Improving quality of depression care using organized systems of care: a review of the literature.
ABSTRACT To establish the need for a chronic disease management strategy for major depressive disorder (MDD), discuss the challenges involved in implementing guideline-level treatment for MDD, and provide examples of successful implementation of collaborative care programs.
A systematic literature search of MEDLINE and the US National Library of Medicine was performed.
We reviewed clinical studies evaluating the effectiveness of collaborative care interventions for the treatment of depression in the primary care setting using the keywords collaborative care, depression, and MDD. This review includes 45 articles relevant to MDD and collaborative care published through May 2010 and excludes all non-English-language articles.
Collaborative care interventions include a greater role for nonmedical specialists and a supervising psychiatrist with the major goal of improving quality of depression care in primary care systems. Collaborative care programs restructure clinical practice to include a patient care strategy with specific goals and an implementation plan, support for self-management training, sustained patient follow-up, and decision support for medication changes. Key components associated with the most effective collaborative care programs were improvement in antidepressant adherence, use of depression case managers, and regular case load supervision by a psychiatrist. Across studies, primary care patients randomized to collaborative care interventions experienced enhanced treatment outcomes compared with those randomized to usual care, with overall outcome differences approaching 30%.
Collaborative care interventions may help to achieve successful, guideline-level treatment outcomes for primary care patients with MDD. Potential benefits of collaborative care strategies include reduced financial burden of illness, increased treatment adherence, and long-term improvement in depression symptoms and functional outcomes.
- SourceAvailable from: W. A. Nolen[Show abstract] [Hide abstract]
ABSTRACT: OBJECTIVE: Examine time to recurrence of major depressive disorder (MDD) across different treatment settings and assess predictors of time to recurrence of MDD. METHODS: Data were from 375 subjects with a MDD diagnosis from the Netherlands Study of Depression and Anxiety (NESDA). The study sample was restricted to subjects with a remission of at least three months. These subjects were followed until recurrence or the end of the two year follow-up. DSM-IV based diagnostic interviews and Life Chart Interviews were used to assess time to recurrence of MDD across treatment settings. Predictors of time to recurrence were determined using Cox's proportional hazards analyses. RESULTS: Although trends indicated a slightly higher rate of and shorter time to recurrence in specialized mental health care, no significant difference in recurrence rate (26.8% versus 33.5%, p=0.23) or in time to recurrence (controlled for covariates) of MDD was found between respondents in specialized mental health care and respondents treated in primary care (average 6.6 versus 5.5 months, p=0.09). In multivariable analyses, a family history of MDD and previous major depressive episodes were associated with a shorter time to recurrence. Predictors did not differ across treatment settings. LIMITATIONS: The study sample may not be representative of the entire population treated for MDD in specialized mental health care. CONCLUSIONS: Health care professionals in both settings should be aware of the same risk factors since the recurrence risk and its predictors appeared to be similar across settings.Journal of affective disorders 12/2012; · 3.76 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: OBJECTIVE: For patients with an initial primary care (PC) encounter in the Veterans Health Administration (VHA) that included a mental health diagnosis, we evaluate whether same-day receipt of Primary Care-Mental Health Integration (PC-MHI) services is associated with the likelihood of receiving a subsequent mental-health-related encounter in the following 90 days. METHOD: Using VHA administrative data, we identified 9046 patients who received VHA care for the first time in fiscal year 2009, received a PC encounter that included a mental health diagnosis on the first day of their VHA services and initiated care at a VHA facility that provided PC-MHI services. Using multivariable generalized estimating equations logistic regression, we examined whether receipt of same-day PC-MHI was associated with receipt of a subsequent encounter with a mental health diagnosis within 90 days. Analyses adjusted for Operation Enduring Freedom/Operation Iraqi Freedom Veteran status, demographic characteristics, service-connected disability, psychiatric and non-psychiatric diagnoses, and psychotropic medication initiation on the index day of service use. RESULTS: Receipt of same-day PC-MHI services was positively associated with having a mental-health-related encounter in the following 90 days (adjusted odds ratio=2.05; 95% confidence interval=1.66-2.54). CONCLUSIONS: PC-MHI services may enhance mental health continuation of care among PC patients with mental health conditions who initiate VHA services.General hospital psychiatry 10/2012; · 2.67 Impact Factor
- [Show abstract] [Hide abstract]
ABSTRACT: By 2030, depression is forecast to be the leading cause of disease burden worldwide. 1 Despite its high prevalence rates, numerous barriers prevent seeking and accessing help so that depression remains vastly undertreated. 2 In the UK, 54% of people experiencing a depressive episode did not contact their general practitioner (GP). 3 In addition, although the public prefer psychological treatment over medication for depression, 4 psychological services have been very limited. 5 In the UK, access to psychological therapies is currently mostly via referral from a GP or a health professional. Despite a recent increase in funding, the capacity of psychological treatment services remains limited. In addition, Black and minority ethnic (BME) groups are often underrepresented in psychological therapy services, 6 as shown in the demonstration sites for the Improving Access to Psychological Therapies (IAPT) initiative in the UK. 7 Cognitive–behavioural therapy (CBT) is as effective as medication in individuals with moderate to severe depression, and has long-term benefits. 8 Individual and group CBT for depression have comparable effectiveness. 9 Clinical guidelines in the UK recommend intensive individual CBT for those with moderate or severe depression, whereas individuals with mild to moderate depression who decline first-line low-intensity treatments (e.g. computerised CBT and guided self-help) should be offered group CBT. 10 Traditional group CBT tends to be small scale, with 8–10 participants meeting for 10–12 2 h sessions. A credible alternative is to offer larger-scale psychoeducational CBT groups that can reach more people. This approach has been successfully used with primary care patients with generalised anxiety who were offered evening classes 11 and members of the public who self-referred to 1-day stress workshops. 12 However, psychoeducational interventions advertised as 'depression' workshops had a lower uptake, attracting mostly people who had already used specialist services. 13 Changing the name of the workshops to a non-diagnostic label of 'self-confidence' workshop led to a much higher uptake, with 39% of self-referrers never having previously consulted their GP for depression. 14 A small randomised controlled trial (RCT) of 1-day self-confidence workshops v. a waiting list control found the intervention to be effective in reducing depression and improving self-esteem after 12 weeks. A naturalistic follow-up study found that the benefits were maintained at 2 years but only for those who were depressed. 15 So far, the effectiveness of these brief workshops has only been demonstrated with a group of people varying in depression symptoms in one relatively deprived part of London, and no full economic evaluation has been undertaken. This study aims to assess whether the self-confidence workshops can be effective and cost-effective in areas with different deprivation levels, focusing just on people with depression. If shown to be successful, this could provide an alternative effective and cost-effective psychological intervention for people with depression in the community, given the low take-up rates for treatment for depression and preferences for psychological treatment. Method Design A multicentre open RCT design was used, with self-confidence workshops run across eight boroughs in south London, with experimental and waiting list control arm participants followed up after 12 weeks. Workshops were run between April 2010 and July 2011. Ethical approval was obtained from the King's College Ethical Committee (Ref: PNM/09/10-65). S. L Brown on behalf of the CLASSIC trial group Background Despite its high prevalence, help-seeking for depression is low.The British Journal of Psychiatry 12/2013; · 6.61 Impact Factor