Improving Care for Depression in Obstetrics and Gynecology A Randomized Controlled Trial

University of Washington Seattle, Seattle, Washington, United States
Obstetrics and Gynecology (Impact Factor: 5.18). 05/2014; 123(6). DOI: 10.1097/AOG.0000000000000231
Source: PubMed


To evaluate an evidence-based collaborative depression care intervention adapted to obstetrics and gynecology clinics compared with usual care.
A two-site, randomized controlled trial included screen-positive women (Patient Health Questionnaire-9 score of at least 10) who met criteria for major depression, dysthymia, or both (Mini-International Neuropsychiatric Interview). Women were randomized to 12 months of collaborative depression management or usual care; 6-month, 12-month, and 18-month outcomes were compared. The primary outcomes were change from baseline to 12 months in depression symptoms and functional status. Secondary outcomes included at least 50% decrease and remission in depressive symptoms, global improvement, treatment satisfaction, and quality of care.
Participants were, on average, 39 years old, 44% were nonwhite, and 56% had posttraumatic stress disorder. Intervention (n=102) compared with usual care (n=103) patients had greater improvement in depressive symptoms at 12 months (P<.001) and 18 months (P=.004). The intervention group compared with usual care group had improved functioning over the course of 18 months (P<.05), were more likely to have at least 50% decrease in depressive symptoms at 12 months (relative risk [RR] 1.74, 95% confidence interval [CI] 1.11-2.73), greater likelihood of at least four specialty mental health visits (6-month RR 2.70, 95% CI 1.73-4.20; 12-month RR 2.53, 95% CI 1.63-3.94), adequate dose of antidepressant (6-month RR 1.64, 95% CI 1.03-2.60; 12-month RR 1.71, 95% CI 1.08-2.73), and greater satisfaction with care (6-month RR 1.70, 95% CI 1.19-2.44; 12-month RR 2.26, 95% CI 1.52-3.36).
Collaborative depression care adapted to women's health settings improved depressive and functional outcomes and quality of depression care.
Clinical,, NCT01096316. LEVEL OF EVIDENCE:: I.

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    ABSTRACT: Patients seen in general medical settings commonly have behavioral health conditions comorbid with other chronic medical disorders, each requiring high levels of integrated care management. With recent health care policy reform, the number of such patients recognized in the US health care system will likely increase, intensifying the need for practical integrated care models that address co-occurring behavioral and general medical disorders. Access to evidence-based integrated care can be enhanced by viewing general medical settings, especially primary care settings where people with behavioral health comorbidities are frequently seen for general medical problems, as opportunities for engagement in behavioral health care. We now have multiple evidence-based models for delivering integrated care in general medical settings. Embedded within these models are specific strategies to promote access to and engagement in evidence-based behavioral health care, such as patient activation, culturally acceptable care, shared decision making, patient education, self-management support, care coordination, reducing patients' logistical barriers to care, and use of health information technology. Yet many settings in which integrated behavioral health care could and should be accessed remain untapped or underutilized. While barriers at multiple levels hinder progress, abundant opportunities to overcome these deficits exist, such as the development of flexible integrated care models applicable to large patient populations, enhanced training for the workforce delivering integrated care, health information technology tools that support delivery of integrated care, minimization of financial barriers to evidence-based integrated care, and expansion of the integrated care science base. © 2014 Springer Science+Business Media New York. All rights are reserved.
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    ABSTRACT: Objective: The authors evaluated whether an obstetrics-gynecology clinic-based collaborative depression care intervention is differentially effective compared with usual care for socially disadvantaged women with either no health insurance or with public coverage compared with those with commercial insurance. Method: The study was a two-site randomized controlled trial with an 18-month follow-up. Women were recruited who screened positive (a score of at least 10 on the Patient Health Questionnaire-9) and met criteria for major depression or dysthymia. The authors tested whether insurance status had a differential effect on continuous depression outcomes between the intervention and usual care over 18 months. They also assessed differences between the intervention and usual care in quality of depression care and dichotomous clinical outcomes (a decrease of at least 50% in depressive symptom severity and patient-rated improvement on the Patient Global Improvement Scale). Results: The treatment effect was significantly associated with insurance status. Compared with patients with commercial insurance, those with no insurance or with public coverage had greater recovery from depression symptoms with collaborative care than with usual care over the 18-month follow-up period. At the 12-month follow-up, the effect size for depression improvement compared with usual care among women with no insurance or with public coverage was 0.81 (95% CI=0.41, 0.95), whereas it was 0.39 (95% CI=-0.08, 0.84) for women with commercial insurance. Conclusions: Collaborative depression care adapted to obstetrics-gynecology settings had a greater impact on depression outcomes for socially disadvantaged women with no insurance or with public coverage compared with women with commercial insurance.
    Preview · Article · Aug 2014 · American Journal of Psychiatry
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