Depression Care Management Research Articles

In the Name of … Consultation-Liaison Psychiatry

In the Name of … Consultation-Liaison Psychiatry

DESCRIPTIVE TITLE OF APPLICANT'S PROJECT* INSPIRE HHC: Interactive Nursing Support to Promote Integrated Care for Elders REceiving Home Health Care

Background: Integrated Care Management (ICM) that delivers patient-centered physical and psychosocial nursing care, produces superior health outcomes (e.g., less disability /depression/hospitalization) in older vulnerable persons who have multimorbid conditions including depression. 1-4 However, physical and psychosocial ICM is rarely found in Medicare home healthcare (HHC) settings, where the bulk of healthcare services are provided to older persons with multimorbidity. Instead, current HHC services provide care management for HHC patients short-term needs, following an acute illness, injury, or disease exacerbation,5 despite the existence of high levels of disability (40-70%), depression (40-70%) 6-10 and multiple illnesses (80%+). When multimorbidity needs are identified, the emphasis for care is placed on treatment strategies for physical health rather than ICM.9,10 This traditional service approach results in persons receiving segregated physical and mental healthcare as well as a lack of coordination between providers leading to untoward outcomes (e.g. medication errors).20-26 Yet, providing ICM to persons with multi-morbidities receiving HHC requires a uniquely different skill set for nurses.9 Thus, we developed a novel ICM education/training course, for nurses designed to provide them with skills needed to deliver ICM to their older patients to prevent disability worsening and improve psychosocial health. Design: The study used a mixed method design to develop an evidence-based hybrid online educational program. The program focused on the following 4 content areas and is informed/guided by the Chronic Care Model (CCM), ICM competencies, and expert panel (PNP, DNP, Ph.D.): (1) recognizing, treating, and providing depression care management (2) learning communication skills and developing therapeutic relationships, (3) goal setting and behavior change self-care management (4) facilitating integrated, coordinated, and interprofessional teams’ management.After development/pre-testing the course with supervisory staff, the course was pilot-tested with experienced nurses. Results: Surveys results from the pre-test by the expert panel demonstrated agreement the course was acceptable to use within the Medicare HHC reimbursement system. The panel provided useful modifications for educational content, skill building, and videos. Nurse post-test scores on module tests and comprehensive exam -showed significant improvement in knowledge and skill building scores and nurses agreed that training was useful and applicable. Lessons Learned and Suggestions for Future Research: The training curriculum showed improved nurse knowledge and skills needed to address the needs of older persons with multimorbidity and health complexity. We also found that leveraging the on-going nurse-patient relationship occurring during the HHC episode, addressed a missed opportunity to expand and enhance the therapeutic communication skills of HHC nurses’ well within their scope of practice. We will use this course as foundational part of pilot-testing a novel, nurse-supported ICM intervention, for older patients with multimorbid conditions- INSPIRE (Interactive Nursing Support to Promote Integrated care for elders REcieving HHC) designed to prevent disability worsening and improve psychosocial health. The course will be used to train intervention nurses, to ensure they have competencies to assess and provide ICM interventions that address the physical, mental and social health issues of study subjects. Thus, the ICM activities incorporated in this course have the potential to transform the way traditional HHC is practiced.

Understanding collaborative care implementation in the Department of Veterans Affairs: core functions and implementation challenges

BackgroundThe collaborative care model is an evidence-based practice for treatment of depression in which designated care managers provide clinical services, often by telephone. However, the collaborative care model is infrequently adopted in the Department of Veterans Affairs (VA). Almost all VA medical centers have adopted a co-located or embedded approach to integrating mental health care for primary care patients. Some VA medical centers have also adopted a telephone-based collaborative care model where depression care managers support patient education, patient activation, and monitoring of adherence and progress over time.This study evaluated two research questions: (1) What does a dedicated care manager offer in addition to an embedded-only model? (2) What are the barriers to implementing a dedicated depression care manager?MethodsThis study involved 15 qualitative, multi-disciplinary, key informant interviews at two VA medical centers where reimbursement options were the same— both with embedded mental health staff, but one with a depression care manager. Participant interviews were recorded and transcribed. Thematic analysis was used to identify descriptive and analytical themes.ResultsFindings suggested that some of the core functions of depression care management are provided as part of embedded-only mental health care. However, formal structural attention to care management may improve the reliability of care management functions, in particular monitoring of progress over time. Barriers to optimal implementation were identified at both sites. Themes from the care management site included finding assertive care managers to hire, cross-discipline integration and collaboration, and primary care provider burden. Themes from interviews at the embedded site included difficulty getting care management on leaders’ agendas amidst competing priorities and logistics (staffing and space).ConclusionsProviders and administrators see depression care management as a valuable healthcare service that improves patient care. Barriers to implementation may be addressed by team-building interventions to improve cross-discipline integration and communication. Findings from this study are limited in scope to the VA healthcare system. Future investigation of whether alternative barriers exist in implementation of depression care management programs in non-VA hospital systems, where reimbursement rates may be a more prominent concern, would be valuable.

