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Kloppe T, Pohontsch NJ, Scherer M. Types of Utilization and Types of Treatment Response in a Collaborative Care Approach for Depressive Disorders in Old Age in Primary Care. Front Psychiatry 2020; 11:565929. [PMID: 33192688 PMCID: PMC7644545 DOI: 10.3389/fpsyt.2020.565929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/16/2020] [Indexed: 11/13/2022] Open
Abstract
Background: Treatment of depressive disorders in old age is hindered by several barriers. Most common are time pressure in primary care and latency for specialized therapeutic care. To improve treatment, the collaborative care approach GermanIMPACT was evaluated in a cluster-randomized controlled trial. Care managers offered a complex stepped-care intervention of monitoring, psychoeducation, and behavioral activation techniques. Twenty-six percent of the intervention group responds with a remission of depressive symptoms compared with 11% who received treatment as usual (TAU). The low-threshold intervention was more successful than TAU. Nevertheless, three-quarters did not respond with a remission. The aim of this study is to identify and describe the different types of utilization and of treatment response to understand what constitutes an effective intervention. Methods: Of 64 patients from the intervention group, we carried out problem-centered interviews with 26 patients from the intervention group. We analyzed the interviews using a qualitative type-building content analysis. For type construction, we performed a contrasting case comparison, regarding inductive and deductive categories of the intervention utilization and the symptom development. Results: The 26 participants' ages ranged from 62 to 87 years (mean = 72 years). Three participants were male. We identified five types of utilization, which differ primarily in the realization of pleasant activations, depending on own activity at the beginning and during the therapy: "activatable relief seekers," "active relief seekers," "active relaxation seekers," "passive problem-solving seekers," and "passive relief seekers." In the second typology, we analyzed four deductively determined types of treatment response responders, slight improvers, constant moderates, and non-responders. Patient-specific characteristics are a recent history of depression, an affinity for activities, supportive contacts, and limited comorbidity. In contrast, non-responders report contrary characteristics. Conclusion: Our two typologies emphasize that an effective intervention requires a match between intervention components and patient characteristics. We saw no intersections between utilization and treatment response. GermanIMPACT is an effective low-threshold intervention for moderately burdened patients, who are still capable of self-activation. An expansion of the intervention, especially for depression with a long history and comorbidities impairing mobility, could increase the effectiveness and improve the care situation of older people suffering from depression.
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Affiliation(s)
- Thomas Kloppe
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nadine Janis Pohontsch
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Scherer
- Department of General Practice and Primary Care, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Hammarberg SAW, Hange D, André M, Udo C, Svenningsson I, Björkelund C, Petersson EL, Westman J. Care managers can be useful for patients with depression but their role must be clear: a qualitative study of GPs' experiences. Scand J Prim Health Care 2019; 37:273-282. [PMID: 31286807 PMCID: PMC6713154 DOI: 10.1080/02813432.2019.1639897] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Objective: Explore general practitioners' (GPs') views on and experiences of working with care managers for patients treated for depression in primary care settings. Care managers are specially trained health care professionals, often specialist nurses, who coordinate care for patients with chronic diseases. Design: Qualitative content analysis of five focus-group discussions. Setting: Primary health care centers in the Region of Västra Götaland and Dalarna County, Sweden. Subjects: 29 GPs. Main outcome measures: GPs' views and experiences of care managers for patients with depression. Results: GPs expressed a broad variety of views and experiences. Care managers could ensure care quality while freeing GPs from case management by providing support for patients and security and relief for GPs and by coordinating patient care. GPs could also express concern about role overlap; specifically, that GPs are already care managers, that too many caregivers disrupt patient contact, and that the roles of care managers and psychotherapists seem to compete. GPs thought care managers should be assigned to patients who need them the most (e.g. patients with life difficulties or severe mental health problems). They also found that transition to a chronic care model required change, including alterations in the way GPs worked and changes that made depression treatment more like treatment for other chronic diseases. Conclusion: GPs have varied experiences of care managers. As a complementary part of the primary health care team, care managers can be useful for patients with depression, but team members' roles must be clear. KEY POINTS A growing number of primary health care centers are introducing care managers for patients with depression, but knowledge about GPs' experiences of this kind of collaborative care is limited. GPs find that care managers provide support for patients and security and relief for GPs. GPs are concerned about potential role overlap and desire greater latitude in deciding which patients can be assigned a care manager. GPs think depression can be treated using a chronic care model that includes care managers but that adjusting to the new way of working will take time.
