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Context: Depression is a leading cause of disability worldwide, but treatment rates in primary care are low.Objective: To determine the cost-effectiveness from a societal perspective of 2 quality improvement (QI) interventions to improve treatment of depression in primary care and their effects on patient employment.Design: Group-level randomized controlled trial conducted June 1996 to July 1999.Setting: Forty-six primary care clinics in 6 community-based managed care organizations.Participants: One hundred eighty-one primary care clinicians and 1356 patients with positive screening results for current depression.Interventions: Matched practices were randomly assigned to provide usual care (n = 443 patients) or to 1 of 2 QI interventions offering training to practice leaders and nurses, enhanced educational and assessment resources, and either nurses for medication follow-up (QI-meds; n = 424 patients) or trained local psychotherapists (QI-therapy; n = 489). Practices could flexibly implement the interventions, which did not assign type of treatment.Main Outcome Measures: Total health care costs, costs per quality-adjusted life-year (QALY), days with depression burden, and employment over 24 months, compared between usual care and the 2 interventions.Results: Relative to usual care, average health care costs increased $419 (11%) in QI-meds (P =.35) and $485 (13%) in QI-therapy (P =.28); estimated costs per QALY gained were between $15 331 and $36 467 for QI-meds and $9478 and $21 478 for QI-therapy; and patients had 25 (P =.19) and 47 (P =.01) fewer days with depression burden and were employed 17.9 (P =.07) and 20.9 (P =.03) more days during the study period.Conclusions: Societal cost-effectiveness of practice-initiated QI efforts for depression is comparable with that of accepted medical interventions. The intervention effects on employment may be of particular interest to employers and other stakeholders. [ABSTRACT FROM AUTHOR]

Context: Care of patients with depression in managed primary care settings often fails to meet guideline standards, but the long-term impact of quality improvement (QI) programs for depression care in such settings is unknown.Objective: To determine if QI programs in managed care practices for depressed primary care patients improve quality of care, health outcomes, and employment.Design: Randomized controlled trial initiated from June 1996 to March 1997.Setting: Forty-six primary care clinics in 6 US managed care organizations.Participants: Of 27332 consecutively screened patients, 1356 with current depressive symptoms and either 12-month, lifetime, or no depressive disorder were enrolled.Interventions: Matched clinics were randomized to usual care (mailing of practice guidelines) or to 1 of 2 QI programs that involved institutional commitment to QI, training local experts and nurse specialists to provide clinician and patient education, identification of a pool of potentially depressed patients, and either nurses for medication follow-up or access to trained psychotherapists.Main Outcome Measures: Process of care (use of antidepressant medication, mental health specialty counseling visits, medical visits for mental health problems, any medical visits), health outcomes (probable depression and health-related quality of life [HRQOL]), and employment at baseline and at 6- and 12-month follow-up.Results: Patients in QI (n = 913) and control (n = 443) clinics did not differ significantly at baseline in service use, HRQOL, or employment after nonresponse weighting. At 6 months, 50.9% of QI patients and 39.7% of controls had counseling or used antidepressant medication at an appropriate dosage (P<.001), with a similar pattern at 12 months (59.2% vs 50.1%; P = .006). There were no differences in probability of having any medical visit at any point (each P > or = .21). At 6 months, 47.5% of QI patients and 36.6% of controls had a medical visit for mental health problems (P = .001), and QI patients were more likely to see a mental health specialist at 6 months (39.8% vs 27.2%; P<.001) and at 12 months (29.1% vs 22.7%; P = .03). At 6 months, 39.9% of QI patients and 49.9% of controls still met criteria for probable depressive disorder (P = .001), with a similar pattern at 12 months (41.6% vs 51.2%; P = .005). Initially employed QI patients were more likely to be working at 12 months relative to controls (P = .05).Conclusions: When these managed primary care practices implemented QI programs that improve opportunities for depression treatment without mandating it, quality of care, mental health outcomes, and retention of employment of depressed patients improved over a year, while medical visits did not increase overall. [ABSTRACT FROM AUTHOR]

Depression is a common, disabling, and costly condition encountered in older patients. Effective strategies for detection and treatment of late-life depression are summarized based on a case of a 69-year-old woman who struggled with prolonged depression. Clinicians should screen older patients for depression using a standard rating scale, initiate treatment such as antidepressant medications or evidence-based psychotherapy, and monitor depression symptoms. Patients who are not improving should be considered for psychiatric consultation and treatment changes including electroconvulsive therapy. Several changes in treatment approaches are usually needed before patients achieve complete remission. Maintenance treatment and relapse-prevention planning (summarization of early warning signs for depression, maintenance treatments such as medications, and other strategies to reduce the risk of relapse [eg, regular physical activity or pleasant activities]) can reduce the risk of relapse. Collaborative programs, in which primary care clinicians work closely with mental health specialists following a measurement-based treatment-to-target approach, are significantly more effective than typical primary care treatment. [ABSTRACT FROM AUTHOR]

