING

Six primary care clinic-CBO sites across California.

PARTICIPANTS

Care managers, administrators and primary care providers participated in this study.

RESULTS

Three unique contributions of CBOs to depression care in these clinic-CBO partnerships were identified: (1) CBOs added new services that focus on social needs and enhanced depression care; (2) CBOs strengthened core aspects of collaborative care for depression; (3) CBOs provided new avenues for building connections and trust with underserved patients.

CONCLUSIONS

CBOs, when partnered with clinics, enhanced both medical and social aspects of depression treatment for older adults. CBOs are well positioned to assist primary care clinics in treating the complex health needs of older adults by providing new and strengthening existing aspects of partnered depression care while building patient trust among culturally diverse populations.

Barriers, facilitators, and proposals for improvement in the implementation of a collaborative care program for depression: a qualitative study of primary care physicians and nurses

BACKGROUND

Primary care plays a central role in the treatment of depression. Nonetheless, shortcomings in its management and suboptimal outcomes have been identified. Collaborative care models improve processes for the management of depressive disorders and associated outcomes. We developed a strategy to implement the INDI collaborative care program for the management of depression in primary health care centers across Catalonia. The aim of this qualitative study was to evaluate a trial implementation of the program to identify barriers, facilitators, and proposals for improvement.

METHODS

One year after the implementation of the INDI program in 18 public primary health care centers we performed a qualitative study in which the opinions and experiences of 23 primary care doctors and nurses from the participating centers were explored in focus groups. We performed thematic content analysis of the focus group transcripts.

RESULTS

The results were organized into three categories: facilitators, barriers, and proposals for improvement as perceived by the health care professionals involved. The most important facilitator identified was the perception that the INDI collaborative care program could be a useful tool for reorganizing processes and improving the management of depression in primary care, currently viewed as deficient. The main barriers identified were of an organizational nature: heavy workloads, lack of time, high staff turnover and shortages, and competing demands. Additional obstacles were inertia and resistance to change among health care professionals. Proposals for improvement included institutional buy-in to guarantee enduring support and the organizational changes needed for successful implementation.

CONCLUSIONS

The INDI program is perceived as a useful, viable program for improving the management of depression in primary care. Uptake by primary care centers and health care professionals, however, was poor. The identification and analysis of barriers and facilitators will help refine the strategy to achieve successful, widespread implementation.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03285659 ; Registered 18th September, 2017.

Men and suicide: Primary care prevention in the era of COVID-19 and beyond

ABSTRACT

The COVID-19 pandemic has had detrimental effects on mental health, including a predicted increase in suicidality, making suicide prevention a high priority. The rate of men's suicide in the United States is significantly higher than that of women's suicide. This case study considers the role of primary care advanced practice nurses in addressing the risks of suicide in their practice with male patients. It is argued that a gender-sensitive approach is necessary to be effective in male suicide prevention efforts.

A Pilot Study of Brief, Stepped Behavioral Activation for Primary Care Patients with Depressive Symptoms

In a prior pilot study with primary care patients experiencing depressive symptoms, we observed positive outcomes for a behavioral activation protocol involving one visit and three calls. We aimed to pilot test a stepped version with flexible numbers of contacts. Fifteen primary care patients scoring 5–14 on the Patient Health Questionnaire-9 engaged in the three-tiered telephone-based intervention: (1) two calls (15–20 min each); (2) one 30–60 min encounter followed by two calls; and (3) one to six calls. Participants completed assessments at pre-treatment, post-treatment, and three months later. Participants improved from baseline to post-treatment and three months later for depressive symptoms, anxiety symptoms, and disability. Most participants (9 of 15) engaged in the first tier only, averaging less than one hour of contact, and reported benefits and high satisfaction. This intervention showed preliminary evidence of feasibility, acceptability, satisfaction, and benefits, warranting further pilot testing with primary care personnel.

"What else can we do?"-Provider perspectives on treatment-resistant depression in late life

BACKGROUND

Treatment-resistant depression in late-life (TRLLD) is common. Perspectives of primary care providers (PCPs) and psychiatrists treating TRLLD could give insights into the challenges and potential solutions for managing this condition.

