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Williams NJ, Russo J, Vredevoogd M, Grover T, Green P, Proctor E, Bhat A, Unützer J, Bennett IM. Association of organizational culture and climate with variation in the clinical outcomes of collaborative care for maternal depression in community health centers. IMPLEMENTATION RESEARCH AND PRACTICE 2023; 4:26334895231205891. [PMID: 37936965 PMCID: PMC10576428 DOI: 10.1177/26334895231205891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2023] Open
Abstract
Background Organizational factors may help explain variation in the effectiveness of evidence-based clinical innovations through implementation and sustainment. This study tested the relationship between organizational culture and climate and variation in clinical outcomes of the Collaborative Care Model (CoCM) for treatment of maternal depression implemented in community health centers. Method Organizational cultures and climates of 10 community health centers providing CoCM for depression among low-income women pregnant or parenting were assessed using the organizational social context (OSC) measure. Three-level hierarchical linear models tested whether variation in culture and climate predicted variation in improvement in depression symptoms from baseline to 6.5-month post-baseline for N = 468 women with care ±1 year of OSC assessment. Depression symptomology was measured using the Patient Health Questionnaire (PHQ-9). Results After controlling for patient characteristics, case mix, center size, and implementation support, patients served by centers with more proficient cultures improved significantly more from baseline to 6.5-month post-baseline than patients in centers with less proficient cultures (mean improvement = 5.08 vs. 0.14, respectively, p = .020), resulting in a large adjusted effect size of dadj = 0.78. A similar effect was observed for patients served by centers with more functional climates (mean improvement = 5.25 vs. 1.12, p < .044, dadj = 0.65). Growth models indicated that patients from all centers recovered on average after 4 months of care. However, those with more proficient cultures remained stabilized whereas patients served by centers with less proficient cultures deteriorated by 6.5-month post-baseline. A similar pattern was observed for functional climate. Conclusions Variation in clinical outcomes for women from historically underserved populations receiving Collaborative Care for maternal depression was associated with the organizational cultures and climates of community health centers. Implementation strategies targeting culture and climate may improve the implementation and effectiveness of integrated behavioral health care for depression.
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Affiliation(s)
| | - Joan Russo
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Melinda Vredevoogd
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Tess Grover
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Phillip Green
- Center for Behavioral Health Research, University of Tennessee, Knoxville, TN, USA
| | - Enola Proctor
- Brown School of Social Work, Washington University, Saint Louis, MO, USA
| | - Amritha Bhat
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Jürgen Unützer
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
| | - Ian M. Bennett
- Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Seattle, WA, USA
- Department of Family Medicine, University of Washington School of Medicine, Seattle, WA, USA
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Blackmore MA, Patel UB, Stein D, Carleton KE, Ricketts SM, Ansari AM, Chung H. Collaborative Care for Low-Income Patients From Racial-Ethnic Minority Groups in Primary Care: Engagement and Clinical Outcomes. Psychiatr Serv 2022; 73:842-848. [PMID: 35139653 DOI: 10.1176/appi.ps.202000924] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To assess model impact and opportunities for improvement, this study examined collaborative care model (CoCM) engagement and clinical outcomes among low-income patients from racial-ethnic minority groups with depression and anxiety. METHODS Starting in 2015, the CoCM was implemented in seven primary care practices of an urban academic medical center serving patients from racial-ethnic minority backgrounds, predominantly Medicaid beneficiaries. Eligible individuals scored positive for depressive or anxiety symptoms (or both) on the Patient Health Questionnaire-2 (PHQ-2) and PHQ-9 and the Generalized Anxiety Disorder Scale-2 (GAD-2) and GAD-7 during systematic screening in primary care settings. Screening rates and yield, patient characteristics, and CoCM engagement and outcomes were examined. Clinical improvement was measured by the difference in PHQ-9 and GAD-7 scores at baseline and at 10-to-14-week follow-up. RESULTS High rates of screening (87%, N=88,236 of 101,091) and identification of individuals with depression or anxiety (13%, N=11,886) were observed, and 58% of 3,957 patients who engaged in minimally adequate CoCM treatment had significant clinical improvement. Nevertheless, only 56% of eligible patients engaged in the model, and 25% of those individuals did not return for at least one follow-up appointment. Being female with clinically significant comorbid anxiety and depressive symptoms and having Medicaid or commercial insurance increased the likelihood of CoCM engagement. CONCLUSIONS CoCM can help engage vulnerable patients in behavioral health care and improve clinical symptoms. However, significant opportunity exists to advance the model's impact in treating depressive and anxiety disorders and decreasing health disparities by addressing engagement barriers.