Objective: This study evaluated a large demonstration project of collaborative care of depression at community health centers by examining the role of clinic site on two measures of quality care (early follow-up and appropriate pharmacotherapy) and on improvement of symptoms (score on Patient Health Questionnaire-9 reduced by 50% or ≤ 5).Methods: A quasi-experimental study examined data on the treatment of 2,821 patients aged 18 and older with depression symptoms between 2006 and 2009 at six community health organizations selected in a competitive process to implement a model of collaborative care. The model's key elements were use of a Web-based disease registry to track patients, care management to support primary care providers and offer proactive follow-up of patients, and organized psychiatric consultation.Results: Across all sites, a plurality of patients achieved meaningful improvement in depression, and in many sites, improvement occurred rapidly. After adjustment for patient characteristics, multivariate logistic regression models revealed significant differences across clinics in the probability of receiving early follow-up (range .34-.88) or appropriate pharmacotherapy (range .27-.69) and in experiencing improvement (.36 to .84). Similarly, after adjustment for patient characteristics, Cox proportional hazards models revealed that time elapsed between first evaluation and the occurrence of improvement differed significantly across clinics (p<.001).Conclusions: Despite receiving similar training and resources, organizations exhibited substantial variability in enacting change in clinical care systems, as evidenced by both quality indicators and outcomes. Sites that performed better on quality indicators had better outcomes, and the differences were not attributable to patients' characteristics. [ABSTRACT FROM AUTHOR]

Objective: Integration of general medical and mental health services is a growing priority for safety-net providers. The authors describe a project that established a one-year learning collaborative focused on integration of services between community health centers (CHCs) and community mental health centers (CMHCs). Specific targets were treatment for general medical and psychiatric symptoms related to depression, bipolar disorder, alcohol use disorders, and metabolic syndrome.Methods: This observational study used mixed methods. Quantitative measures included 15 patient-level health indicators, practice self-assessment of resources and support for chronic disease self-management, and participant satisfaction.Results: Sixteen CHC-CMHC pairs were selected for the learning collaborative series. One pair dropped out because of personnel turnover. All teams increased capacity on one or more patient health indicators. CHCs scored higher than CMHCs on support for chronic disease self-management. Participation in the learning collaborative increased self-assessment scores for CHCs and CMHCs. Participant satisfaction was high. Observations by faculty indicate that quality improvement challenges included tracking patient-level outcomes, workforce issues, and cross-agency communication.Conclusions: Even though numerous systemic barriers were encountered, the findings support existing literature indicating that the learning collaborative is a viable quality improvement approach for enhancing integration of general medical and mental health services between CHCs and CMHCs. Real-world implementation of evidence-based guidelines presents challenges often absent in research. Technical resources and support, a stable workforce with adequate training, and adequate opportunities for collaborator communications are particular challenges for integrating behavioral and general medical services across CHCs and CMHCs. [ABSTRACT FROM AUTHOR]

Objectives: To To examine the role of cognitive impairment and caregiver support in diabetes care adherence and glycemic control. Methods: Fifty-one veteran male outpatients (27 with caregivers) aged 60 years and older with type 2 diabetes were evaluated for cognitive impairment with the Cognitive Abilities Screening Instrument. Patients or caregivers completed diabetes self-care and depression scales. Medical morbidity information and HbA1c plasma levels at baseline and 1 year later were obtained from electronic medical records. Results: Greater cognitive impairment (F = 5.1, p < .05), and presence of a caregiver (F = 5.3, p < .05), were independently associated with worse diabetes care adherence (adjusting for age, education, medical comorbidity, and depression). In addition, Mean HbA1c levels were worse in the cognitively impaired group with caregivers relative to the three other groups (F = 4.10, p < .05, (eta)2 =.09). One year later, mean HbA1c levels rose from 7.7 to 8.2% in the cognitively impaired group with caregivers. Conclusion: Cognitive impairment is associated with worse diabetes care management. Surprisingly, the presence of a caregiver is not protective. Further research is necessary to examine the healthcare needs of cognitively impaired, diabetic patients and their caregivers. [ABSTRACT FROM AUTHOR]