A Randomized Trial of Off‐Site Collaborative Care for Depression in Chronic Hepatitis C Virus

To test the effectiveness of a collaborative depression care model in improving depression and hepatitis C virus (HCV) care. Hepatitis C virus clinic patients who screened positive for depression at four Veterans Affairs Hospitals. We compared off-site depression collaborative care (delivered by depression care manager, pharmacist, and psychiatrist) with usual care in a randomized trial. Primary depression outcomes were treatment response (≥50 percent decrease in 20-item Hopkins Symptoms Checklist [SCL-20] score), remission (mean SCL-20 score, <0.5), and depression-free days (DFDs). Primary HCV outcome was receipt of HCV treatment. Patient data were collected by self-report telephone surveys at baseline and 12months, and from electronic medical records. Baseline screening identified 292 HCV-infected patients with depression, and 242 patients completed 12-month follow-up (82.9 percent). Intervention participants were more likely to report depression treatment response, remission, and more DFDs than usual care participants. Intervention participants were more likely to receive antiviral treatment; however, the difference was not statistically significant. Off-site depression collaborative care improved depression outcomes in HCV patients and may serve as a model for collaboration between mental health and specialty physical health providers in other high co-occurring conditions.

Prediction of Primary Care Depression Outcomes at Six Months: Validation of DOC-6 ©.

The goal of this study was to develop and validate an assessment tool for adult primary care patients diagnosed with depression to determine predictive probability of clinical outcomes at 6 months. We retrospectively reviewed 3096 adult patients enrolled in collaborative care management (CCM) for depression. Patients enrolled on or before December 31, 2013, served as the training set (n = 2525), whereas those enrolled after that date served as the preliminary validation set (n = 571). Six variables (2 demographic and 4 clinical) were statistically significant in determining clinical outcomes. Using the validation data set, the remission classifier produced the receiver operating characteristics (ROC) curve with a c-statistic or area under the curve (AUC) of 0.62 with predicted probabilities than ranged from 14.5% to 79.1%, with a median of 50.6%. The persistent depressive symptoms (PDS) classifier produced an ROC curve with a c-statistic or AUC of 0.67 and predicted probabilities that ranged from 5.5% to 73.1%, with a median of 23.5%. We were able to identify readily available variables and then validated these in the prediction of depression remission and PDS at 6 months. The DOC-6 tool may be used to predict which patients may be at risk for worse outcomes.

Depression Care Management from Implementation to Expansion: “No More Wasted Years”

Depression Care Management from Implementation to Expansion: “No More Wasted Years”

Six-Month Outcomes for Collaborative Care Management of Depression Among Smoking and Nonsmoking Patients.

Background:Collaborative care management (CCM) is an evidence-based model that contributes to better outcomes for depression treatment in the primary care setting. Tobacco use increases overall economic costs, morbidity, and mortality and has been shown to impact behavioral health outcomes. Our study aims to observe clinical outcomes for depression treatment for patients with comorbid tobacco use and depression within the CCM model.Methods:A retrospective chart review study of 2826 adult patients with depression enrolled in CCM was performed to determine the association between regular tobacco use and depression outcomes. Baseline intake data consisting of clinical and demographic variables along with 6-month follow-up of Patient Health Questionnaire-9 (PHQ-9) scores for smokers (n = 727, 25.7%) and nonsmokers (n = 2099, 74.3%) were obtained. Depression remission was defined as a PHQ-9 score <5 and persistent depressive symptoms (PDS) as a PHQ-9 score ≥10 at 6 months.Results:Using an intention-to-treat analysis, the multivariate modeling demonstrated that smokers, at 6 months, had an increased adjusted odds ratio (AOR) for PDS: 1.624 (95% CI: 1.353-1.949). Furthermore, smokers had a lower AOR of depression remission: 0.603 (95% CI: 0.492-0.739). Patient adherence to treatment was also lower in smokers with an AOR of 0.666 (95% CI: 0.553-0.802).Conclusions:Smokers enrolled in CCM were associated with reduced treatment adherence and worse outcomes for depression treatment at 6 months compared to nonsmokers, even when baseline clinical and demographic variables were controlled. Thus, new tailored practices may be warranted within the CCM model to treat comorbid depression and tobacco use disorders.