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Affiliation(s)
- Michelle A Blackmore
- Montefiore Care Management Organization (Blackmore, Ricketts), Einstein College of Medicine (Patel, Chung), and Montefiore Medical Group (Ansari), Montefiore Health System, Yonkers, New York; CareMount Medical, Population Health (Stein), and Mantra Health (Carleton), New York City
| | - Urvashi B Patel
- Montefiore Care Management Organization (Blackmore, Ricketts), Einstein College of Medicine (Patel, Chung), and Montefiore Medical Group (Ansari), Montefiore Health System, Yonkers, New York; CareMount Medical, Population Health (Stein), and Mantra Health (Carleton), New York City
| | - Dana Stein
- Montefiore Care Management Organization (Blackmore, Ricketts), Einstein College of Medicine (Patel, Chung), and Montefiore Medical Group (Ansari), Montefiore Health System, Yonkers, New York; CareMount Medical, Population Health (Stein), and Mantra Health (Carleton), New York City
| | - Kelly E Carleton
- Montefiore Care Management Organization (Blackmore, Ricketts), Einstein College of Medicine (Patel, Chung), and Montefiore Medical Group (Ansari), Montefiore Health System, Yonkers, New York; CareMount Medical, Population Health (Stein), and Mantra Health (Carleton), New York City
| | - Sarah M Ricketts
- Montefiore Care Management Organization (Blackmore, Ricketts), Einstein College of Medicine (Patel, Chung), and Montefiore Medical Group (Ansari), Montefiore Health System, Yonkers, New York; CareMount Medical, Population Health (Stein), and Mantra Health (Carleton), New York City
| | - Asif M Ansari
- Montefiore Care Management Organization (Blackmore, Ricketts), Einstein College of Medicine (Patel, Chung), and Montefiore Medical Group (Ansari), Montefiore Health System, Yonkers, New York; CareMount Medical, Population Health (Stein), and Mantra Health (Carleton), New York City
| | - Henry Chung
- Montefiore Care Management Organization (Blackmore, Ricketts), Einstein College of Medicine (Patel, Chung), and Montefiore Medical Group (Ansari), Montefiore Health System, Yonkers, New York; CareMount Medical, Population Health (Stein), and Mantra Health (Carleton), New York City
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Ten-year trends in depression care in Taiwan. J Formos Med Assoc 2022; 121:2001-2011. [DOI: 10.1016/j.jfma.2022.02.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 11/24/2021] [Accepted: 02/11/2022] [Indexed: 12/15/2022] Open
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Factors Affecting Health-Promoting Behaviors in Patients with Cardiovascular Disease. Healthcare (Basel) 2021; 9:healthcare9010060. [PMID: 33435583 PMCID: PMC7827905 DOI: 10.3390/healthcare9010060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/31/2020] [Accepted: 01/05/2021] [Indexed: 11/29/2022] Open
Abstract
Cardiovascular disease is the leading cause of death globally and the second most common cause of death in South Korea. Health-promoting behaviors recommended for patients with cardiovascular disease include control of diet, physical activity, cessation of smoking, medication adherence, and adherence to medical recommendations. This study aimed to determine the relationship between depression, anxiety, perception of health status, and health-promoting behavior in patients from South Korea who have suffered from cardiovascular disease. The study population comprised 161 patients at the cardiovascular center at H Hospital who were diagnosed with cardiovascular disease. Descriptive statistics and stepwise multiple regression were employed to analyze the data. Negative correlations existed between depression, perception of health status, and health-promoting behavior. By contrast, a positive correlation existed between the perception of health status and health-promoting behavior. The main factors affecting health-promoting behaviors were alcohol consumption, duration of diagnosis, perception of health status, and depression. These variables explained 15.8% of the variance. To prevent adverse cardiac events, patients who suffer from cardiovascular disease should be assessed as soon as possible to identify psychiatric symptoms, thereby developing a potential intervention aimed at decreasing negative illness consequences.