METHODS

To identify perspectives of providers who treat TRLLD, we conducted a qualitative descriptive study using semi-structured interviews with providers treating older adults with TRLLD in five locations across North America (i.e., Los Angeles, New York City, Pittsburgh, St. Louis, and Toronto). We conducted semi-structured interviews with 50 care providers (24 primary care providers [PCPs], 22 psychiatrists, and 4 depression care managers). Interviews elicited providers' perspectives on treatment options for TRLLD, including treatment within the primary care setting and referral to psychiatry, and sought suggestions for improvement.

RESULTS

We identified four themes. (1) Treating TRLLD takes an emotional toll on providers; (2) existing psychiatric services are inadequate to meet the needs of patients with TRLLD, mainly because of lack of access; (3) PCPs often attempt to treat TRLLD, even when they are not comfortable doing so; and (4) to better meet the needs of patients with TRLLD, providers recommend integrated care models involving PCPs, psychiatrists, and psychotherapists, potentially made more feasible by the growth of telehealth.

CONCLUSIONS

Findings from these qualitative interviews show the challenges in providing care for TRLLD. These findings can guide knowledge dissemination to psychiatrists, PCPs, policy-makers, and other stakeholders involved in the mental health system. They can also inform structural changes to clinical practice that may increase the implementation of the best treatment strategies across settings to improve long-term outcomes for TRLLD.

Postpartum Depressive Symptoms and Screening Opportunities at Health Care Encounters

Background: The American College of Obstetricians and Gynecologists recommends that providers screen women for depression at the postpartum checkup. If this checkup is the only screening opportunity, women who do not attend or whose depressive episode occurs at a different time may not be identified. We evaluated women's encounters with postpartum health care to identify screening opportunities for postpartum depressive symptoms (PDS). Materials and Methods: Pregnancy Risk Assessment Monitoring System (PRAMS) data for 2012-2015 from eight jurisdictions (n = 23,990, representing 1,939,865 women) were used to calculate percentage of women reporting attendance at postpartum checkups, well-child visits, or postpartum home visitation, by presence of PDS. PDS were assessed using a modified two-item Patient Health Questionnaire. Using Modified Poisson regression, adjusted prevalence ratios (aPR) and confidence intervals (95% CI) were calculated to compare health services by PDS, adjusted for sociodemographic characteristics. Results: Almost all women with or without PDS attended a postpartum checkup (85.1% and 91.4%; aPR: 0.96; 95% CI: 0.93-0.99) and their infants attended a well-child visit (97.3% and 98.9%; aPR: 0.99; 95% CI: 0.98-1.00); 13.7% and 10.9% received home visitation (aPR: 1.18; 95% CI: 1.02-1.35). Of women with PDS who missed their postpartum checkup, 13.5% reported infant attendance at well-child visits, and 2.0% received home visitation. Of women with PDS, 98.8%, 86.1%, and 11.2% attended 1, 2, or 3 health services. Conclusion: A large percentage of women with PDS may attend well-child visits or receive home visitation, representing opportunities for depression screening and referral for care.

Barriers and facilitators to the integration of mental health services into primary health care: a systematic review

BACKGROUND

The objective of the review was to synthesize evidence of barriers and facilitators to the integration of mental health services into PHC from existing literature. The structure of the review was guided by the SPIDER framework which involves the following: Sample or population of interest-primary care providers (PCPs); Phenomenon of Interest-integration of mental health services into primary health care (PHC); Design-influenced robustness and analysis of the study; Evaluation-outcomes included subjective outcomes (views and attitudes); and Research type-qualitative, quantitative, and mixed methods studies.

METHODS

Studies that described mental health integration in PHC settings, involved primary care providers, and presented barriers/facilitators of mental health integration into PHC were included in the review. The sources of information included PubMed, PsycINFO, Cochrane Central Register of Controlled trials, the WHO website, and OpenGrey. Assessment of bias and quality was done using two separate tools: the Critical Appraisal Skills Program (CASP) qualitative checklist and the Effective Public Health Practice Project Quality Assessment Tool for Quantitative Studies.

RESULTS

Twenty studies met the inclusion criteria out of the 3353 search results. The most frequently reported barriers to integration of mental health services into PHC were (i) attitudes regarding program acceptability, appropriateness, and credibility; (ii) knowledge and skills; (iii) motivation to change; (iv) management and/or leadership; and (v) financial resources. In order to come up with an actionable approach to addressing the barriers, these factors were further analyzed along a behavior change theory.

