Quality of depression care for people with coincident chronic medical conditions

Treatment Satisfaction Among Patients Taking Antidepressant Medication

This study sought to assess treatment satisfaction among patients on antidepressants, ascertaining whether there might be an association with depressive symptomatology and other variables. Cross-sectional study conducted on 564 adult patients taking antidepressant medication. Satisfaction with antidepressant treatment was assessed using the Assessment of Satisfaction with Antidepressant Treatment Questionnaire (ESTA/Evaluación de la Satisfacción con el Tratamiento Antidepresivo). A moderate negative correlation was observed between satisfaction and intensity of depressive symptoms, as assessed with the Montgomery-Asberg scale. A weak negative correlation was observed between greater satisfaction and less favourable views about taking medication. Satisfaction scale scores were higher among those who took antidepressant medication for 1 year or more versus shorter periods. Most patients reported being satisfied with the antidepressant treatment but the level of satisfaction was higher among those who presented with less marked depressive symptoms, received longer-term treatment and viewed drug treatments favourably. Treatment satisfaction is one of the patient-reported outcome measures that can serve to complement clinical evaluation of depressive disorders.

Impact of multi-morbidity on quality of healthcare and its implications for health policy, research and clinical practice. A scoping review

The simultaneous presence of multiple conditions in one patient (multi-morbidity) is a key challenge facing healthcare systems globally. It potentially threatens the coordination, continuity and safety of care. In this paper, we report the results of a scoping review examining the impact of multi-morbidity on the quality of healthcare. We used its results as a basis for a discussion of the challenges that research in this area is currently facing. In addition, we discuss its implications for health policy and clinical practice. The review identified 37 studies focussing on multi-morbidity but using conceptually different approaches. Studies focusing on 'comorbidity' (i.e. the 'index disease' approach) suggested that quality may be enhanced in the presence of synergistic conditions, and impaired by antagonistic or neutral conditions. Studies on 'multi-morbidity' (i.e. multiplicity of problems) and 'morbidity burden' (i.e. the total severity of conditions) suggested that increasing number of conditions and severity may be associated with better quality of healthcare when measured by process or intermediate outcome indicators, but with worse quality when patient-centred measures are used. However, issues related to the conceptualization and measurement of multi-morbidity (inconsistent across studies) and of healthcare quality (restricted to evaluations for each separate condition without incorporating considerations about multi-morbidity itself and its implications for management) compromised the generalizability of these observations. Until these issues are addressed and robust evidence becomes available, clinicians should apply minimally invasive and patient-centred medicine when delivering care for clinically complex patients. Health systems should focus on enhancing primary care centred coordination and continuity of care.

Diagnostic accuracy and adequacy of treatment of depressive and anxiety disorders: A comparison of primary care and specialized care patients

BACKGROUND

Clinical diagnosis of depressive and anxiety disorders has poor sensitivity, and treatment is often not guideline-concordant. This longitudinal study aims to compare diagnostic validity and treatment adequacy in primary care (PC) and specialized care (SC), to assess associated risk factors, and to evaluate their impact on clinical outcome at one-month and three-month follow-ups.

METHODS

Two hundred twelve patients with depressive and anxious symptoms were recruited from 3 PC and 1 SC centers in Barcelona, Spain. Sensitivity and specificity were calculated comparing medical records׳ diagnoses with a reference (MINI interview). Adequate treatment was defined according to clinical guidelines. Logistic regression was used to estimate associations with risk factors. Impact on outcome was assessed with MANOVA models.

RESULTS

Valid diagnosis of depression was more frequent in patients attending SC. Sensitivity for depression was 0.75 in SC and 0.49 in PC (adjusted OR=17.34, 95% CI=4.73-63.61). Detection of anxious comorbidity in depressed patients was low (50%) in SC. Treatment adequacy of depressive disorders was higher in SC than in PC (94.4% vs. 80.6%, adjusted OR=8.11, 95% CI=1.39-47.34). Depression severity was associated with valid diagnosis.

LIMITATIONS

Only four disorders (major depression, dysthymia, panic disorder and generalized anxiety disorder) were evaluated with the MINI interview in a convenience clinical sample. Treatment dosage was unavailable.

CONCLUSIONS

Our results suggest that GPs need tools to improve detection of depression and its severity. Psychiatrists should enhance recognition of anxious comorbidity. Evaluation of the impact on outcome deserves further research.

Quality of depression treatment in Black Americans with major depression and comorbid medical illness

OBJECTIVE

The objective was to evaluate how comorbid type 2 diabetes (T2DM) and hypertension (HT) influence depression treatment and to assess whether these effects operate differently in a nationally representative community-based sample of Black Americans.