Objective: This study examined longitudinal trends in the use of mood stabilizers and antipsychotics for treatment of bipolar disorder in a large public mental health system and whether trends differed by age, gender, and race-ethnicity.Methods: Data were from Medicaid beneficiaries with bipolar disorder receiving services in the San Diego County public mental health system from 2001 to 2004. For each year the proportion of clients receiving any pharmacotherapy and the proportion receiving antipsychotics alone, mood stabilizers alone, or antipsychotics plus mood stabilizers were determined. Pharmacotherapy use was examined by age, gender, and race-ethnicity.Results: A total of 1,473 clients were identified who were continuously enrolled in Medicaid during the four years. Seventy-five percent received mood stabilizers or antipsychotics. Of this group, 33% received antipsychotics alone, 23% mood stabilizers alone, and 44% both antipsychotics and mood stabilizers. The percentage receiving mood stabilizers or antipsychotics increased significantly, from 71% in 2001 to 77% in 2004, primarily because of increased use among women. Use of mood stabilizers alone declined from 25% to 20%, and use of antipsychotics alone increased from 32% to 36%. African Americans and Latinos were less likely than non-Latino whites to receive mood stabilizers or antipsychotics; this pattern was stable over time.Conclusions: Antipsychotics were prescribed for a larger percentage of clients than mood stabilizers. Persons from ethnic minority groups were less likely to receive either medication type. Research is needed to examine factors affecting pharmacotherapy in bipolar disorder and mechanisms underlying racial-ethnic disparities in pharmacotherapy, including their persistence over time. [ABSTRACT FROM AUTHOR]

Objective: Older adults with low incomes rarely use mental health care, and untreated depression is a serious problem in this population. This study examined whether a collaborative care model for depression in primary care would increase use of depression treatment and treatment outcomes for low-income elderly adults as well as for higher-income older adults.Methods: A multisite randomized clinical trial that included 1,801 adults aged 60 years and older who were diagnosed as having depression compared collaborative care for depression with treatment as usual in primary care. Participants were divided into groups by income definitions on the basis of criteria used by the U.S. Census Bureau and the U.S. Department of Housing and Urban Development (HUD). A total of 315 participants (18%) were living below the poverty level by the U.S. Census criteria, 261 (15%) were living below 30% of the area median income (AMI) (HUD criteria) but above poverty, 438 (24%) were living between 30% and 50% of the AMI, 327 (18%) were living between 50% and 80% of the AMI, and 460 (26%) were not poor. The income groups were compared on service use, satisfaction, depression severity, and physical health at baseline and at three, six, and 12 months after being randomly assigned to collaborative care or usual care.Results: The benefits for low-income older adults were similar to those for middle- and higher-income older adults. At 12 months, intervention patients in all economic brackets had significantly greater rates of depression care for both antidepressant medication and psychotherapy, greater satisfaction, lower depression severity, and less health-related functional impairment than usual care participants.Conclusions: Lower-income older adults can experience benefits from collaborative management of depression in primary care similar to those of higher-income older adults, although they may require up to a year to reap physical health benefits. [ABSTRACT FROM AUTHOR]

A prospective randomized trial was conducted to examine the effectiveness, feasibility, and degree of implementation of home health care quality improvement interventions when implemented under usual conditions by usual care providers. A total of 311 older adults were randomized to enhanced usual care (EUC) that included routine depression screening and staff training in depression care management for older adults or to the intervention group (INT) that included antidepressants and/or psychotherapy treatment plus EUC. Implementing a routine screening protocol using the PHQ-9 and depression care management quality improvements is feasible in diverse home health care organizations and results in consistently better (but not statistically significant) depression outcomes in the INT group. [ABSTRACT FROM AUTHOR]

BACKGROUND: Recent models integrating depression care management into primary care have demonstrated improved clinical outcomes and patient satisfaction. To date, none have examined psychiatric--mental health clinical nurse specialists (PCNSs) as providers in primary care. OBJECTIVES: To describe patient perception of and satisfaction with care provided by PCNSs, to compare patients with high versus lower levels of satisfaction and clinical outcomes, and to explore patient preference for future depression treatment and willingness to copay for PCNS services. STUDY DESIGN: A postintervention survey after a 12-month late-life depression care program delivered by a PCNS in primary care. Participants were 105 adults age 60 or older with major depression and/or dysthymia. RESULTS: A majority of patients perceived PCNS care as excellent, were highly satisfied with the relationship with the PCNS, would seek future treatment with the PCNS, preferred the primary care physician's office for mental health care, and reported improved clinical and functional outcomes. CONCLUSIONS: PCNS services are well received by patients in the primary care setting. PCNSs are uniquely qualified to help patients achieve significant clinical improvement in collaboration with their primary care providers. [ABSTRACT FROM AUTHOR]