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Rasmussen LR, Videbech P, Mainz J, Johnsen SP. Gender- and age-related differences in the quality of mental health care among inpatients with unipolar depression: a nationwide study. Nord J Psychiatry 2020; 74:569-576. [PMID: 32401125 DOI: 10.1080/08039488.2020.1764619] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Objective: The relationship between gender, age and the quality of mental health care among inpatients with depression is unclear. This study examined gender- and age-related differences in the quality of care as reflected by the fulfilment of process performance measures of care among inpatients with unipolar depression in Denmark.Methods: In a nationwide cohort study, 16,858 patients admitted to psychiatric hospital wards for depression between 2011 and 2016 were identified from the Danish Depression Database. Patients were divided according to age (18-39, 40-65, 66-79 and ≥80 years) and stratified by gender. Quality of care was defined as having fulfilled process performance measures of care, reflecting national clinical guideline recommendations. High overall quality of care was defined as having received ≥80% of the processes. The associations were assessed using binomial regressions.Results: With men in the age group 18-39 years serving as the reference, men and women in the age category ≥80 years were more likely to receive higher quality of care with an adjusted relative risk (aRR) of 1.43 [95% confidence interval (CI) = 0.98; 2.10] and 1.30 (95% CI = 0.90; 1.90), respectively. Likewise, for men and women aged 66-79 years, the aRRs as 1.34 (95% CI = 1.07; 1.67) and 1.47 (95% CI = 1.14; 1.90). For men and women aged 40-65, the aRRs was 1.15 (95% CI = 1.00; 1.33) and 1.07 (95% CI = 0.93; 1.24), respectively.Conclusion: Older patients received higher quality of inpatient care for depression, as reflected by a higher proportion of fulfilled guideline supported process measures. In contrast, we found no gender-related differences.
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Affiliation(s)
- Line Ryberg Rasmussen
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg University Hospital, Aalborg, Denmark
| | - Poul Videbech
- Center for Neuropsychiatric Depression Research, Mental Health Center, Copenhagen University Hospital, Glostrup, Denmark
| | - Jan Mainz
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg University Hospital, Aalborg, Denmark.,Department of Psychiatry, Aalborg University Hospital, Aalborg, Denmark.,Department for Community Mental Health, University of Haifa, Haifa, Israel
| | - Søren Paaske Johnsen
- Danish Center for Clinical Health Services Research (DACS), Department of Clinical Medicine, Aalborg University, Aalborg University Hospital, Aalborg, Denmark
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Leung LB, Rubenstein LV, Post EP, Trivedi RB, Hamilton AB, Yoon J, Jaske E, Yano EM. Association of Veterans Affairs Primary Care Mental Health Integration With Care Access Among Men and Women Veterans. JAMA Netw Open 2020; 3:e2020955. [PMID: 33079197 PMCID: PMC7576407 DOI: 10.1001/jamanetworkopen.2020.20955] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
IMPORTANCE Women veterans increasingly seek care yet continue to face barriers in the Veterans Health Administration (VA), which predominantly cares for men. Evidence-based collaborative care models can improve patient access to treatment of depression, which is experienced at higher rates by women. While the VA has implemented these care models nationally, it is not known whether access improvements occur equitably across genders in primary care. OBJECTIVE To examine whether the VA's national Primary Care-Mental Health Integration (PC-MHI) initiative (beginning 2007) expanded realized access to mental health care similarly for men and women. DESIGN, SETTING, AND PARTICIPANTS This cohort study included 5 377 093 million primary care patients assigned to 396 VA clinics that provided integrated mental health services nationally between October 2013 and September 2016. Data analysis occurred between May 2017 and July 2020. EXPOSURES Clinic PC-MHI penetration, calculated as the proportion of clinic patients who saw an integrated specialist per fiscal year. MAIN OUTCOMES AND MEASURES Estimates of mean VA health care utilization (mental health, primary care, other specialty care, telephone, hospitalizations) and median total costs for men and women. Multilevel models adjusted for year, clinic, patient characteristics, and interactions between patient-defined gender and clinic PC-MHI penetration. RESULTS This study examined 5 377 093 veterans (448 455 [8.3%] women; 3 744 140 [69.6%] White) with a mean (SD) baseline age 62.0 (16.6) years. Each percentage-point increase in the proportion of clinic patients who saw an integrated specialist was associated with 38% fewer mental health visits per year for women (incidence rate ratio [IRR], 0.62; 95% CI, 0.60-0.65), but 39% more visits for men (IRR, 1.39; 95% CI, 