METHODS

Data came from the National Survey of American Life (N=3673), and analysis is limited to respondents who met lifetime criteria for major depression (MD) (N=402). Depression care was defined according to American Psychiatric Association (APA) guidelines and included psychotherapy, pharmacotherapy and satisfaction with services. Logistic regression was used to examine the effects of T2DM and HT on quality of depression care.

RESULTS

Only 19.2% of Black Americans with MD alone, 7.8% with comorbid T2DM and 22.3% with comorbid HT reported APA-guideline-concordant psychotherapy or antidepressant treatment. Compared to respondents with MD alone, respondents with MD+T2DM/HT were no more or less likely to receive depression care. Respondents with MD+HT+T2DM were more likely to report any guideline-concordant care (odds ratio=3.32; 95% confidence interval, 1.07-10.31).

CONCLUSIONS

Although individuals with MD and comorbid T2DM+HT were more likely to receive depression care, guideline-concordant depression care is low among Black Americans, including those with comorbid medical conditions.

Predictors of adequate depression treatment among Medicaid-enrolled youth

PURPOSE

To determine if Medicaid-enrolled youth with depressive symptoms receive adequate acute treatment, and to identify the characteristics of those receiving inadequate treatment.

METHODS

We used administrative claims data from a Medicaid-enrolled population in a large urban community to identify youth aged 6-24 years who started a new episode of treatment for a depressive disorder between August 2006 and February 2010. We examined rates and predictors of minimally adequate psychotherapy (four visits in first 12 weeks) and pharmacotherapy (filled antidepressant prescription for 84 of the first 144 days) among youth with a new treatment episode during the study period (n = 930).

RESULTS

Fifty-nine percent of depressed youth received minimally adequate psychotherapy, but 13 % received minimally adequate pharmacotherapy. Youth who began their treatment episode with an inpatient psychiatric stay for depression and racial minorities were significantly less likely to receive minimally adequate pharmacotherapy and significantly more likely to receive inadequate overall treatment.

CONCLUSIONS

While the majority of youth appear to be receiving minimally adequate acute care for depression, a substantial number are not. Given current child mental health workforce constraints, efforts to substantially improve the provision of adequate care to depressed youth are likely to require both quality improvement and system redesign efforts.

Chronic illness and patient satisfaction

OBJECTIVE

To examine how the relationship between patient characteristics, patient experience with the health care system, and overall satisfaction with care varies with illness complexity.

DATA SOURCES/STUDY SETTING

Telephone survey in 14 U.S. geographical areas.

STUDY DESIGN

Structural equation modeling was used to examine how relationships among patient characteristics, three constructs representing patient experience with the health care system, and overall satisfaction with care vary across patients by number of chronic illnesses.

DATA COLLECTION/EXTRACTION METHODS

Random digital dial telephone survey of adults with one or more chronic illnesses.

PRINCIPAL FINDINGS

Patients with more chronic illnesses report higher overall satisfaction. The total effects of better patient-provider interaction and support for patient self-management are associated with higher satisfaction for all levels of chronic illness. The latter effect increases with illness burden. Older, female, or insured patients are more satisfied; highly educated patients are less satisfied.

CONCLUSIONS

Providers seeking to improve their patient satisfaction scores could do so by considering patient characteristics when accepting new patients or deciding who to refer to other providers for treatment. However, our findings suggest constructive actions that providers can take to improve their patient satisfaction scores without selection on patient characteristics.

Measuring patient-provider trust in a primary care population: refinement of the health care relationship trust scale

Accurately measuring trust between patients and health care providers is important because low patient-provider trust can lead to poor treatment adherence and negative health outcomes. To measure patient-provider trust, we developed the Health Care Relationship (HCR) Trust scale. Findings from our initial use of the scale suggested the need to examine the scale's psychometric performance in a larger sample of adults with various chronic health conditions. We therefore examined the psychometric properties of the HCR Trust Scale in a random sample of adult primary care patients. Thirteen of the original 15 items fit the data best; a single-factor structure explained 67% of the variance in patient-provider trust. The Cronbach's alpha for the 13-item HCR Trust Scale-Revised was .96.

Crowd-out and exposure effects of physical comorbidities on mental health care use: implications for racial-ethnic disparities in access

OBJECTIVES

In disparities models, researchers adjust for differences in "clinical need," including indicators of comorbidities. We reconsider this practice, assessing (1) if and how having a comorbidity changes the likelihood of recognition and treatment of mental illness; and (2) differences in mental health care disparities estimates with and without adjustment for comorbidities.