DISCUSSION

We have shown that the integration of mental health services into PHC has been carried out by various countries. The analysis from this review provides evidence to inform policy on the existing barriers and facilitators to the implementation of the mental health integration policy option. Not all databases may have been exhausted.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO 2016 (Registration Number: CRD42016052000 ) and published in BMC Systematic Reviews August 2017.

Development and assessment of an active strategy for the implementation of a collaborative care approach for depression in primary care (the INDI·i project)

Background

Primary care is the principal clinical setting for the management of depression. However, significant shortcomings have been detected in its diagnosis and clinical management, as well as in patient outcomes. We developed the INDI collaborative care model to improve the management of depression in primary care. This intervention has been favorably evaluated in terms of clinical efficacy and cost-effectiveness in a clinical trial. Our aim is to bring this intervention from the scientific context into clinical practice.

Methods

Objective: To test for the feasibility and impact of a strategy for implementing the INDI model for depression in primary care.

Design: A quasi-experiment conducted in primary care. Several areas will be established to implement the new program and other, comparable areas will serve as control group. The study constitutes the preliminary phase preceding generalization of the model in the Catalan public healthcare system.

Participants: The target population of the intervention are patients with major depression. The implementation strategy will also involve healthcare professionals, primary care centers, as well as management departments and the healthcare organization itself in the geographical areas where the study will be conducted: Camp de Tarragona and Vallès Occidental (Catalonia).

Intervention: The INDI model is a program for improving the management of depression involving clinical, instructional, and organizational interventions including the participation of nurses as care managers, the efficacy and efficiency of which has been proven in a clinical trial. We will design an active implementation strategy for this model based on the PARIHS (Promoting Action on Research Implementation in Health Services) framework.

Measures: Qualitative and quantitative measures will be used to evaluate variables related to the successful implementation of the model: acceptability, utility, penetration, sustainability, and clinical impact.

Discussion

This project tests the transferability of a healthcare intervention supported by scientific research to clinical practice. If implementation is successful in this experimental phase, we will use the information and experience obtained to propose and plan the generalization of the INDI model for depression in the Catalan healthcare system. We expect the program to benefit patients, the healthcare system, and society.

Trial registration

ClinicalTrials.gov identifier: NCT03285659; Registered 12th September, 2017.

Barriers and facilitators to the integration of mental health services into primary health care: a systematic review protocol

BACKGROUND

Mental health is an integral part of health and well-being and yet health systems have not adequately responded to the burden of mental disorders. Integrating mental health services into primary health care (PHC) is the most viable way of closing the treatment gap and ensuring that people get the mental health care they need. PHC was formally adapted by the World Health Organization (WHO), and they have since invested enormous amounts of resources across the globe to ensure that integration of mental health services into PHC works.

METHODS

This review will use the SPIDER (Sample, Phenomenon of Interest, Design, Evaluation, Research type) framework approach to identify experiences of mental health integration into PHC; the findings will be reported using the "Best fit" framework synthesis. PubMed, EMBASE, PsycINFO, and Cochrane Central Register of Controlled trials (CENTRAL) will be searched including other sources like the WHO website and OpenGrey database. Assessment of bias and quality will be done at study level using two separate tools to check for the quality of evidence presented. Data synthesis will take on two synergistic approaches (qualitative and quantitative studies). Synthesizing evidence from countries across the globe will provide useful insights into the experiences of integrating mental health services into PHC and how the barriers and challenges have been handled. The findings will be useful to a wide array of stakeholders involved in the implementation of the mental health integration into PHC.

DISCUSSION

The SPIDER framework has been chosen for this review because of its suitable application to qualitative and mixed methods research and will be used as a guide when selecting articles for inclusion. Data extracted will be synthesized using the "Best fit" framework because it has been used before and proved its suitability in producing new conceptual models for explaining decision-making and possible behaviors. Synthesizing evidence from countries across the globe will provide useful insights into the experiences of integrating mental health services into PHC and how the barriers and challenges have been handled.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42016052000.

