ABSTRACT: Short-term quality improvement (QI) interventions for depression can improve long-term mental health but mechanisms are unknown. We hypothesized that 1 pathway for such health benefits was an indirect effect with QI reducing risk factors for depression such as stressful life events.
To determine whether 6-12 month QI programs for depression reduce negative life events at 5-year follow-up and to model the relationship between program implementation, life events and mental health over 9 years.
Forty-six primary care clinics in 6 managed care organizations were randomized to usual care or 1 of 2 QI interventions. We focus on the intervention that provided resources to assess and manage depression while particularly facilitating access to evidence-based psychotherapy ("QI-Therapy").
A total of 1300 enrolled patients with current depressive symptoms, who had data at any of 4 data points: baseline, or follow-up year 1, 5, or 9.
Total and negatively-evaluated life events and psychologic well-being.
A path model showed that QI-Therapy, in addition to improving psychologic well-being at year 1 (P = 0.0033), reduced negative life events at year 5 (P = 0.0033). This effect was not fully explained by improved psychologic well-being. Better mental health (P < 0.0001) and fewer negative life events (P = 0.0013) at year 5 were associated with improved psychologic well-being at 9 years.
Depression QI programs that include resources for psychotherapy can reduce occurrence of life events, further protecting subsequent mental health. Implications for the design of QI programs and development of prevention interventions are discussed.
Medical Care 01/2008; 46(1):78-84. · 3.41 Impact Factor
ABSTRACT: We sought to examine whether a quality improvement (QI) program for depression care is effective for both men and women and whether their responses differed.
We instituted a group-level, randomized, controlled trial in 46 primary care practices within 6 managed care organizations. Clinics were randomized to usual care or to 1 of 2 QI programs that supported QI teams, provider training, nurse assessment and patient education, and resources to support medication management (QI-Meds) or psychotherapy (QI-Therapy).
There were 1299 primary care patients who screened positive for depression and completed at least one questionnaire during the course of 24 months.
Outcomes were probable depression, mental health-related quality of life (HRQOL), work status, use of any antidepressant or psychotherapy, and probable unmet need, which was defined as having probable depression but not receiving probable appropriate care.
Women were more likely to receive depression care than men over time, regardless of intervention status. The effect of QI-Meds on probable unmet need was delayed for men, and the magnitude of the effect was significantly greater for men than for women; therefore, this intervention reduced differences in probable unmet need between men and women. QI reduced the likelihood of probable depression equally for men and women. QI-Therapy had a greater impact on mental HRQOL and work status for men than for women. QI-Meds improved these outcomes for women.
To affect both quality and outcomes of care for men and women while reducing gender differences, QI programs may need to facilitate access to both medication management and effective psychotherapy for depression.
Medical Care 01/2005; 42(12):1186-93. · 3.41 Impact Factor
ABSTRACT: To compare adults with different insurance coverage in care for alcohol, drug abuse, and mental health (ADM) problems.
From a national telephone survey of 9,585 respondents.
Follow-up of adult participants in the Community Tracking Study.
Self-report survey of insurance plan (Medicare, Medicaid, unmanaged, fully, or partially managed private, or uninsured), ADM need, use of ADM services and treatments, and satisfaction with care in the last 12 months. PRINCIPAL METHODS: Logistic and linear regressions were used to compare persons by insurance type in ADM use.
The likelihood of ADM care was highest under Medicaid and lowest for the uninsured and those under Medicare. Perceived unmet need was highest for the uninsured and lowest under Medicare. Persons in fully rather than partially managed private plans tend to be more likely to have ADM care and ADM treatments given need. Satisfaction with care was high in public plans and low for the uninsured.
The uninsured have the most problems with access to and quality of ADM care, relative to the somewhat comparable Medicaid population. Persons in fully managed plans had better rather than worse access and quality compared to partially managed plans, but findings are exploratory. Despite low ADM use, those with Medicare tend to be satisfied. Across plans, unmet need for ADM care was high, suggesting changes are needed in policy and practice.
Health Services Research 09/2002; 37(4):1055-66. · 2.16 Impact Factor
ABSTRACT: This paper describes the development and evaluation of a brief, multidimensional, self- administered, social support survey that was developed for patients in the Medical Outcomes Study (MOS), a two-year study of patients with chronic conditions. This survey was designed to be comprehensive in terms of recent thinking about the various dimensions of social support. In addition, it was designed to be distinct from other related measures. We present a summary of the major conceptual issues considered when choosing items for the social support battery, describe the items, and present findings based on data from 2987 patients (ages 18 and older). Multitrait scaling analyses supported the dimensionality of four functional support scales (emotional/informational, tangible, affectionate, and positive social interaction) and the construction of an overall functional social support index. These support measures are distinct from structural measures of social support and from related health measures. They are reliable (all Alphas >0.91), and are fairly stable over time. Selected construct validity hypotheses were supported.
Social Science & Medicine. 01/1991; 32(6):705-714.