Increased Anxiety and Length of Treatment Associated With Depressed Patients Who are Readmitted to Collaborative Care

Depression Outcomes in Smokers and Nonsmokers: Comparison of Collaborative Care Management Versus Usual Care

Background: Depression is common in the primary care setting and tobacco use is more prevalent among individuals with depression. Recent research has linked smoking to poorer outcomes of depression treatment. We hypothesized that in adult primary care patients with the diagnosis of depression, current smoking would have a negative impact on clinical outcomes, regardless of treatment type (usual primary care [UC] vs collaborative care management [CCM]). Methods: A retrospective chart review study of 5155 adult primary care patients with depression in a primary care practice in southeast Minnesota was completed. Variables obtained included age, gender, marital status, race, smoking status, initial Patient Health Questionnaire-9 (PHQ-9), and 6-month PHQ-9. Clinical remission (CR) was defined as 6-month PHQ-9 <5. Persistent depressive symptoms (PDS) were defined as PHQ-9 ≥10 at 6 months. Treatment in both CCM and UC were compared. Results: Using intention to treat analysis, depressed smokers treated with CCM were 4.60 times as likely (95% CI 3.24-6.52, P < .001) to reach CR and were significantly less likely to have PDS at 6 months (adjusted odds ratio [AOR] 0.19, 95% CI 0.14-0.25, P < .001) compared with smokers in UC. After a 6-month follow-up, depressed smokers treated with CCM were 1.75 times as likely (95% CI 1.18-2.59, P = .006) to reach CR and were significantly less likely to have PDS (AOR 0.45, 95% CI 0.31-0.64, P < .001) compared with smokers in UC. Conclusions: CCM significantly improved depression outcomes for smokers at 6 months compared with UC. However, in the UC group, smoking outcomes were not statistically different at 6 months for either remission or PDS. Also, nonsmokers in CCM had the best clinical outcomes at 6 months in both achieving clinical remission and reduction of PDS when compared with smokers in UC as the reference group.

Six-Month Outcomes for Collaborative Care Management of Depression Among Smoking and Nonsmoking Patients

Background:

Collaborative care management (CCM) is an evidence-based model that contributes to better outcomes for depression treatment in the primary care setting. Tobacco use increases overall economic costs, morbidity, and mortality and has been shown to impact behavioral health outcomes. Our study aims to observe clinical outcomes for depression treatment for patients with comorbid tobacco use and depression within the CCM model.

Methods:

A retrospective chart review study of 2826 adult patients with depression enrolled in CCM was performed to determine the association between regular tobacco use and depression outcomes. Baseline intake data consisting of clinical and demographic variables along with 6-month follow-up of Patient Health Questionnaire-9 (PHQ-9) scores for smokers (n = 727, 25.7%) and nonsmokers (n = 2099, 74.3%) were obtained. Depression remission was defined as a PHQ-9 score <5 and persistent depressive symptoms (PDS) as a PHQ-9 score ≥10 at 6 months.

Results:

Using an intention-to-treat analysis, the multivariate modeling demonstrated that smokers, at 6 months, had an increased adjusted odds ratio (AOR) for PDS: 1.624 (95% CI: 1.353-1.949). Furthermore, smokers had a lower AOR of depression remission: 0.603 (95% CI: 0.492-0.739). Patient adherence to treatment was also lower in smokers with an AOR of 0.666 (95% CI: 0.553-0.802).

Conclusions:

Smokers enrolled in CCM were associated with reduced treatment adherence and worse outcomes for depression treatment at 6 months compared to nonsmokers, even when baseline clinical and demographic variables were controlled. Thus, new tailored practices may be warranted within the CCM model to treat comorbid depression and tobacco use disorders.

Secondary depression in severe anxiety disorders: a population-based cohort study in Denmark

BACKGROUND

Depression and anxiety disorders are highly comorbid conditions and a worldwide disease burden; however, large-scale studies delineating their association are scarce. In this retrospective study, we aimed to assess the effect of severe anxiety disorders on the risk and course of depression.

METHODS

We did a population-based cohort study with prospectively gathered data in Denmark using data from three Danish population registers: The Danish Civil Registration System, the Danish Psychiatric Central Register, and the Danish National Hospital Registry. We selected the cohort from people born in Denmark between Jan 1, 1955, and Dec 31, 2002, who we followed up from Jan 1, 1994, to Dec 31, 2012. The cohort was restricted to individuals with known parents. First, we investigated the effect of specific anxiety diagnoses on risk of single depressive episodes and recurrent depressive disorder. Second, we investigated the effect of comorbid anxiety on risk of readmission for depression, adjusting for sex, age, calendar year, parental age, place at residence at time of birth, and the interaction of age with sex.