1.34-1.44; P < .001). Both men and women had more primary care visits (men: IRR, 1.40; 95% CI, 1.36-1.45; women: IRR, 1.22; 95% CI, 1.17-1.28; P < .001) and total costs (men: β [SE], 2.23 [0.10]; women: β [SE], 1.24 [0.15]; P = .06), but women had 74% fewer hospitalizations than men related to clinics with mental health integration (IRR, 0.26; 95% CI, 0.19-0.36 vs IRR, 1.02; 95% CI, 0.83-1.24; P < .001). CONCLUSIONS AND RELEVANCE While greater outpatient service use for men was observed in this study, PC-MHI was associated with a decrease in mental health specialty visits (and hospitalizations) for women veterans, potentially signifying a shift of services to primary care. With increasing patient choice for where veterans receive care, the VA must tailor medical care to the needs of rising numbers of women patients. Differences in health care utilization by gender highlight the importance of anticipating policy impacts on and tailoring services for patients in the numerical minority in the VA and other health systems.
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Affiliation(s)
- Lucinda B. Leung
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
| | - Lisa V. Rubenstein
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, University of California, Los Angeles
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
- RAND Corporation, Santa Monica, California
| | - Edward P. Post
- Center for Clinical Management Research, VA Ann Arbor Health Care System, Ann Arbor, Michigan
- Department of Medicine, University of Michigan Medical School, Ann Arbor
| | - Ranak B. Trivedi
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California
- VA Palo Alto Health Care System, Menlo Park, California
| | - Alison B. Hamilton
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Psychiatry and Biobehavioral Sciences, Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles
| | - Jean Yoon
- VA Palo Alto Health Care System, Menlo Park, California
- Department of General Internal Medicine, University of California, San Francisco
| | - Erin Jaske
- VA Puget Sound Health Care System, Seattle, Washington
| | - Elizabeth M. Yano
- Center for the Study of Healthcare Innovation, Implementation, and Policy, VA Greater Los Angeles Healthcare System, Los Angeles, California
- Department of Health Policy and Management, Fielding School of Public Health, University of California, Los Angeles
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Treatment Initiation for New Episodes of Depression in Primary Care Settings. J Gen Intern Med 2018; 33:1283-1291. [PMID: 29423624 PMCID: PMC6082193 DOI: 10.1007/s11606-017-4297-2] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2017] [Revised: 08/30/2017] [Accepted: 12/22/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Depression is prevalent and costly, but despite effective treatments, is often untreated. Recent efforts to improve depression care have focused on primary care settings. Disparities in treatment initiation for depression have been reported, with fewer minority and older individuals starting treatment. OBJECTIVE To describe patient characteristics associated with depression treatment initiation and treatment choice (antidepressant medications or psychotherapy) among patients newly diagnosed with depression in primary care settings. DESIGN A retrospective observational design was used to analyze electronic health record data. PATIENTS A total of 241,251 adults newly diagnosed with depression in primary care settings among five health care systems from 2010 to 2013. MAIN MEASURES ICD-9 codes for depression, following a 365-day period with no depression diagnosis or treatment, were used to identify new depression episodes. Treatment initiation was defined as a completed psychotherapy visit or a filled prescription for antidepressant medication within 90 days of diagnosis. Depression severity was measured with Patient Health Questionnaire (PHQ-9) scores on the day of diagnosis. KEY RESULTS Overall, 35.7% of patients with newly diagnosed depression initiated treatment. The odds of treatment initiation among Asians, non-Hispanic blacks, and Hispanics were at least 30% lower than among non-Hispanic whites, controlling for all other variables. The odds of patients aged ≥ 60 years starting treatment were half those of patients age 44 years and under. Treatment initiation increased with depression severity, but was only 53% among patients with a PHQ-9 score of ≥ 10. Among minority patients, psychotherapy was initiated significantly more often than medication. CONCLUSIONS Screening for depression in primary care is a positive step towards improving detection, treatment, and outcomes for depression. However, study results indicate that treatment initiation remains suboptimal, and disparities persist. A better understanding of patient factors, and particularly system-level factors, that influence treatment initiation is needed to inform efforts by heath care systems to improve depression treatment engagement and to reduce disparities.