HIV patient and provider feedback on a telehealth collaborative care for depression intervention

ABSTRACTIn the HIV Translating Initiatives for Depression into Effective Solutions project, we conducted a randomized controlled effectiveness and implementation trial comparing depression collaborative care with enhanced usual care in Veterans Health Administration HIV clinics in the US. An offsite HIV depression care team including a psychiatrist, a depression care manager (DCM), and a clinical pharmacist provided collaborative care using a stepped-care model of treatment and made recommendations to providers through the electronic health record system. The DCM delivered care management to HIV patients through phone calls, performing routine assessments and providing counseling in self-management and problem-solving. The DCM documented all calls in each patient’s electronic medical record. In this paper we present results from interviews conducted with patients and clinical staff in a multi-stage formative evaluation (FE). We conducted semi-structured FE interviews with 26 HIV patients and 30 clinical staff at the three participating sites during and after the trial period to gather their experiences and perspectives concerning the intervention components. Interviews were transcribed verbatim and analyzed using rapid content analysis techniques. Patients reported high satisfaction with the depression care manager (DCM) phone calls. Both HIV and mental health providers reported that the DCM’s chart notes in the electronic health record were very helpful, and most felt that a dedicated DCM for HIV patients is ideal to meet patient needs. Sites encountered barriers to achieving and maintaining universal depression screening, but had greater success when such screening was incorporated into routine intake processes. FE results demonstrated that depression care management via telehealth from an offsite team is acceptable and helpful to both HIV patients and their providers. Given that a centralized offsite depression care team can deliver effective, cost-effective, cost-saving services for multiple HIV clinics in different locations with high patient and provider satisfaction, broad implementation should be considered.

Integrating Depression Care Management into Medicare Home Health Reduces Risk of 30‐ and 60‐Day Hospitalization: The Depression Care for Patients at Home Cluster‐Randomized Trial

To determine whether a depression care management intervention in Medicare home health recipients decreases risk of hospitalization. Cluster-randomized trial. Nurse teams were randomized to intervention (12 teams) or enhanced usual care (EUC; 9 teams). Six home health agencies from distinct geographic regions. Home health recipients were interviewed at home and over the telephone. Individuals aged 65 and older who screened positive for depression on nurse assessments (N = 755) and a subset who consented to interviews (n = 306). The Depression CARE for PATients at Home (CAREPATH) guides nurses in managing depression during routine home visits. Clinical functions include weekly symptom assessment, medication management, care coordination, patient education, and goal setting. Researchers conducted telephone conferences with team supervisors every 2 weeks. Hospitalization while receiving home health services was assessed using data from the home health record. Hospitalization within 30 days of starting home health, regardless of how long recipients received home health services, was assessed using data from the home care record and research assessments. The relative hazard of being admitted to the hospital directly from home health was 35% lower within 30 days of starting home health care (hazard ratio (HR) = 0.65, P = .01) and 28% lower within 60 days (HR = 0.72, P = .03) for CAREPATH participants than for participants receiving EUC. In participants referred to home health directly from the hospital, the relative hazard of being rehospitalized was approximately 55% lower (HR = 0.45, P = .001) for CAREPATH participants. Integrating CAREPATH depression care management into routine nursing practice reduces hospitalization and rehospitalization risk in older adults receiving Medicare home health nursing services.

Implementing Collaborative Care Management for Depression, Diabetes, and Cardiovascular Disease Across Eight Health Care Systems

Implementing Collaborative Care Management for Depression, Diabetes, and Cardiovascular Disease Across Eight Health Care Systems

A Depression Care Management Project to Improve Treatment Coordination and Outcomes in Patients With Comorbid Conditions

Background/Aims: Appropriate clinical management of major depression and comorbid medical conditions represents a significant challenge for providers. Adopting a patent-centered treatment perspective, qualified nonphysician behavioral health specialists can support monitoring complex needs, enhance care provision and satisfaction with medical encounters, and improve cost-effective outcomes. This demonstration project evaluated a depression management program, examining effects on depressive symptoms, chronic disease and medication management, utilization and treatment costs.

Collaborative Care for Depression in Chronic Hepatitis C Clinics.