Mental Health Utilization Patterns During a Stepped, Collaborative Care Effectiveness Trial for PTSD and Depression in the Military Health System

BACKGROUND

Integrated health care models aim to improve access and continuity of mental health services in general medical settings. STEPS-UP is a stepped, centrally assisted collaborative care model designed to improve posttraumatic stress disorder (PTSD) and depression care by providing the appropriate intensity and type of care based on patient characteristics and clinical complexity. STEPS-UP demonstrated improved PTSD and depression outcomes in a large effectiveness trial conducted in the Military Health System. The objective of this study was to examine differences in mental health utilization patterns between patients in the stepped, centrally assisted collaborative care model relative to patients in the collaborative care as usual-treatment arm.

METHODS

Patients with probable PTSD and/or depression were recruited at 6 large military treatment facilities, and 666 patients were enrolled and randomized to STEPS-UP or usual collaborative care. Utilization data acquired from Military Health System administrative datasets were analyzed to determine mental health service use and patterns. Clinical complexity and patient characteristics were based on self-report questionnaires collected at baseline.

RESULTS

Compared with the treatment as usual arm, STEPS-UP participants received significantly more mental health services and psychiatric medications across primary and specialty care settings during the year of their participation. Patterns of service use indicated that greater clinical complexity was associated with increased service use in the STEPS-UP group, but not in the usual-care group.

CONCLUSIONS

Results suggest that stepped, centrally assisted collaborative care models may increase the quantity of mental health services patients receive, while efficiently matching care on the basis of the clinical complexity of patients.

Mental Health Conditions and Medical and Surgical Hospital Utilization

OBJECTIVE

Mental health conditions are prevalent among children hospitalized for medical conditions and surgical procedures, but little is known about their influence on hospital resource use. The objectives of this study were to examine how hospitalization characteristics vary by presence of a comorbid mental health condition and estimate the association of a comorbid mental health condition with hospital length of stay (LOS) and costs.

METHODS

Using the 2012 Kids' Inpatient Database, we conducted a retrospective, nationally representative, cross-sectional study of 670 161 hospitalizations for 10 common medical and 10 common surgical conditions among 3- to 20-year-old patients. Associations between mental health conditions and hospital LOS were examined using adjusted generalized linear models. Costs of additional hospital days associated with mental health conditions were estimated using hospital cost-to-charge ratios.

RESULTS

A comorbid mental health condition was present in 13.2% of hospitalizations. A comorbid mental health condition was associated with a LOS increase of 8.8% (from 2.5 to 2.7 days, P < .001) for medical hospitalizations and a 16.9% increase (from 3.6 to 4.2 days, P < .001) for surgical hospitalizations. For hospitalizations in this sample, comorbid mental health conditions were associated with an additional 31 729 (95% confidence interval: 29 085 to 33 492) hospital days and $90 million (95% confidence interval: $81 to $101 million) in hospital costs.

CONCLUSIONS

Medical and surgical hospitalizations with comorbid mental health conditions were associated with longer hospital stay and higher hospital costs. Knowledge about the influence of mental health conditions on pediatric hospital utilization can inform clinical innovation and case-mix adjustment.

Caring for Depression in Older Home Health Patients

Depression is common in older home health patients and increases their risk of adverse outcomes. Depression screening is required by Medicare's Outcome and Assessment Information Set. The Depression Care for Patients at Home (CAREPATH) was developed as a feasible strategy for home health nurses to manage depression in their patients. The protocol builds on nurses' existing clinical skills and is designed to fit within routine home visits. Major components include ongoing clinical assessment, care coordination, medication management, education, and goal setting. In a randomized trial, Depression CAREPATH patients had greater improvement in depressive symptoms compared to usual care. The difference between groups was significant at 3 months, growing larger and more clinically meaningful over 1 year. The intervention had no impact on patient length of stay, number of home visits, or duration of visits. Thus, nurses can play a pivotal role in the long-term course and outcomes of patients with depression.

