Integrating clinical nurse specialists into the treatment of primary care patients with depression
To examine the effectiveness of integrating generalist and specialist care for veterans with depression.
We conducted a randomized trial of patients screening positive for depression at two Veterans Affairs Medical Center general medicine clinic firms. Control firm physicians were notified prior to the encounter when eligible patients had PRIME-MD depression diagnoses. In the intervention firm, a mental health clinical nurse specialist (CNS) was to: design a treatment plan; implement that plan with the primary care physician; and monitor patients via telephone or visits at two weeks, one month and two months. Primary outcomes (depressive symptoms, patient satisfaction with health care) were collected at 3 and 12 months.
Of 268 randomized patients, 246 (92%) and 222 (83%) completed 3- and 12-month follow-up interviews. There were no between-group differences in depressive symptoms or satisfaction at 3 or 12 months. The intervention group had greater chart documentation of depression at baseline (63% versus 33%, p = 0.003) and a higher referral rate to mental health services at 3 months (27% versus 9%, p = 0.019). There was no difference in the rate of new prescriptions for, or adequate dosing of, anti-depressant medications. In 40% of patients, CNSs disagreed with the PRIME-MD depression diagnosis, and their rates of watchful waiting were correspondingly high.
Implementing an integrated care model did not occur as intended. Experienced CNSs often did not see the need for treatment in many primary care patients identified by the PRIME-MD. Integrating integrated care models in actual practice may prove challenging.
Available from: Marie-Josée Fleury
- "Suicide ideation or attempts are higher among sufferers of panic disorder, which explains their frequent use of emergency departments and ambulatory services
[32,92]. As observed in other studies, however, the only professional usually called upon for panic disorder was the family physician
[87-89], probably because related symptoms are generally physical (hyperventilation, heart palpitation, chest pain, etc.). It is possible that individuals with panic disorder seek the services of several professionals according to the severity of their condition but use their family doctor as a regular source of healthcare. "
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ABSTRACT: This study has a dual purpose: 1) identify determinants of healthcare service utilization for mental health reasons (MHR) in a Canadian (Montreal) catchment area; 2) determine the patterns of recourse to healthcare professionals in terms of frequency of visits and type of professionals consulted, and as it relates to the most prevalent mental disorders (MD) and psychological distress.
Data was collected from a random sample of 1,823 individuals interviewed after a two-year follow-up period. A regression analysis was performed to identify variables associated with service utilization and complementary analyses were carried out to better understand participants' patterns of healthcare service utilization in relation to the most prevalent MD.
Among 243 individuals diagnosed with a MD in the 12 months preceding an interview, 113 (46.5%) reported having used healthcare services for MHR. Determinants of service utilization were emotional and legal problems, number of MD, higher personal income, lower quality of life, inability of individuals to influence events occurring in their neighborhood, female gender and, marginally, lack of alcohol dependence in the past 12 months. Emotional problems were the most significant determinant of healthcare service utilization. Frequent visits with healthcare professionals were more likely associated with major depression and number of MD with or without dependence to alcohol or drugs. People suffering from major depression, psychological distress and social phobia were more likely to consult different professionals, while individuals with panic disorders relied on their family physician only. Concerning social phobia, panic disorders and psychological distress, more frequent visits with professionals did not translate into involvement of a higher number of professionals or vice-versa.
This study demonstrates the impact of emotional problems, neighborhood characteristics and legal problems in healthcare service utilization for MHR. Interventions based on inter-professional collaboration could be prioritized to increase the ability of healthcare services to take care especially of individuals suffering from social phobia, panic disorders and psychological distress. Others actions that could be prioritized are training of family physicians in the treatment of MD, use of psychiatric consultants, internet outreach, and reimbursement of psychological consultations for individuals with low income.
BMC Health Services Research 04/2014; 14(1):161. DOI:10.1186/1472-6963-14-161 · 1.71 Impact Factor
Available from: Jeffrey Donald Fuller
- "The most consistent finding was in prescribing and drug treatment adherence in favour of shared care interventions. The six studies of shared care for depression alone reported evidence of benefits in rates of recovery or remission [33-38]. Nevertheless, Smith drew the sobering conclusion that overall "consistent evidence for the effectiveness of shared care is lacking for most of the outcomes studied". "
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ABSTRACT: While integrated primary healthcare for the management of depression has been well researched, appropriate models of primary care for people with severe and persistent psychotic disorders are poorly understood. In 2010 the NSW (Australia) Health Department commissioned a review of the evidence on "shared care" models of ambulatory mental health services. This focussed on critical factors in the implementation of these models in clinical practice, with a view to providing policy direction. The review excluded evidence about dementia, substance use and personality disorders.
A rapid review involving a search for systematic reviews on The Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects (DARE). This was followed by a search for papers published since these systematic reviews on Medline and supplemented by limited iterative searching from reference lists.
Shared care trials report improved mental and physical health outcomes in some clinical settings with improved social function, self management skills, service acceptability and reduced hospitalisation. Other benefits include improved access to specialist care, better engagement with and acceptability of mental health services. Limited economic evaluation shows significant set up costs, reduced patient costs and service savings often realised by other providers. Nevertheless these findings are not evident across all clinical groups. Gains require substantial cross-organisational commitment, carefully designed and consistently delivered interventions, with attention to staff selection, training and supervision. Effective models incorporated linkages across various service levels, clinical monitoring within agreed treatment protocols, improved continuity and comprehensiveness of services.
"Shared Care" models of mental health service delivery require attention to multiple levels (from organisational to individual clinicians), and complex service re-design. Re-evaluation of the roles of specialist mental health staff is a critical requirement. As expected, no one model of "shared" care fits diverse clinical groups. On the basis of the available evidence, we recommended a local trial that examined the process of implementation of core principles of shared care within primary care and specialist mental health clinical services.
International Journal of Mental Health Systems 11/2011; 5:31. DOI:10.1186/1752-4458-5-31 · 1.06 Impact Factor
Available from: Roger G Kathol
- "ith extractable data , there is no discernable effect of level of clinician integration level on outcomes based on these data . Of the plotted data , only the IMPACT ( Callahan et al . , 2005 ; Unutzer et al . , 2001 , 2002 , 2006 ) trial shows consistent improvement in symptom severity . If the weaker study design results ( Hilty et al . , 2007 ; Swindle et al . , 2003 ) are ignored in Appendix 7 , there is some indication of more symp - tom severity improvement with higher clini - cal integration ( largely the effect of IMPACT studies ) . In contrast , however , significant im - provements in treatment response ( Appendix 8 ) and remission ( Appendix 9 ) are consistent across the integration levels ."
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ABSTRACT: Care management-based interventions promoting integrated care by combining primary care with mental health services in a coordinated and colocated manner are increasingly popular; yet, the benefits of specific approaches are not well established. We conducted a systematic review of integrated care trials in US primary care settings to assess whether the level of integration of provider roles or care process affects clinical outcomes. Although most trials showed positive effects, the degree of integration was not significantly related to depression outcomes. Integrated care appears to improve depression management in primary care patients, but questions remain about its specific form and implementation.
The Journal of ambulatory care management 04/2011; 34(2):113-25. DOI:10.1097/JAC.0b013e31820ef605
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