The Effects of Quality Improvement for Depression in Primary Care at Nine Years

The RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, USA.
Health Services Research (Impact Factor: 2.78). 12/2008; 43(6):1952-74. DOI: 10.1111/j.1475-6773.2008.00871.x
Source: PubMed


To examine 9-year outcomes of implementation of short-term quality improvement (QI) programs for depression in primary care.
Depressed primary care patients from six U.S. health care organizations.
Group-level, randomized controlled trial.
Patients were randomly assigned to short-term QI programs supporting education and resources for medication management (QI-Meds) or access to evidence-based psychotherapy (QI-Therapy); and usual care (UC). Of 1,088 eligible patients, 805 (74 percent) completed 9-year follow-up; results were extrapolated to 1,269 initially enrolled and living. Outcomes were psychological well-being (Mental Health Inventory, five-item version [MHI5]), unmet need, services use, and intermediate outcomes.
At 9 years, there were no overall intervention status effects on MHI5 or unmet need (largest F (2,41)=2.34, p=.11), but relative to UC, QI-Meds worsened MHI5, reduced effectiveness of coping and among whites lowered tangible social support (smallest t(42)=2.02, p=.05). The interventions reduced outpatient visits and increased perceived barriers to care among whites, but reduced attitudinal barriers due to racial discrimination and other factors among minorities (smallest F (2,41)=3.89, p=.03).
Main intervention effects were over but the results suggest some unintended negative consequences at 9 years particularly for the medication-resource intervention and shifts to greater perceived barriers among whites yet reduced attitudinal barriers among minorities.

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    • "With the severe shortage of psychiatric specialists in Uganda and SSA, and limited numbers of physicians to care for ever-growing numbers of PLWHIV in care, task-shifting models are essential, but establishing feasibility, efficacy and cost-effectiveness are critical for widespread implementation. Task-shifting, protocolized approaches to overcoming shortages of highly trained mental health professionals in the provision of depression treatment have been shown to be effective in resource-constrained settings and the US [41-51], but this may be the first study of such a model with PLWHIV, and in SSA. With active engagement and collaboration with key community stakeholders, policy makers and the clinic staff involved in implementation, we have sought to adapt a nurse-driven, protocolized model of depression care that is resource-efficient and not overly burdensome for already busy clinics, with the goal of being sustainable in the long term. "
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    ABSTRACT: Background Despite 10 to% of persons living with HIV in sub-Saharan Africa having clinical depression, and the consequences of depression for key public health outcomes (HIV treatment adherence and condom use), depression treatment is rarely integrated into HIV care programs. Task-shifting, protocolized approaches to depression care have been used to overcome severe shortages of mental health specialists in developing countries, but not in sub-Saharan Africa and not with HIV clients. The aims of this trial are to evaluate the implementation outcomes and cost-effectiveness of a task-shifting, protocolized model of antidepressant care for HIV clinics in Uganda. Methods/Design INDEPTH-Uganda is a cluster randomized controlled trial that compares two task-shifting models of depression care - a protocolized model versus a model that relies on the clinical acumen of trained providers to provide depression care in ten public health HIV clinics in Uganda. In addition to data abstracted from routine data collection mechanisms and supervision logs, survey data will be collected from patient and provider longitudinal cohorts; at each site, a random sample of 150 medically stable patients who are depressed according to the PHQ-2 screening will be followed for 12 months, and providers involved in depression care implementation will be followed over 24 months. These data will be used to assess whether the two models differ on implementation outcomes (proportion screened, diagnosed, treated; provider fidelity to model of care), provider adoption of treatment care knowledge and practices, and depression alleviation. A cost-effectiveness analysis will be conducted to compare the relative use of resources by each model. Discussion If effective and resource-efficient, the task-shifting, protocolized model will provide an approach to building the capacity for sustainable integration of depression treatment in HIV care settings across sub-Saharan Africa and improving key public health outcomes. Trial registration INDEPTH-Uganda has been registered with the National Institutes of Health sponsored clinical trials registry (3 February 2013) and has been assigned the identifier NCT02056106.
    Full-text · Article · Jun 2014 · Trials
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    • "The existing studies focus almost exclusively on the cross-sectional pictures of outcome, thus ignoring recurrences, chronicity and duration of illness states. Moreover, the available primary care studies vary greatly in their methods and definitions for diagnostic criteria (Widmer & Cadoret, 1978 ; Ormel et al. 1993 ; van Weel-Baumgarten et al. 1998 ; Oldehinkel et al. 2000 ; Simon, 2000 ; Wilson et al. 2003 ; Jackson et al. 2007 ; Poutanen et al. 2007 ; Wells et al. 2008 ; Yiend et al. 2009) and have seldom used structured or semi-structured interviews. Assessment of depression has often been based exclusively on selfreported scales, which may render the clinical significance uncertain. "
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    ABSTRACT: BACKGROUND: Primary health care provides treatment for most patients with depression. Despite their importance for organizing services, long-term course of depression and risk factors for poor outcome in primary care are not well known.MethodIn the Vantaa Primary Care Depression Study, a stratified random sample of 1119 patients representing primary care patients in a Finnish city was screened for depression with the Primary Care Evaluation of Mental Disorders. SCID-I/P and SCID-II interviews were used to diagnose Axis I and II disorders. The 137 patients with DSM-IV depressive disorder were prospectively followed up at 3, 6, 18 and 60 months. Altogether, 82% of patients completed the 5-year follow-up, including 102 patients with a research diagnosis of major depressive disorder (MDD) at baseline. Duration of the index episode, recurrences, time spent in major depressive episodes (MDEs) and partial or full remission were examined with a life-chart. RESULTS: Of the MDD patients, 70% reached full remission, in a median time of 20 months. One-third had at least one recurrence. The patients spent 34% of the follow-up time in MDEs, 24% in partial remission and 42% in full remission. Baseline severity of depression and substance use co-morbidity predicted time spent in MDEs. CONCLUSIONS: This prospective, naturalistic, long-term study of a representative cohort of primary care patients with depression indicated slow or incomplete recovery and a commonly recurrent course, which need to be taken into account when developing primary care services. Severity of depressive symptoms and substance use co-morbidity should be systematically evaluated in planning treatment.
    Full-text · Article · Nov 2011 · Psychological Medicine
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