Eradicating Barriers to Mental Health Care Through Integrated Service Models: Contemporary Perspectives for Psychiatric-Mental Health Nurses

There has been renewed, global interest in developing new and transformative models of facilitating access to high-quality, cost-effective, and individually-centered health care for severe mentally-ill (SMI) persons of diverse racial/ethnic, cultural and socioeconomic backgrounds. However, in our present-day health-service delivery systems, scholars have identified layers of barriers to widespread dispersal of well-needed mental health care both nationally and internationally. It is crucial that contemporary models directed at eradicating barriers to mental health services are interdisciplinary in context, design, scope, sequence, and best-practice standards. Contextually, nurses are well-positioned to influence the incorporation and integration of new concepts into operationally interdisciplinary, evidence-based care models with measurable outcomes. The aim of this concept paper is to use the available evidence to contextually explicate how the blended roles of psychiatric mental health (PMH) nursing can be influential in eradicating barriers to care and services for SMI persons through the integrated principles of collaboration, integration and service expansion across health, socioeconomic, and community systems. A large body of literature proposes that any best-practice standards aimed at eliminating barriers to the health care needs of SMI persons require systematic, well-coordinated interdisciplinary partnerships through evidence-based, high-quality, person-centered, and outcome-driven processes. Transforming the conceptual models of collaboration, integration and service expansion could be revolutionary in how care and services are coordinated and dispersed to populations across disadvantaged communities. Building on their longstanding commitment to individual and community care approaches, and their pivotal roles in research, education, leadership, practice, and legislative processes; PMH nurses are well-positioned to be both influential and instrumental in the development of innovative, revolutionary, and transformative paradigmatic models aimed at eradicating treatment barriers, promoting well-being, and reducing preventable mortalities and morbidities among SMI persons.

Managing Depression Among Homeless Mothers: Pilot Testing an Adapted Collaborative Care Intervention

OBJECTIVE

Although depression is common among homeless mothers, little progress has been made in testing treatment strategies for this group. We describe pilot test results of an adapted collaborative care model for homeless mothers with depression.

METHOD

We conducted a pilot intervention study of mothers screening positive for depression in 2 randomly selected shelter-based primary care clinics in New York over 18 months in 2010-2012. Study participants completed a psychosocial, health, and mental health assessment at baseline, 3 months, and 6 months.

RESULTS

One-third of women screened positive for depression (123 of 328 women). Sixty-seven women (63.2% of the eligible sample) enrolled in the intervention. At 6 months, compared to usual-care women, intervention group women were more likely to be receiving depression treatment (40.0% vs 5.9%, P = .01) and antidepressant medication (73.3% vs 5.9%, P = .001, respectively) and had more primary care physician and care manager visits at both 3 months (74.3% vs 53.3%, P = .009 and 91.4% vs 26.7%, P < .001, respectively) and 6 months (46.7% vs 23.5%, P = .003 and 70% vs 17.7%, P = .001, respectively). More women in the intervention group compared to usual-care women reported ≥ 50% improvement in depression symptoms at 6 months (30% vs 5.9%, P = .07).

CONCLUSIONS

This pilot study found that implementing an adapted collaborative care intervention was feasible in a shelter-based primary care clinic and had promising results that require further testing.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02723058.

Collaborative Depression Care in a Safety Net Medical Home: Facilitators and Barriers to Quality Improvement

Little is known about how to integrate primary care with mental/behavioral services outside of clinical trials. The authors implemented a collaborative care model (CCM) for depression in a safety net patient-centered medical home. The model focused on universal screening for symptoms, risk stratification based on symptom severity, care management for intensive follow-up, and psychiatry consultation. CCM increased rates of primary care physician encounters, timely follow-up for monitoring symptoms of depression, and documentation of treatment response. Contextual factors that facilitated or hindered practice redesign included clinic leadership, quality improvement culture, staffing, technology infrastructure, and external incentives/disincentives for organizational change.

Depression and onset of cardiovascular disease in the US middle-aged and older adults

OBJECTIVES

To examine the relationship between depression and onset of cardiovascular disease (CVD) among the US middle-aged and older adults.

METHODS

The study sample came from 1992-2010 waves of the Health and Retirement Study, a nationally representative longitudinal survey, consisting of 8597 community-dwelling adults aged 51-61 years old in 1992 with no CVD history. A score of ≥3 on the 8-item Center for Epidemiologic Studies Depression Scale was used to define clinically relevant depressive symptoms. Kaplan-Meier estimator and Cox proportional hazards model were performed to examine the association between baseline depressive symptoms and future CVD event. Subgroup analyses were conducted by sex and race/ethnicity.