Objective: To determine the incremental cost-effectiveness and net benefit of a depression collaborative care program compared with usual care for patients with diabetes and depression.Research Design and Methods: This article describes a preplanned subgroup analysis of patients with diabetes from the Improving Mood-Promoting Access to Collaborative (IMPACT) randomized controlled trial. The setting for the study included 18 primary care clinics from eight health care organizations in five states. A total of 418 of 1,801 patients randomized to the IMPACT intervention (n = 204) versus usual care (n = 214) had coexisting diabetes. A depression care manager offered education, behavioral activation, and a choice of problem-solving treatment or support of antidepressant management by the primary care physician. The main outcomes were incremental cost-effectiveness and net benefit of the program compared with usual care.Results: Relative to usual care, intervention patients experienced 115 (95% CI 72-159) more depression-free days over 24 months. Total outpatient costs were 25 dollars (95% CI -1,638 to 1,689) higher during this same period. The incremental cost per depression-free day was 25 cents (-14 dollars to 15 dollars) and the incremental cost per quality-adjusted life year ranged from 198 dollars (144-316) to 397 dollars (287-641). An incremental net benefit of 1,129 dollars (692-1,572) was found.Conclusions: The IMPACT intervention is a high-value investment for older adults with diabetes; it is associated with high clinical benefits at no greater cost than usual care. [ABSTRACT FROM AUTHOR]

OBJECTIVE: Little is known about the long-term success of quality improvement efforts for the treatment of depression in primary care. This study assessed factors associated with the successful implementation, maintenance, and spread of such efforts. METHODS: The authors conducted an independent process evaluation of data from monthly progress reports and 18-month telephone interviews from multidisciplinary quality improvement teams in 17 diverse primary care organizations that participated in the Institute for Healthcare Improvement's Breakthrough Series for Depression from February 2000 through March 2001. RESULTS: All sites made changes toward improving care in three of six categories: delivery system redesign, self-management strategies, and information systems. The changes that were most commonly viewed as major successes were delivery system changes (ten sites, or 59 percent) and information system changes (nine sites, or 53 percent); these types of changes were also the most often sustained over time (ten sites, or 59 percent, and 16 sites, or 94 percent, respectively). Fifteen sites made changes in decision support, community linkages, and health system support but were less likely to view these changes as major successes or to sustain them. Organizational structure and leadership support were the most common facilitators. Staff resistance, time constraints, and information technology were the most common barriers. Implementation strategies varied with sets of barriers. CONCLUSIONS: Despite substantial challenges, there was evidence of broad success at implementation and maintenance of quality improvement for depression treatment in primary care. [ABSTRACT FROM AUTHOR]

This study aimed to examine: the prevalence and correlates of depression among adults age 65 and over on admission to diverse home health care programs; nurse compliance with routine screening using the PHQ-9; and concordance between the number of depressed individuals identified by the PHQ-9 and Medicare-mandated nursing assessment following targeted nurse training in identifying depression among the elderly using a standard diagnostic screen. Data are drawn from routine screening of 9,178 patients (a 77% screening compliance rate). Of all patients screened, 782 (8.5%) met criteria for probable major depression and 148 (1.6%) for mild depression. Concordance between nurse identified depression via PHQ-9 and OASIS depression assessment improved over that reported in previous studies. Findings suggest that the use of a routine screening tool for depression can be implemented with minimal in-house training and improves detection of depression among older adults with significant physical and functional impairment. [ABSTRACT FROM AUTHOR]

Objective: Few older minorities receive adequate treatment of depression in primary care. This study examines whether a collaborative care model for depression in primary care is as effective in older minorities as it is in nonminority elderly patients in improving depression treatment and outcomes.Study Design: A multisite randomized clinical trial of 1801 older adults comparing collaborative care for depression with treatment as usual in primary care. Twelve percent of the sample were black (n = 222), 8% were Latino (n = 138), and 3% (n = 53) were from other minority groups. We compared the 3 largest ethnic groups (non-Latino white, black, and Latino) on depression severity, quality of life, and mental health service use at baseline, 3, 6, and 12 months after randomization to collaborative care or usual care.Principal Findings: Compared with care as usual, collaborative care significantly improved rates and outcomes of depression care in older adults from ethnic minority groups and in older whites. At 12 months, intervention patients from ethnic minorities (blacks and Latinos) had significantly greater rates of depression care for both antidepressant medication and psychotherapy, lower depression severity, and less health-related functional impairment than usual care participants (64%, 95% confidence interval [CI] 55-72 versus 45%, CI 36-55, P = 0.003 for antidepressant medication; 37%, CI 28-47 versus 13%, CI 6-19, P = 0.002 for psychotherapy; mean = 0.9, CI 0.8-1.1 versus mean = 1.4, CI 1.3-1.5, P < 0.001 for depression severity, range 0-4; mean = 3.7, CI 3.2-4.1, versus mean = 4.7, CI 4.3-5.1, P < 0.0001 for functional impairment, range 0-10).Conclusions: Collaborative Care is significantly more effective than usual care for depressed older adults, regardless of their ethnicity. Intervention effects in ethnic minority participants were similar to those observed in whites. [ABSTRACT FROM AUTHOR]