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Collaborative Care for Depression among Patients with Limited English Proficiency: a Systematic Review. J Gen Intern Med 2018; 33:347-357. [PMID: 29256085 PMCID: PMC5834967 DOI: 10.1007/s11606-017-4242-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 10/13/2017] [Accepted: 11/17/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Patients with limited English proficiency (LEP) have high rates of depression, yet face challenges accessing effective care in outpatient settings. We undertook a systematic review to investigate the effectiveness of the collaborative care model for depression for LEP patients in primary care. METHODS We queried online PubMed, PsycINFO, CINAHL and EMBASE databases (January 1, 2000, to June 10, 2017) for quantitative studies comparing collaborative care to usual care to treat depression in adults with LEP in primary care. We evaluated the impact of collaborative care on depressive symptoms or on depression treatment. Two reviewers independently extracted key data from the studies and assessed risk of bias using the Cochrane bias and quality assessment tool (RCTs) and the Newcastle-Ottawa Quality Assessment Scale (non-RCTs). RESULTS Of 86 titles identified, 15 were included (representing 9 studies: 5 RCTs, 3 cohort studies, and 1 case-control study). Studies included 4859 participants; 2679 (55%) reported LEP. The majority spoke Spanish (93%). The wide variability in study design and outcome definitions precluded performing a meta-analysis. Follow-up ranged from 3 months to 2 years. Three of four high-quality RCTs reported that 13-25% more patients had improved depressive symptoms when treated with culturally tailored collaborative care compared to usual care; the last had high treatment in the control arm and found equal improvement. Two non-RCT studies suggest that Spanish-speaking patients may benefit as much as, if not more than, English-speaking patients treated with collaborative care. The remaining studies reported increased receipt of preferred depression treatment (therapy vs. antidepressants) in the intervention groups. Eight of nine studies used bilingual providers to deliver the intervention. DISCUSSION While limited by the number and variability of studies, the available research suggests that collaborative care for depression delivered by bilingual providers may be more effective than usual care among patients with LEP. Implementation studies of collaborative care, particularly among Asian and non-Spanish-speakers, are needed.
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Grubbs KM, Cheney AM, Fortney JC, Edlund C, Han X, Dubbert P, Sherbourne CD, Craske MG, Stein MB, Roy-Byrne PP, Sullivan JG. The role of gender in moderating treatment outcome in collaborative care for anxiety. Psychiatr Serv 2015; 66:265-71. [PMID: 25727114 PMCID: PMC4453769 DOI: 10.1176/appi.ps.201400049] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE The aim of this study was to test whether gender moderates intervention effects in the Coordinated Anxiety Learning and Management (CALM) intervention, a 12-month, randomized controlled trial of a collaborative care intervention for anxiety disorders (panic disorder, generalized anxiety disorder, posttraumatic stress disorder, and social anxiety disorder) in 17 primary care clinics in California, Washington, and Arkansas. METHODS Participants (N=1,004) completed measures of symptoms (Brief Symptom Inventory [BSI]) and functioning (mental and physical health components of the 12-Item Short Form [MCS and PCS] and Healthy Days, Restricted Activity Days Scale) at baseline, six, 12, and 18 months. Data on dose, engagement, and beliefs about psychotherapy were collected for patients in the collaborative care group. RESULTS Gender moderated the relationship between treatment and its outcome on the BSI, MCS, and Healthy Days measures but not on the PCS. Women who received collaborative care showed clinical improvements on the BSI, MHC, and Healthy Days that were significantly different from outcomes for women in usual care. There were no differences for men in collaborative care compared with usual care on any measures. In the intervention group, women compared with men attended more sessions of psychotherapy, completed more modules of therapy, expressed more commitment, and viewed psychotherapy as more helpful. CONCLUSIONS These findings contribute to the broader literature on treatment heterogeneity, in particular the influence of gender, and may inform personalized care for people seeking anxiety treatment in primary care settings.