DATA

Longitudinal data from 2000 to 2007 Medical Expenditure Panel Survey (n=11,083) split into pre and postperiods for white, Latino, and black adults with probable need for mental health care.

STUDY DESIGN

First, we tested a crowd-out effect (comorbidities decrease initiation of mental health care after a primary care provider [PCP] visit) using logistic regression models and an exposure effect (comorbidities cause more PCP visits, increasing initiation of mental health care) using instrumental variable methods. Second, we assessed the impact of adjustment for comorbidities on disparity estimates.

PRINCIPAL FINDINGS

We found no evidence of a crowd-out effect but strong evidence for an exposure effect. Number of postperiod visits positively predicted initiation of mental health care. Adjusting for racial/ethnic differences in comorbidities increased black-white disparities and decreased Latino-white disparities.

CONCLUSIONS

Positive exposure findings suggest that intensive follow-up programs shown to reduce disparities in chronic-care management may have additional indirect effects on reducing mental health care disparities.

Association of general medical and psychiatric comorbidities with receipt of guideline-concordant care for depression

OBJECTIVE

This study described the association of general medical and psychiatric comorbidities with receipt of guideline-concordant depression care.

METHODS

Pharmacy, medical, and behavioral claims and enrollment data from OptumHealth in 2003-2006 were linked for 1,835 adults with a new depression diagnosis or a new antidepressant fill. Multiple logistic regression was used to estimate the association of comorbidities with receipt of guideline-concordant pharmacotherapy, guideline-concordant psychotherapy, and any guideline-concordant therapy.

RESULTS

Eleven percent of patients received guideline-concordant psychotherapy; 23%, guideline-concordant pharmacotherapy; and 33%, any guideline-concordant therapy. Having a psychiatric but no medical comorbidity was associated with higher rates of guideline-concordant psychotherapy and overall guideline concordance; conversely, having a general medical but no psychiatric comorbidity was associated with lower rates of guideline-concordant psychotherapy. Comorbidities were associated with the probability of receiving any guideline-concordant therapy, but they were not associated with improved guideline concordance among patients already receiving therapy.

CONCLUSIONS

Patients with general medical comorbidities may not receive psychotherapy referrals, perhaps because of well-established relationships with their primary care providers.

Predictors of adequate depression treatment among Medicaid-enrolled adults

OBJECTIVE

To determine whether Medicaid-enrolled depressed adults receive adequate treatment for depression and to identify the characteristics of those receiving inadequate treatment.

DATA SOURCE

Claims data from a Medicaid-enrolled population in a large mid-Atlantic state between July 2006 and January 2008.

STUDY DESIGN

We examined rates and predictors of minimally adequate psychotherapy and pharmacotherapy among adults with a new depression treatment episode during the study period (N=1,098).

PRINCIPAL FINDINGS

Many depressed adults received either minimally adequate psychotherapy or pharmacotherapy. Black individuals and individuals who began their depression treatment episode with an inpatient psychiatric stay for depression were markedly less likely to receive minimally adequate psychotherapy and more likely to receive inadequate treatment.

CONCLUSIONS

Racial minorities and individuals discharged from inpatient treatment for depression are at risk for receiving inadequate depression treatment.

Effect of depression treatment on chronic pain outcomes

OBJECTIVE

To examine the effect of depression treatment on medical and social outcomes for individuals with chronic pain and depression. People with chronic pain and depression have worse health outcomes than those with chronic pain alone. Little is known about the effectiveness of depression treatment for this population.

METHODS

Propensity score-weighted analyses, using both waves (1997-1998 and 2000-2001) of the National Survey of Alcohol, Drug, and Mental Health Problems, were used to examine the effect of a) any depression treatment and b) minimally adequate depression treatment on persistence of depression symptoms, depression severity, pain severity, overall health, mental health status, physical health status, social functioning, employment status, and number of workdays missed. Analyses were limited to those who met Composite International Diagnostic Interview Short-Form criteria for major depressive disorder, reported having at least one chronic pain condition, and completed both interviews (n = 553).

RESULTS

Receiving any depression treatment was associated with higher scores on the mental component summary of the Medical Outcomes Study Short Form-12, indicating better mental health (difference = 2.65 points, p = .002) and less interference of pain on work (odds ratio = 0.57, p = .02). Among those receiving treatment, minimal adequacy of treatment was not significantly associated with better outcomes.

CONCLUSIONS

Depression treatment improves mental health and reduces the effects of pain on work among those with chronic pain and depression. Understanding the effect of depression treatment on outcomes for this population is important for employers, healthcare providers treating this population, and policymakers working in this decade of pain control and research to improve care for chronic pain sufferers.