OBJECTIVE: This study compared psychiatrists' assessments of their ability to deliver high-quality care with those of other physicians. METHODS: Data were used from the Community Tracking Study Physician Survey, a national survey of 12,528 physicians. Linear regression models were used to investigate the effects of type of physician (psychiatrist or other physician), managed care involvement, and ability to obtain inpatient care on four measures of physicians' assessments of quality. RESULTS: In models that did not control for difficulty in obtaining inpatient services, assessments of quality were significantly lower among psychiatrists than among other physicians. Furthermore, although managed care involvement was associated with lower assessments of quality for all physicians in these models, the effects were stronger for psychiatrists than for other physicians. However, after difficulty in obtaining inpatient services was controlled for, psychiatrists' and other physicians' assessments of quality were similar. CONCLUSIONS: Compared with other physicians, psychiatrists' assessments of the quality of care that they provide were lower and their assessments were more influenced by involvement with managed care. These differences may be mediated by difficulty in obtaining inpatient services. When designing and administering behavioral health benefits packages, clinical policy makers should consider the possible effects of reduction in inpatient services on quality of care. [ABSTRACT FROM AUTHOR]

Background. Despite the availability of efficacious medications and psychotherapies, care of bipolar disorder in everyday practice is often deficient. This trial evaluated the effectiveness of a multi-component care management program in a population-based sample of people with bipolar disorder.Method. Four hundred and forty-one patients treated for bipolar disorder during the prior year were randomly assigned to continued usual care or usual care plus a systematic care management program including: initial assessment and care planning, monthly telephone monitoring including brief symptom assessment and medication monitoring, feedback to and coordination with the mental health treatment team, and a structured group psychoeducational program-all provided by a nurse care manager. Blinded quarterly assessments generated week-by-week ratings of severity of depression and mania symptoms using the Longitudinal Interval Follow-Up Evaluation.Results. Participants assigned to the intervention group had significantly lower mean mania ratings averaged across the 12-month follow-up period (Z=2.44, p=0.015) and approximately one-third less time in hypomanic or manic episode (2.59 weeks v. 1.69 weeks). Mean depression ratings across the entire follow-up period did not differ significantly between the two groups, but the intervention group showed a greater decline in depression ratings over time (Z statistic for group-by-time interaction=1.98, p=0.048).Conclusions. A systematic care program for bipolar disorder significantly reduces risk of mania over 12 months. Preliminary results suggest a growing effect on depression over time, but longer follow-up will be needed. [ABSTRACT FROM AUTHOR]

Background: Although effective treatment of depressed patients requires regular follow-up contacts and symptom monitoring, an efficient method for assessing treatment outcome is lacking. We investigated responsiveness to treatment, reproducibility, and minimal clinically important difference of the Patient Health Questionnaire-9 (PHQ-9), a standard instrument for diagnosing depression in primary care.Methods: This study included 434 intervention subjects from the IMPACT study, a multisite treatment trial of late-life depression (63% female, mean age 71 years). Changes in PHQ-9 scores over the course of time were evaluated with respect to change scores of the SCL-20 depression scale as well as 2 independent structured diagnostic interviews for depression during a 6-month period. Test-retest reliability and minimal clinically important difference were assessed in 2 subgroups of patients who completed the PHQ-9 twice exactly 7 days apart.Results: The PHQ-9 responsiveness as measured by effect size was significantly greater than the SCL-20 at 3 months (-1.3 versus -0.9) and equivalent at 6 months (-1.3 versus -1.2). With respect to structured diagnostic interviews, both the PHQ-9 and the SCL-20 change scores accurately discriminated patients with persistent major depression, partial remission, and full remission. Test-retest reliability of the PHQ-9 was excellent, and its minimal clinically important difference for individual change, estimated as 2 standard errors of measurement, was 5 points on the 0 to 27 point PHQ-9 scale.Conclusions: Well-validated as a diagnostic measure, the PHQ-9 has now proven to be a responsive and reliable measure of depression treatment outcomes. Its responsiveness to treatment coupled with its brevity makes the PHQ-9 an attractive tool for gauging response to treatment in individual patient care as well as in clinical research. [ABSTRACT FROM AUTHOR]