Depression is highly prevalent yet underdiagnosed and undertreated among patients with chronic hepatitis C virus (HCV) infection. Collaborative care models have improved depression outcomes in primary care settings, and this study aimed to provide more information on testing such methods in specialty HCV care. Hepatitis C Translating Initiatives for Depression Into Effective Solutions (HEPTIDES) was a randomized controlled trial that tested a collaborative depression care model in HCV clinics at four Veterans Affairs facilities. The HEPTIDES intervention consisted of an offsite depression care team (depression care manager, pharmacist, and psychiatrist) that delivered collaborative care. Participant interview data were collected at baseline and at six months. The outcome was depression severity measured with the Hopkins Symptom Checklist (SCL-20) and reported as treatment response (≥50% decrease in SCL-20 item score), remission (mean SCL-20 item score <.5), and depression-free days (DFDs). Baseline screening identified 263 HCV-infected patients with depression. In unadjusted analyses, intervention participants' reports trended toward more treatment response (19% versus 13%) and remission (12% versus 6%), but total number of DFDs (50.9) was similar to that of usual care participants (50.7). These trends did not reach statistical significance for the overall sample in the adjusted analyses: response (odds ratio [OR]=2.02, 95% confidence interval [CI]=.98-4.20), remission (OR=2.63, CI=1.00-6.94), and DFDs (β=7.6 days, CI=-.99 to 16.2). However, the intervention was effective in improving all three outcomes for patients who did not meet criteria for remission at baseline (SCL-20 score >.5, N=245). Depression collaborative care resulted in modest improvements in HCV patient depression outcomes. Future research should investigate intervention modifications to improve outcomes in specialty HCV clinics.

Primary care management of depression in children and adolescents.

Depression is the most common mental health disorder in children and adolescents, and primary care is often the first point of contact for children and adolescents with depression. Depression impacts all areas of life, impairing academics and interactions with family and friends. The purpose of this article is to help NPs identify and treat children and adolescents presenting with depression in the primary care setting.

Primary care management of depression in children and adolescents.

Primary care management of depression in children and adolescents.

Recurrent Major Depressive Disorder of a Young Woman.

Questions are presented at “consideration points” that follow a section that gives information about the case. One or more choices may be correct for each question; make your choices on the basis of your clinical knowledge and the history provided. Read all of the options for each question before making any selections. You are given points on a graded scale for the best possible answer(s), and points are deducted for answers that would result in a poor outcome or delay your arriving at the right answer. Answers that have little or no impact receive zero points. At the end of the exercise, you will add up your points to obtain a total score.

Screening for Depression—A Tale of Two Questions

The US Preventive Services Task Force (USPSTF)1 has issued new recommendations on Screening for Depression inwhich they concluded, “TheUSPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accuratediagnosis, effective treatment, andappropriate follow-up (B recommendation).”GradeB indicateshighcertainty that the netbenefit ismoderateormoderate certainty that thenetbenefit is moderate to substantial. An “adequate system” includes a depression care manager who ensures that patients are screened and, if they screen positive for depression, appropriatelydiagnosedandtreatedwithevidence-basedstepped careor referred toa setting that canprovide thenecessarycare. The newguidelines are similar to the 2002 and 2009USPSTF depression screening recommendations except for 1 major change:neither the2002nor the2009recommendationsmentioned pregnant or postpartumwomen.2,3 The recentUSPSTF recommendations are largelybasedon a systematic review evaluating the potential benefits of depressionscreening inpregnantorpostpartumwomen.4Nonew randomized trials of depression screening in (nonpregnant or postpartum) adults have been added since the 2009 guidelines. One example of the new studies included in the USPSTF systematic review was a trial that randomized 462 postpartum women (who were not already receiving psychiatric treatment) toadepressionscreening interventionvsusual care.5 Intervention groupparticipants completed the 10-item Edinburgh Postnatal Depression Scale (EPDS); control group participants completed a general self-efficacy scale (similar in length and format) but didnot complete theEPDS.All participants underwent a clinical assessment by a nurse who was blinded to their group allocation; patients (fromeither group) who were assessed by this nurse as having probable postnatal depression were referred for further evaluation and treatment. Intervention patients with an EDPS score of at least 10 (or any suicidal ideation)were referred for further evaluation and treatment (regardless of the clinical assessment). In an intention to treat analysis, 13% of the intervention group and 22.1% of the control group had EDPS scores of at least 10 at 6 months (risk ratio, 0.59; 95% CI, 0.39-0.89; number needed to screen, 11). Basedon this andother studies, theUSPSTFconcluded that screening results in the reduction or remission of depression symptoms and that the magnitude of harms of screening for depression in adults is small to none. Whether the available evidence justifies routine screening of unselected adults for depression is debatable. Notably, the Canadian Task Force on Preventive Health Care does not recommend routine screening for depression in adults at average risk.6 However, multiple other organizations (eg, American Academy of Family Physicians, American College of Physicians,AmericanCollegeofObstetriciansandGynecologists)do recommendroutinescreeningfordepression,especially forsubgroupsofpatientswhoareathighrisk, suchaspersonswith low socioeconomic status, limitedsocial support, chronicpain,disability, unintended pregnancy, comorbid mental health issues, or chronicmedical conditions.Moreover,most US insuranceproviders, including theCenter forMedicareandMedicaid Services, coverannual screening fordepression inprimarycare settingsthathavestaff-assisteddepressioncaresupports inplace to assure accurate diagnosis, effective treatment, and followup.Therefore,primarycarecliniciansmustbefamiliarwithhow to implement a depression screening program.