FINDINGS

We included 3,380,059 individuals in our study cohort. The adjusted incidence rate ratio (IRR) for single depressive episodes was 3·0 (95% CI 2·8-3·1, p<0·0001) and for recurrent depressive disorder was 5·0 (4·8-5·2) in patients with severe anxiety disorders compared with the general population. Compared with control individuals, the offspring of parents with anxiety disorders were more likely to be diagnosed with single depressive episodes (1·9, 1·8-2·0) or recurrent depressive disorder (2·1, 1·9-2·2). Comorbid anxiety increased the readmission rates in both patients with single depressive episodes and patients with recurrent depressive disorder.

INTERPRETATION

Severe anxiety constitutes a significant risk factor for depression. Focusing on specific anxiety disorders might help to identify individuals at risk of depression, thereby providing new insights for prevention and treatment.

FUNDING

The Lundbeck Foundation Initiative for Integrative Psychiatric Research (iPSYCH).

Impact of symptom remission on outpatient visits in depressed primary care patients treated with collaborative care management and usual care

Depression symptoms contribute to significant morbidity and health care utilization. The aim of this study was to determine the impact of symptom improvement (to remission) on outpatient clinical visits by depressed primary care patients. This study was a retrospective chart review analysis of 1733 primary care patients enrolled into collaborative care management (CCM) or usual care (UC) with 6-month follow-up data. Baseline data (including demographic information, clinical diagnosis, and depression severity) and 6-month follow-up data (Patient Health Questionnaire scores and the number of outpatient visits utilized) were included in the data set. To control for individual patient complexity and pattern of usage, the number of outpatient visits for 6 months prior to enrollment also was measured as was the presence of medical comorbidities. Multiple logistic regression analysis demonstrated that clinical remission at 6 months was an independent predictor of outpatient visit outlier status (>8 visits) (odds ratio [OR] 0.609, confidence interval (CI) 0.460-0.805, P<0.01) when controlling for all other independent variables including enrollment into CCM or UC. The OR of those patients not in remission at 6 months having outpatient visit outlier status was the inverse of this at 1.643 (CI 1.243-2.173). The most predictive variable for determining increased outpatient visit counts after diagnosis of depression was increased outpatient visits prior to diagnosis (OR 4.892, CI 3.655-6.548, P<0.01). In primary care patients treated for depression, successful treatment to remission at 6 months decreased the likelihood of the patient having more than 8 visits during the 6 months after diagnosis.

Future Complexity of Care Tier Affected by Depression Outcomes

Background: The inclusion of mental health issues in the evaluation of multimorbidity generally has been as the presence or absence of the condition rather than severity, complexity, or stage. The hypothesis for this study was that clinical outcome of the depression 6 months after enrollment into collaborative care management would have a role in predicting future complexity of care tier. Methods: This study was a retrospective chart review of 1894 primary care patients who were diagnosed with major depressive disorder or dysthymia as of December 2012. Multiple logistic regression analysis was used to test the independent associations between each variable and the odds of being included in the higher tiers (HT) group. Results: Age (odds ratio [OR] = 1.022, confidence interval [CI] = 1.013-1.030, P < .001), female gender (OR = 1.380, CI = 1.020-1.868, P = .037), being married (OR = 0.730, CI = 0.563-0.947, P = .018), and the presence of comorbidities (1, OR = 1.986, CI = 1.485-2.656, P < .001; ≥2, OR = 4.678, CI = 3.242-6.750, P < .001) were independently associated with future HT levels. The presence of persistent depressive symptoms (PHQ-9 ≥10) at 6 months conferred 2.280 (CI = 1.673-3.107, P < .001) times likely odds of HT level compared with clinical remission at 6 months. Conclusion: Patients with the diagnosis of major depression or dysthymia had greater odds of complex tier levels in the future, if depression was not treated to remission by 6 months. This study demonstrated the importance of the goal of significant improvement (ie, remission) of depression symptoms by 6 months (especially those older patients with more comorbidity) from entering into the higher complexity tiers.

Patient self-assessment factors predictive of persistent depressive symptoms 6 months after enrollment in collaborative care management

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.