Background: Depression frequently occurs in combination with diabetes mellitus, adversely affecting the course of illness.Objective: To determine whether enhancing care for depression improves affective and diabetic outcomes in older adults with diabetes and depression.Design: Preplanned subgroup analysis of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) randomized, controlled trial.Setting: 18 primary care clinics from 8 health care organizations in 5 states.Patients: 1801 patients 60 years of age or older with depression; 417 had coexisting diabetes mellitus.Intervention: A care manager offered education, problem-solving treatment, or support for antidepressant management by the patient's primary care physician; diabetes care was not specifically enhanced.Measurements: Assessments at baseline and at 3, 6, and 12 months for depression, functional impairment, and diabetes self-care behaviors. Hemoglobin A(1c) levels were obtained for 293 patients at baseline and at 6 and 12 months.Results: At 12 months, diabetic patients who were assigned to intervention had less severe depression (range, 0 to 4 on a checklist of 20 depression items; between-group difference, -0.43 [95% CI, -0.57 to -0.29]; P < 0.001) and greater improvement in overall functioning (range, 0 [none] to 10 [unable to perform activities]; between-group difference, -0.89 [CI, -1.46 to -0.32]) than did participants who received usual care. In the intervention group, weekly exercise days increased (between-group difference, 0.50 day [CI, 0.12 to 0.89 day]; P = 0.001); other self-care behaviors were not affected. At baseline, mean (+/-SD) hemoglobin A1c levels were 7.28% +/- 1.43%; follow-up values were unaffected by the intervention (P > 0.2).Limitations: Because patients had good glycemic control at baseline, power to detect small but clinically important improvements in glycemic control was limited.Conclusions: Collaborative care improves affective and functional status in older patients with depression and diabetes; however, among patients with good glycemic control, such care minimally affects diabetes-specific outcomes. [ABSTRACT FROM AUTHOR]

Background Quality improvement (QI) programs for depressed primary care patients can improve health outcomes for 6 to 28 months; effects for longer than 28 months are unknown. Objective To assess how QI for depression affects health outcomes, quality of care, and health outcome disparities at 57-month follow-up. Design A group-level randomized controlled trial. Setting Forty-six primary care practices in 6 managed care organizations. Patients Of 1356 primary care patients who screened positive for depression and enrolled in the trial, 991 (73%, including 451 Latinos and African Americans) completed 57-month telephone follow-up. Interventions Clinics were randomly assigned to usual care or to 1 of 2 QI programs supporting QI teams, provider training, nurse assessment, and patient education, plus resources to support medication management (QI-meds) or psychotherapy (QI-therapy) for 6 to 12 months. Main Outcome Measures Probable depressive disorder in the previous 6 months, mental health–related quality of life in the previous 30 days, primary care or mental health specialty visits, counseling or antidepressant medications in the previous 6 months, and unmet need, defined as depressed but not receiving appropriate care. Results Combined QI-meds and QI-therapy, relative to usual care, reduced the percentage of participants with probable disorder at 5 years by 6.6 percentage points (P = .04). QI-therapy improved health outcomes and reduced unmet need for appropriate care among Latinos and African Americans combined but provided few long-term benefits among whites, reducing outcome disparities related to usual care (P = .04 for QI-ethnicity interaction for probable depressive disorder). Conclusions Programs for QI for depressed primary care patients implemented by managed care practices can improve health outcomes 5 years after implementation and reduce health outcome disparities by markedly improving health outcomes and unmet need for appropriate care among Latinos and African Americans relative to whites; thus, equity was improved in the long run. [ABSTRACT FROM AUTHOR]

Gynecological variables and service use were examined in a sample of 65 older women outpatients who had schizophrenia and in a control group of 51 women who were not known to have a psychiatric diagnosis. The groups were similar in their age at menarche and at menopause, use of oral contraceptives, and number of pregnancies and births. The groups differed in their receipt of several gynecological services; women with schizophrenia were less likely to have received mammograms or pelvic examinations and Pap tests or to have ever been prescribed hormone replacement therapy. These results suggest that women with schizophrenia receive fewer gynecological services than other women. Interventions at the patient, provider, and system levels may be needed to address this disparity in service use. [ABSTRACT FROM AUTHOR]

