Improving quality of depression care using organized systems of care: A review of the literature

Article · February 2011with10 Reads
DOI: 10.4088/PCC.10r01019blu · Source: PubMed
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.
    • "standard deviations . These are the kind of effects that can be expected for an intervention like ICC [42] . For dichotomous outcomes , we will be able to detect a difference of 13–14 percentage points under the assumption that the SAU group has a 15% rate of receiving the outcome. "
    [Show abstract] [Hide abstract] ABSTRACT: Millions of people who need treatment for substance use disorders (SUD) do not receive it. Evidence-based practices for treating SUD exist, and some are appropriate for delivery outside of specialty care settings. Primary care is an opportune setting in which to deliver SUD treatment because many individuals see their primary care providers at least once a year. Further, the Patient Protection and Affordable Care Act (PPACA) increases coverage for SUD treatment and is increasing the number of individuals seeking primary care services. In this article, we present the protocol for a study testing the effects of an organizational readiness and service delivery intervention on increasing the uptake of SUD treatment in primary care and on patient outcomes. In a randomized controlled trial, we test the combined effects of an organizational readiness intervention consisting of implementation tools and activities and an integrated collaborative care service delivery intervention based on the Chronic Care Model on service system (patient-centered care, utilization of substance use disorder treatment, utilization of health care services and adoption and sustainability of evidence-based practices) and patient (substance use, consequences of use, health and mental health, and satisfaction with care) outcomes. We also use a repeated measures design to test organizational changes throughout the study, such as acceptability, appropriateness and feasibility of the practices to providers, and provider intention to adopt the practices. We use provider focus groups, provider and patient surveys, and administrative data to measure outcomes. The present study responds to critical gaps in health care services for people with substance use disorders, including the need for greater access to SUD treatment and greater uptake of evidence-based practices in primary care. We designed a multi-level study that combines implementation tools to increase organizational readiness to adopt and sustain evidence-based practices (EBPs) and tests the effectiveness of a service delivery intervention on service system and patient outcomes related to SUD services. Current controlled trials: NCT01810159.
    Full-text · Article · May 2015
    • "Educational and organizational interventions have been proposed to improve the management of depression in primary care [12][13][14][15]. Recent reviews have identified collaborative care programs as the most effective of these approaches [13,14,16]. The collaborative care model is based on the principles of chronic disease management and involves a number of different interventions. "
    [Show abstract] [Hide abstract] ABSTRACT: This was a multicenter cluster-randomized controlled trial. A total of 227 patients ≥18 years old with a new onset of depressive symptoms who screened positive on the first two items of the Patient Health Questionnaire-9 (PHQ-9) were recruited by primary care physicians (PCPs) of eight health districts of three Italian regions from September 2009 to June 2011. PCPs of the intervention group received a specific collaborative care program including 2 days of intensive training, implementation of a stepped care protocol, depression management toolkit and scheduled meetings with a dedicated consultant psychiatrist. The objective was to determine whether a collaborative care program for depression management in primary care leads to higher remission rate than usual PCP care. Outcome was clinical remission as expressed on PHQ-9 <5 at 3 months. An independent researcher used computer-generated randomization to assign involved primary care groups to the two alternative arms. PCPs and research personnel were not blinded. The 223 PCPs enrolled recruited 227 patients (128 in collaborative care arm, 99 in the usual care arm). At 3 months (n=210), the proportion of patients who achieved remission was higher, though the difference was not statistically significant, in the collaborative care group. The effect size was of 0.11. When considering only patients with minor/major depression, collaborative care appeared to be more effective than usual care (P=.015). The present intervention for managing depression in primary care, designed to be applicable to the Italian context, appears to be effective and feasible.
    Article · Aug 2013
    • "Another possibility is to expand these programmes beyond specialized mental health care. To improve the management of recurrence prevention of MDD, collaborative care models (Katon and Guico-Pabia, 2011), in which long term management and communication between primary-and specialized mental health care professionals are optimized across psychiatric services, may be helpful. "
    [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.
    Full-text · Article · Dec 2012
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