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Affiliation(s)
- Kathleen M Grubbs
- Dr. Grubbs and Dr. Dubbert are with the Mental Illness Research, Education, and Clinical Center (MIRECC) and Central Arkansas Veterans Healthcare System (CAVHS), North Little Rock (e-mail: ). Dr. Cheney, Dr. Fortney, and Ms. Han are with the Center for Mental Health Outcomes Research, CAVHS. They are also with the Department of Psychiatry, University of Arkansas for Medical Sciences, Little Rock, where Dr. Sullivan is affiliated. Ms. Edlund is with MIRECC and the Department of Psychiatry, University of Arkansas for Medical Sciences. Dr. Sherbourne is with the Health Program of RAND, Santa Monica, California. Dr. Craske is with the Department of Clinical Psychiatry, University of California, Los Angeles. Dr. Stein is with the Department of Psychiatry and the Department of Family and Preventive Medicine, University of California, San Diego. Dr. Roy-Byrne is with the Department of Psychiatry, Harborview Medical Center, University of Washington School of Medicine, Seattle
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Ratzliff ADH, Ni K, Chan YF, Park M, Unützer J. A collaborative care approach to depression treatment for Asian Americans. Psychiatr Serv 2013; 64:487-90. [PMID: 23632577 PMCID: PMC4841443 DOI: 10.1176/appi.ps.001742012] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study examined effectiveness of collaborative care for depression among Asians treated either at a community health center that focuses on Asians (culturally sensitive clinic) or at general community health centers and among a matched population of whites treated at the same general community clinics. METHODS For 345 participants in a statewide collaborative care program, use of psychotropic medications, primary care visits with depression care managers, and depression severity (as measured with the nine-item Patient Health Questionnaire) were tracked at baseline and 16 weeks. RESULTS After adjustment for differences in baseline demographic characteristics, all three groups had similar treatment process and depression outcomes. Asian patients served at the culturally sensitive clinic (N=129) were less likely than Asians (N=72) and whites (N=144) treated in general community health clinics to be prescribed psychotropic medications. CONCLUSIONS Collaborative care for depression showed similar response rates among all three groups.
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Affiliation(s)
- Anna D H Ratzliff
- Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 N.E. Pacific St., Seattle, WA 98195-6560, USA.
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Angstman KB, Shippee ND, Maclaughlin KL, Rasmussen NH, Wilkinson JM, Williams MD, Katzelnick DJ. Patient self-assessment factors predictive of persistent depressive symptoms 6 months after enrollment in collaborative care management. Depress Anxiety 2013; 30:143-8. [PMID: 23139162 DOI: 10.1002/da.22020] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2012] [Revised: 09/05/2012] [Accepted: 10/12/2012] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND Collaborative care management (CCM) is effective for improving depression outcomes. However, a subset of patients will still have symptoms after 6 months. This study sought to determine whether routinely obtained baseline clinical, demographic, and self-assessment variables would predict which patients endorse persistent depressive symptoms (PDS) after 6 months. By estimating the relative risk associated with the patient variables, we aimed to outline the combinations of factors predictive of PDS after CCM enrollment. METHODS We retrospectively reviewed 1,110 adult primary care patients with the diagnosis of major depressive disorder enrolled in a CCM program and evaluated those with PDS (defined as patient health questionnaire-9score ≥10) 6 months after enrollment. RESULTS At baseline, an increased depression severity, worsening symptoms of generalized anxiety, an abnormal screening on the mood disorder questionnaire (MDQ) and the diagnosis of recurrent episode of depression were independent predictors of PDS. A patient with severe, recurrent depression, an abnormal MDQ screen, and severe anxiety at baseline had a predicted 42.1% probability of PDS at 6 months. In contrast, a patient with a moderate, first episode of depression, normal MDQ screen, and no anxiety symptoms had a low probability of PDS at 6.6%. CONCLUSIONS This study identified several patient self-assessment scores and clinical diagnosis that markedly predicted the probability of PDS 6 months after diagnosis and enrollment into CCM. Knowledge of these high-risk attributes should alert the clinician to monitor select patients more closely and consider altering therapy appropriately.