Context: Few depressed older adults receive effective treatment in primary care settings.Objective: To determine the effectiveness of the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression.Design: Randomized controlled trial with recruitment from July 1999 to August 2001.Setting: Eighteen primary care clinics from 8 health care organizations in 5 states.Participants: A total of 1801 patients aged 60 years or older with major depression (17%), dysthymic disorder (30%), or both (53%).Intervention: Patients were randomly assigned to the IMPACT intervention (n = 906) or to usual care (n = 895). Intervention patients had access for up to 12 months to a depression care manager who was supervised by a psychiatrist and a primary care expert and who offered education, care management, and support of antidepressant management by the patient's primary care physician or a brief psychotherapy for depression, Problem Solving Treatment in Primary Care.Main Outcome Measures: Assessments at baseline and at 3, 6, and 12 months for depression, depression treatments, satisfaction with care, functional impairment, and quality of life.Results: At 12 months, 45% of intervention patients had a 50% or greater reduction in depressive symptoms from baseline compared with 19% of usual care participants (odds ratio [OR], 3.45; 95% confidence interval [CI], 2.71-4.38; P<.001). Intervention patients also experienced greater rates of depression treatment (OR, 2.98; 95% CI, 2.34-3.79; P<.001), more satisfaction with depression care (OR, 3.38; 95% CI, 2.66-4.30; P<.001), lower depression severity (range, 0-4; between-group difference, -0.4; 95% CI, -0.46 to -0.33; P<.001), less functional impairment (range, 0-10; between-group difference, -0.91; 95% CI, -1.19 to -0.64; P<.001), and greater quality of life (range, 0-10; between-group difference, 0.56; 95% CI, 0.32-0.79; P<.001) than participants assigned to the usual care group.Conclusion: The IMPACT collaborative care model appears to be feasible and significantly more effective than usual care for depression in a wide range of primary care practices. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The authors compared treatment and outcomes for depressed primary care patients with and without comorbid medical conditions and assessed the impact of quality improvement programs for these patients. METHOD: The study group included 1,356 patients with major depression, dysthymia, or subthreshold depression from 46 managed primary care clinics. Clinics were randomly assigned depression treatment programs consisting of usual care for depression or one of two quality improvement programs for depression. The quality improvement programs included training experts and nurse specialists to provide education and assessment, plus access to nurse specialists for medication follow-up or access to psychotherapists. Outcomes were assessed at 6 and 12 months. RESULTS: At 6- and 12-month follow-up, the likelihood of having a probable depressive disorder was higher, but the rates of use of antidepressant medication and specialty counseling were similar, for depressed patients with comorbid medical disorders than for depressed patients who did not have comorbid medical disorders. Among the depressed patients with comorbid medical disorders, the combined quality improvement programs resulted in greater use of antidepressant medications and psychotherapy and lower rates of probable depressive disorders at both 6- and 12-month follow-up than did the usual care depression treatment program. CONCLUSIONS: Depressed patients with comorbid medical disorders tend to have similar rates of treatment but worse depression outcomes than depressed patients without comorbid medical illness. Quality improvement programs for depression can improve treatment rates and outcomes for depressed primary care patients with comorbid medical illness. The authors discuss the implications of these findings for clinical practice. [ABSTRACT FROM AUTHOR]

Objective: Evaluate the incremental cost-effectiveness of a depression relapse prevention program in primary care.Materials and Methods: Primary care patients initiating antidepressant treatment completed a standardized telephone assessment 6-8 weeks later. Those recovered from the current episode but at high risk for relapse (based on history of recurrent depression or dysthymia) were offered randomization to usual care or a relapse prevention intervention. The intervention included systematic patient education, two psychoeducational visits with a depression prevention specialist, shared decision-making regarding maintenance pharmacotherapy, and telephone and mail monitoring of medication adherence and depressive symptoms. Outcomes in both groups were assessed via blinded telephone assessments at 3, 6, 9, and 12 months and health plan claims and accounting data.Results: Intervention patients experienced 13.9 additional depression-free days during a 12-month period (95% CI, -1.5 to 29.3). Incremental costs of the intervention were $273 (95% CI, $102 to $418) for depression treatment costs only and $160 (95% CI, -$173 to $512) for total outpatient costs. Incremental cost-effectiveness ratio was $24 per depression-free day (95% CI, -$59 to $496) for depression treatment costs only and $14 per depression-free day (95% CI, -$35 to $248) for total outpatient costs.Conclusions: A program to prevent depression relapse in primary care yields modest increases in days free of depression and modest increases in treatment costs. These modest differences reflect high rates of treatment in usual care. Along with other recent studies, these findings suggest that improved care of depression in primary care is a prudent investment of health care resources. [ABSTRACT FROM AUTHOR]