RESULTS

Compared with their counterparts without clinically relevant depressive symptoms, adults with clinically relevant depressive symptoms in 1992 were 27% (hazard ratio [HR] = 1.27, 95% confidence interval = 1.17-1.39) more likely to report new diagnosis of CVD during the 18 years of follow-up. A significant dose-response relationship was present between severity of depressive symptoms and elevated CVD risk. The adjusted HRs for males and Hispanics appeared moderately larger than for their female and non-Hispanic white or African American counterparts, although the differences were not statistically significant.

CONCLUSION

Holistic promotion of mental health through prevention, education, treatment, and rehabilitation is warranted to reduce CVD risk in the US middle-aged and older population.

Clinical effectiveness of integrating depression care management into medicare home health: the Depression CAREPATH Randomized trial

IMPORTANCE

Among older home health care patients, depression is highly prevalent, is often inadequately treated, and contributes to hospitalization and other poor outcomes. Feasible and effective interventions are needed to reduce this burden of depression.

OBJECTIVE

To determine whether, among older Medicare Home Health recipients who screen positive for depression, patients of nurses receiving randomization to an intervention have greater improvement in depressive symptoms during 1 year than patients receiving enhanced usual care.

DESIGN, SETTING, AND PARTICIPANTS

This cluster randomized effectiveness trial conducted at 6 home health care agencies nationwide assigned nurse teams to an intervention (12 teams) or to enhanced usual care (9 teams). Between January 13, 2009, and December 6, 2012, Medicare Home Health patients 65 years and older who screened positive for depression on routine nursing assessments were recruited, underwent assessment, and were followed up at 3, 6, and 12 months by research staff blinded to intervention status. Patients were interviewed at home and by telephone. Of 502 eligible patients, 306 enrolled in the study.

INTERVENTIONS

The Depression Care for Patients at Home (Depression CAREPATH) trial requires nurses to manage depression at routine home visits by weekly symptom assessment, medication management, care coordination, education, and goal setting. Nurses' training totaled 7 hours (4 onsite and 3 via the web). Researchers telephoned intervention team supervisors every other week.

MAIN OUTCOMES AND MEASURES

Depression severity, assessed by the 24-item Hamilton Scale for Depression (HAM-D).

RESULTS

The 306 participants were predominantly female (69.6%), were racially/ethnically diverse (18.0% black and 16.0% Hispanic), and had a mean (SD) age of 76.5 (8.0) years. In the full sample, the intervention had no effect (P = .13 for intervention × time interaction). Adjusted HAM-D scores (Depression CAREPATH vs control) did not differ at 3 months (10.5 vs 11.4, P = .26) or at 6 months (9.3 vs 10.5, P = .12) but reached significance at 12 months (8.7 vs 10.6, P = .05). In the subsample with mild depression (HAM-D score, <10), the intervention had no effect (P = .90), and HAM-D scores did not differ at any follow-up points. Among 208 participants with a HAM-D score of 10 or higher, the Depression CAREPATH demonstrated effectiveness (P = .02), with lower HAM-D scores at 3 months (14.1 vs 16.1, P = .04), at 6 months (12.0 vs 14.7, P = .02), and at 12 months (11.8 vs 15.7, P = .005).

CONCLUSION AND RELEVANCE

Home health care nurses can effectively integrate depression care management into routine practice. However, the clinical benefit seems to be limited to patients with moderate to severe depression.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01979302.

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.

Grand challenges: integrating mental health services into priority health care platforms

In the last article of a five-part series providing a global perspective on integrating mental health, Vikram Patel and colleagues discuss the competencies, operational innovation, and packages of care needed, and argue that integration will complement primary care system strengthening.

Please see later in the article for the Editors' Summary

Delivering psychiatric services in primary-care setting

Psychiatric disorders, particularly depression and anxiety disorders, are common in primary-care settings, though often overlooked or untreated. Depression and anxiety disorders are associated with a poorer course for and complications from common chronic diseases such as diabetes mellitus and coronary heart disease. Integrating psychiatric services into primary-care settings can improve recognition and treatment of psychiatric disorders for large populations of patients. Numerous research studies demonstrate associations between improved recognition and treatment of psychiatric disorders and improved courses of psychiatric disorders, but also with improvements in other chronic diseases such as diabetes. The evidence bases supporting the use of 2 models of integrated care, colocation of psychiatric care and collaborative care, are reviewed. These models' uses in specific populations are also discussed.