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: Hubertus VrijhoefThe International Journal of Person Centered Medicine. 01/2012; 2(4):716-758.
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ABSTRACT: Persons with bipolar disorder experience a disproportionate burden of medical conditions, notably cardiovascular disease (CVD), leading to impaired functioning and premature mortality. We hypothesized that the Life Goals Collaborative Care (LGCC) intervention, compared to enhanced usual care, would reduce CVD risk factors and improve physical and mental health outcomes in US Department of Veterans Affairs patients with bipolar disorder. Patients with an ICD-9 diagnosis of bipolar disorder and ≥ 1 CVD risk factor (N = 118) enrolled in the Self-Management Addressing Heart Risk Trial, conducted April 2008-May 2010, were randomized to LGCC (n = 58) or enhanced usual care (n = 60). Life Goals Collaborative Care included 4 weekly self-management sessions followed by tailored contacts combining health behavior change strategies, medical care management, registry tracking, and provider guideline support. Enhanced usual care included quarterly wellness newsletters sent during a 12-month period in addition to standard treatment. Primary outcome measures included systolic and diastolic blood pressure, nonfasting total cholesterol, and physical health-related quality of life. Of the 180 eligible patients identified for study participation, 134 were enrolled (74%) and 118 completed outcomes assessments (mean age = 53 years, 17% female, 5% African American). Mixed effects analyses comparing changes in 24-month outcomes among patients in LGCC (n = 57) versus enhanced usual care (n = 59) groups revealed that patients receiving LGCC had reduced systolic (β = -3.1, P = .04) and diastolic blood pressure (β = -2.1, P = .04) as well as reduced manic symptoms (β = -23.9, P = .01). Life Goals Collaborative Care had no significant impact on other primary outcomes (total cholesterol and physical health-related quality of life). Life Goals Collaborative Care, compared to enhanced usual care, may lead to reduced CVD risk factors, notably through decreased blood pressure, as well as reduced manic symptoms, in patients with bipolar disorder. ClinicalTrials.gov identifier: NCT00499096.The Journal of Clinical Psychiatry 07/2013; 74(7):e655-62. · 5.81 Impact Factor
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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; · 7.34 Impact Factor