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Affiliation(s)
- Kurt B Angstman
- Department of Family Medicine, Mayo Clinic, Rochester, Minnesota 55905, USA.
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Hinton L, Apesoa-Varano EC, González HM, Aguilar-Gaxiola S, Dwight-Johnson M, Barker JC, Tran C, Zuniga R, Unützer J. Falling through the cracks: gaps in depression treatment among older Mexican-origin and white men. Int J Geriatr Psychiatry 2012; 27:1283-90. [PMID: 22383214 PMCID: PMC3560929 DOI: 10.1002/gps.3779] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2011] [Accepted: 01/09/2012] [Indexed: 11/11/2022]
Abstract
OBJECTIVES This study aims (i) to compare depression frequency and self-reported depression treatment in Mexican-origin and white men; (ii) to examine ethnic differences in self-reported prior depression diagnosis and types of treatment; and (iii) to determine whether Mexican-origin men (both English and Spanish language preferring) are less likely than white men to report receiving depression treatment after controlling for potential confounders. METHODS This is a cross-sectional, observational study of Mexican-origin and white men (60 years old and over) presenting for primary care visits at six outpatient clinics in California's Central Valley. Clinical depression was assessed with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), module for past-year major depression and questions for chronic depression. Past year, self-reported prior depression diagnosis and treatment (i.e., medication, psychotherapy, mental health referral) were assessed through a structured questionnaire. RESULTS The frequency of past-year clinical depression was similar for both ethnic groups, yet Mexican-origin men were significantly less likely than whites to report receiving a prior diagnosis of depression or prior depression treatment. Compared with whites, the odds of untreated depression in Mexican-origin men was 4.35 (95% CI 1.35-14.08) for those interviewed in English and 10.40 (95% CI 2.11-51.25) for those interviewed in Spanish. For both ethnic groups, the majority (i.e., approximately two-thirds) of men receiving depression treatment also met criteria for past-year clinical depression. CONCLUSIONS Mexican-origin older men in primary care suffer from significant gaps in depression care (i.e., diagnosis and treatment) compared with whites. Delivering effective depression treatment (i.e., so that depression remits) remains elusive for both ethnic groups.
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Affiliation(s)
- Ladson Hinton
- Psychiatry and Behavioral Sciences, University of California Davis, Sacramento, CA, USA.
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Bauer AM, Azzone V, Goldman HH, Alexander L, Unützer J, Coleman-Beattie B, Frank RG. Implementation of collaborative depression management at community-based primary care clinics: an evaluation. Psychiatr Serv 2011; 62:1047-53. [PMID: 21885583 PMCID: PMC3250309 DOI: 10.1176/appi.ps.62.9.1047] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE This study evaluated a large demonstration project of collaborative care of depression at community health centers by examining the role of clinic site on two measures of quality care (early follow-up and appropriate pharmacotherapy) and on improvement of symptoms (score on Patient Health Questionnaire-9 reduced by 50% or ≤ 5). METHODS A quasi-experimental study examined data on the treatment of 2,821 patients aged 18 and older with depression symptoms between 2006 and 2009 at six community health organizations selected in a competitive process to implement a model of collaborative care. The model's key elements were use of a Web-based disease registry to track patients, care management to support primary care providers and offer proactive follow-up of patients, and organized psychiatric consultation. RESULTS Across all sites, a plurality of patients achieved meaningful improvement in depression, and in many sites, improvement occurred rapidly. After adjustment for patient characteristics, multivariate logistic regression models revealed significant differences across clinics in the probability of receiving early follow-up (range .34-.88) or appropriate pharmacotherapy (range .27-.69) and in experiencing improvement (.36 to .84). Similarly, after adjustment for patient characteristics, Cox proportional hazards models revealed that time elapsed between first evaluation and the occurrence of improvement differed significantly across clinics (p<.001). CONCLUSIONS Despite receiving similar training and resources, organizations exhibited substantial variability in enacting change in clinical care systems, as evidenced by both quality indicators and outcomes. Sites that performed better on quality indicators had better outcomes, and the differences were not attributable to patients' characteristics.
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Affiliation(s)
- Amy M Bauer
- Department of Psychiatry and Behavioral Sciences, University of Washington, 1959 NE Pacific St, Box 356560, Seattle, WA 98195, USA.
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