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Affiliation(s)
- Sandra af Winklerfelt Hammarberg
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden;
- Academic Primary Health Care Centre, Stockholm County Council, Stockholm, Sweden;
- CONTACT Sandra af Winklerfelt Hammarberg Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Alfred Nobels Allé 23, Huddinge 141 52, Stockholm, Sweden
| | - Dominique Hange
- Department of Public Health and Community Medicine, Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
| | - Malin André
- Department of Public Health and Caring Sciences – Family Medicine and Preventive Medicine, Uppsala University, Uppsala, Sweden;
| | - Camilla Udo
- School of Education, Health and Social Studies, Dalarna University, Falun, Sweden;
- CKF, Center for Clinical Research Dalarna, Falun, Sweden;
| | - Irene Svenningsson
- Department of Public Health and Community Medicine, Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
- Närhälsan Research and Development Primary Health Care, Region Västra Götaland, Gothenburg, Sweden;
| | - Cecilia Björkelund
- Department of Public Health and Community Medicine, Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
| | - Eva-Lisa Petersson
- Department of Public Health and Community Medicine, Primary Health Care, Institute of Medicine, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden;
- Närhälsan Research and Development Primary Health Care, Region Västra Götaland, Gothenburg, Sweden;
| | - Jeanette Westman
- Division of Family Medicine and Primary Care, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden;
- Academic Primary Health Care Centre, Stockholm County Council, Stockholm, Sweden;
- Division of Nursing, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet, Stockholm, Sweden
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Hölzel LP, Bjerregaard F, Bleich C, Boczor S, Härter M, König HH, Kloppe T, Niebling W, Scherer M, Tinsel I, Hüll M. Coordinated Treatment of Depression in Elderly People in Primary Care. DEUTSCHES ARZTEBLATT INTERNATIONAL 2018; 115:741-747. [PMID: 30565544 DOI: 10.3238/arztebl.2018.0741] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 03/28/2018] [Accepted: 08/09/2018] [Indexed: 11/27/2022]
Abstract
BACKGROUND Depression in the elderly is mainly treated by primary care physicians; the treatment is often suboptimal because of the limited resources available in pri- mary care. New models of care in which treatment by a primary care physician is supplemented by the provision of brief, low-threshold interventions mediated by care managers are showing themselves to be a promising approach. METHODS In this open, cluster-randomized, controlled study, we sought to determine the superiority of a model of this type over the usual form of treatment by a primary care physician. Patients in primary care aged 60 and above with moderate depres- sive manifestations (PHQ-9: 10-14 points) were included in the study. The primary endpoint was the percentage of patients in remission (score <5 on the Patient Health Questionnaire, PHQ-9) after the end of the intervention (12 months after baseline). The study was registered in the German Clinical Studies Registry (Deutsches Register für Klinische Studien) with the number DRKS00003589. RESULTS 71 primary care physicians entered 248 patients in the study, of whom 109 were in the control group and 139 in the intervention group. In an intention-to-treat analysis, the remission rate at 12 months was 25.6% (95% confidence interval [18.3; 32.8]) in the intervention group and 10.9% [5.4; 16.5]) in the control group (p = 0.004). CONCLUSION This study demonstrates the superiority of the new care model in the primary care setting in Germany, as has been found in other countries.
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Affiliation(s)
- Lars P Hölzel
- Department of Psychiatry and Psychotherapy, Medical Center-University of Freiburg, Faculty ofMedicine, University of FreiburgParkklinik Wiesbaden Schlangenbad, SchlangenbadDepartment of Medical Psychology, University Medical Center Hamburg-Eppendorf, HamburgInstitute of General Medicine, University Medical Center Hamburg-Eppendorf, HamburgInstitute for Health Economics and Health Care Research, University Medical Center Hamburg-Eppendorf, HamburgDivision of General Practice, Medical Center-University of Freiburg, Faculty of Medicine, Universityof FreiburgClinic for Gerontopsychiatry and Psychotherapy, Center for Psychiatry, Emmendingen
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Bjerregaard F, Zech J, Frank F, Hüll M, Stieglitz RD, Hölzel L. [Implementation of the GermanIMPACT collaborative care program: A qualitative study on the perspective of care managers and supervisors]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2018; 134:42-48. [PMID: 29907445 DOI: 10.1016/j.zefq.2018.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Revised: 02/17/2018] [Accepted: 04/09/2018] [Indexed: 10/14/2022]
Abstract
BACKGROUND Collaborative Care programs like the Improving Mood Promoting Access to Collaborative Care Program (IMPACT) present an opportunity to support primary care for elderly depressed patients. The GermanIMPACT study evaluates whether this low-threshold model using short behavioral interventions that are conducted by care managers and supervised by a psychotherapist/psychiatrist, is as effective as in other countries. Besides effectiveness, the feasibility of the intervention is also essential for the implementation of the program. METHOD Care managers and supervisors were interviewed using a qualitative interview guide with questions concerning feasibility and effectiveness of the GermanIMPACT intervention, and the interviews were then evaluated using qualitative content analysis. RESULTS The interviewees provided important information on how to optimize the realization of the intervention by selecting patients more carefully and by providing case managers with more training. Moreover, the intervention was described as being supportive of patients and as providing relief for general practitioners. Whereas interviewees wanted the intervention to be expanded to other disorders, they simultaneously highlighted the limits of the intervention. CONCLUSIONS The present study provides practical information for implementing the GermanIMPACT model. Thus, specific recommendations for implementation into standard care can be derived.
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Affiliation(s)
- Frederike Bjerregaard
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Freiburg, Deutschland.
| | - Julia Zech
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Freiburg, Deutschland
| | - Fabian Frank
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Freiburg, Deutschland; Fachbereich Soziale Arbeit, Evangelische Hochschule Freiburg, Freiburg, Deutschland
| | - Michael Hüll
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Freiburg, Deutschland; Klinik für Alterspsychiatrie- und Psychotherapie, Zentrum für Psychiatrie und Psychotherapie Emmendingen, Emmendingen, Deutschland
| | - Rolf-Dieter Stieglitz
- Abteilung klinische Psychologie und Psychiatrie, Fakultät für Psychologie, Universität Basel, Basel, Schweiz
| | - Lars Hölzel
- Klinik für Psychiatrie und Psychotherapie, Universitätsklinikum Freiburg, Freiburg, Deutschland; Parkklinik Wiesbaden Schlangenbad, Schlangenbad, Deutschland
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