Comparative Studies of Collaborative Team Depression Care Adoption in Safety Net Clinics

Purpose: To evaluate three approaches adopting collaborative depression care model in Los Angeles County safety net clinics with predominantly Latino type 2 diabetes patients. Methods: Pre–post differences in treatment rates and symptom reductions were compared between baseline, 6-month, and 12-month follow-ups for each approach: (a) Multifaceted Depression and Diabetes Program (MDDP) grant–hired social workers dedicated for depression care, (b) Diabetes–Depression Care-Management Adoption Trial (DCAT) supported care (SC) by clinic social workers in diabetes disease management teams, and (c) DCAT-automated care-management technology-facilitated care (TC) model. All social workers were guided by a depression care protocol. Results: All approaches significantly increased treatment rate, the largest improvement being MDDP (40%), followed by TC (30%) and then SC (20%). Similar patterns were found in symptom improvement (≥50% depression score reductions) and self-rated health. TC was the only approach to significantly improve patient diabetes self-care. Discussion: Activated social workers and technology facilitation provide promising effective adoption of collaborative depression team care in safety net.

The Impact of Posttraumatic Stress Disorder on the 6-Month Outcomes in Collaborative Care Management for Depression.

Posttraumatic stress disorder (PTSD) has symptoms that exist along a spectrum that includes depression and the 2 disorders may coexist. Collaborative care management (CCM) has been successfully used in outpatient mental health management (especially depression and anxiety) with favorable outcomes. Despite this, there exist limited data on clinical impact of a diagnosis of PTSD on depression outcomes in CCM. The present study used a retrospective cohort design to examine the association of PTSD with depression outcomes among 2121 adult patients involved in CCM in a primary care setting. Using standardized self-report measures, baseline depression scores and 6-month outcome scores were evaluated. Seventy-six patients had a diagnosis of PTSD documented in their electronic medical record. Patients with PTSD reported more severe depressive symptoms at baseline (Patient Health Questionnaire-9 score of 17.9 vs 15.4, P < .001) than those without PTSD. Controlling for sociodemographic and clinical characteristics, a clinical diagnosis of PTSD was associated with lower odds (AOR = 0.457, CI = 0.274-0.760, P = .003) of remission at 6 months and was also associated with higher odds (AOR = 3.112, CI = 1.921-5.041, P < .001) of persistent depressive symptoms at 6 months after CCM. When coexisting with depression, a diagnosis of PTSD was associated with worse depression outcomes, when managed with CCM in primary care. Opportunities still exist for more aggressive management of depression in these patients to help improve remission as well as reduce persistent depressive symptoms.

Poster Number: EI 2 - Course of Suicidal Ideation among Home Health Patients in the CAREPATH Depression Care Management Trial

Poster Number: EI 2 - Course of Suicidal Ideation among Home Health Patients in the CAREPATH Depression Care Management Trial

Care Management Processes Used Less Often For Depression Than For Other Chronic Conditions In US Primary Care Practices.

Primary care physicians play an important role in the diagnosis and management of depression. Yet little is known about their use of care management processes for depression. Using national survey data for the period 2006-13, we assessed the use of five care management processes for depression and other chronic illnesses among primary care practices in the United States. We found significantly less use for depression than for asthma, congestive heart failure, or diabetes in 2012-13. On average, practices used fewer than one care management process for depression, and this level of use has not changed since 2006-07, regardless of practice size. In contrast, use of diabetes care management processes has increased significantly among larger practices. These findings may indicate that US primary care practices are not well equipped to manage depression as a chronic illness, despite the high proportion of depression care they provide. Policies that incentivize depression care management, including additional quality metrics, should be considered.