Late-life depression is common in primary care. However, because of barriers such as stigma and the assumption that depression in older adults is a normal part of aging, it is often underrecognized and undertreated. Further, most primary care providers do not have the time or resources to provide adequate follow-up depression care. By integrating a depression clinical specialist into the primary care setting, many of these barriers to effective treatment can be addressed. In this paper, a collaborative, stepped care treatment program with registered nurses practicing as depression clinical specialists is described. Additionally, three case reports illustrate the model. This intervention program offers a unique opportunity for mental health nurses to practice collaboratively in the primary care setting and to provide much needed care to an underserved population. [ABSTRACT FROM AUTHOR]

Objective: Previous treatment trials have found that approximately one third of depressed patients have persistent symptoms. We examined whether depression severity, comorbid psychiatric illness, and personality factors might play a role in this lack of response.Design: Randomized trial of a stepped collaborative care intervention versus usual care.Setting: HMO in Seattle, Wash.Patients: Patients with major depression were stratified into severe (N = 149) and mild to moderate depression (N = 79) groups prior to randomization.Interventions: A multifaceted intervention targeting patient, physician, and process of care, using collaborative management by a psychiatrist and primary care physician.Measurements and Main Results: Patients with more severe depression had a higher risk for panic disorder (odds ratio [OR], 5.8), loneliness (OR, 2.6), and childhood emotional abuse (OR, 2.1). Among those with less severe depression, intervention patients showed significantly improved depression outcomes over time compared with those in usual care (z = -3.06, P<.002); however, this difference was not present in the more severely depressed groups (z = 0.61, NS). Although the group with severe depression showed differences between the intervention and control groups from baseline to 3 months that were similar to the group with less severe depression (during the acute phase of the intervention), these differences disappeared by 6 months.Conclusions: Initial depression severity, comorbid panic disorder, and other psychosocial vulnerabilities were associated with a decreased response to the collaborative care intervention. Although the intervention was appropriate for patients with moderate depression, individuals with higher levels of depression may require a longer continuation phase of therapy in order to achieve optimal depression outcomes. [ABSTRACT FROM AUTHOR]

OBJECTIVE: The study examined the relationship between mental disorders and the use of complementary and alternative medicine. METHOD: Data from a national household telephone survey conducted in 1997-1998 (N=9,585) were used to examine the relationships between use of complementary and alternative medicine during the past 12 months and several demographic variables and indicators of mental disorders. Structured diagnostic screening interviews were used to establish diagnoses of probable mental disorders. RESULTS: Use of complementary and alternative medicine during the past 12 months was reported by 16.5% of the respondents. Of those respondents, 21.3% met diagnostic criteria for one or more mental disorders, compared to 12.8% of respondents who did not report use of alternative medicine. Individuals with panic disorder and major depression were significantly more likely to use alternative medicine than those without those disorders. Respondents with mental disorders who reported use of alternative medicine were as likely to use conventional mental health services as respondents with mental disorders who did not use alternative medicine. CONCLUSIONS: We found relatively high rates of use of complementary and alternative medicine among respondents who met criteria for common mental disorders. Practitioners of alternative medicine should look for these disorders in their patients, and conventional medical providers should ask their depressed and anxious patients about the use of alternative medicine. More research is needed to determine if individuals with mental disorders use alternative medicine because conventional medical care does not meet their health care needs. [ABSTRACT FROM AUTHOR]

Objective: To examine whether depressive symptoms in older adults contribute to increased cost of general medical services.Design: A 4-year prospective cohort study.Setting: Four primary care clinics of a large staff-model health maintenance organization (HMO) in Seattle, Wash.Patients: A total of 5012 Medicare enrollees older than 65 years were invited to participate in the study; 2558 subjects (51%) were successfully enrolled. Non-participants were somewhat older and had a higher level of chronic medical illness.Main Outcome Measures: Depressive symptoms as measured by the Center for Epidemiological Studies Depression scale, which was administered as part of a mail survey at baseline, at 2 years, and at 4 years; and total cost of medical services from the perspective of the HMO. Data were obtained from the cost accounting system of the HMO.Results: In this cohort of older adults, depressive symptoms were common, persistent, and associated with a significant increase in the cost of general medical services. This increase was seen for every component of health care costs and was not accounted for by an increase in specialty mental health care. The increase in health care costs remained significant after adjusting for differences in age, sex, and chronic medical illness.Conclusions: Depressive symptoms in older adults are associated with a significant increase in the cost of medical services, even after adjusting for the severity of chronic medical illness. [ABSTRACT FROM AUTHOR]