Depression Care Management Research Articles

Capsule Commentary on Gallo et al., Multimorbidity, Depression, and Mortality in Primary Care: Randomized Clinical Trial of an Evidence-Based Depression Care Management Program on Mortality Risk.

O ne problem in translational research is that it usually isolates studies to a narrow class of patients and a single disease. However, as Gallo correctly points out, older adult patients usually present with multiple comorbid diseases, each with their own management algorithm. Such algorithms sometimes suggest strategies for the index disease that might complicate or be contraindicated in patients with comorbid conditions. Primary care physicians are used to dealing with and balancing multiple competing needs of their older patients. Depression commonly complicates disease and numerous observational studies have shown that when present, comorbid depression increases mortality. Unfortunately, subsequent randomized trials of depression management have failed to show a survival benefit. For example, regarding cardiovascular disease, observational studies have found that patients with depression have increased mortality, but randomized controlled trials (RCTs) on managing depression in patients with heart failure or post myocardial infarction have failed to demonstrate a mortality benefit. Gallo et al. provide yet more observational data that improved depression care may save lives. They randomized depressed patients to usual care or more intensive management, and found that depressed participants randomized to usual care with high levels of medical comorbidity were three times more likely to die than those with depression and minimal medical comorbidity. Patients receiving more intensive depression managed with high disease burden experienced a nonsignificant morality rate that was 1.75 times greater than that among those with depression and low levels of medical comorbidity. The authors conclude that, Bdepression management mitigated the combined effect of multimorbidity and depression on mortality^ and Bshould be integral to optimal patient care, not a secondary focus.^ That depression management should be integral to optimal patient care is not an argument that needs buttressing. Depression has a profound impact on the lives of the individual, their family and the workplace. Depression is most commonly managed in primary care and every provider has experienced the remarkable improvement in the quality of their patient’s life with appropriate depression management. This endless, and thus far fruitless, search for an additional mortality reason to justify making depression management an integral skill for primary care physicians seems unnecessary and misguided.

Does a Depression Management Program Decrease Mortality in Older Adults with Specific Medical Conditions in Primary Care? An Exploratory Analysis

To determine whether treating depression decreases mortality from various chronic medical conditions. Long-term follow-up of multisite-practice randomized controlled trial (Prevention of Suicide in Primary Care Elderly: Collaborative Trial). Twenty primary care practices randomized to intervention or usual care. Individuals aged 60 and older identified through depression screening of random patients (N=1,226). For 2 years, a depression care manager worked with primary care physicians in intervention practices to provide algorithm-based care for depression. Mortality risk based on a median follow-up of 98 months (range 0.8-116.4 months) through 2008; chronic medical conditions ascertained through self-report. For heart disease, persons with major depression were at greater risk of death, whether in usual-care or intervention practices. Older adults with major depression and diabetes mellitus in practices randomized to the intervention condition (hazard ratio=0.47, 95% confidence interval=0.24-0.91) were less likely to die. For other medical conditions, the point estimates for risk of death in persons with major depression were all in the direction of indicating lower risk in intervention practices but did not reach statistical significance. Older adults with depression and medical comorbidity pose a significant clinical and public health challenge. Evidence was found of a statistically significant intervention effect on mortality for diabetes mellitus in persons with major depression.

Reducing suicidal ideation in home health care: results from the CAREPATH depression care management trial.

The study evaluated the effectiveness of a depression care management intervention in reducing suicidal ideation (SI) among home health patients. Data come from the cluster-randomized effectiveness trial of the Depression Care for Patients at Home (Depression CAREPATH), an intervention that integrates depression care management into the routine nursing visits of Medicare home health patients screening positive for depression. Patients were interviewed at baseline, 3, 6, and 12-month follow-up. SI was measured using the Hamilton Rating Scale for Depression item. We compared likelihood of any level of SI between intervention and usual care patients using longitudinal logistic mixed-effects models. A total of 306 eligible patients enrolled in the trial. Among them, 70 patients (22.9%) reported SI at baseline. Among patients with SI, patients under the care of nurses randomized to CAREPATH were less likely to report SI over the study period (odds ratio = 0.51, 95% CI; 0.24-1.07), with 63.6% of usual care versus 31.3% of CAREPATH participants continuing to report SI after one year. Baseline major depression, greater perceived burdensomeness, and greater functional disability were associated with greater likelihood of SI. SI is reported in more than 10% of Medicare home health patients. The Depression CAREPATH intervention was associated with a reduction in patients reporting SI at one year, compared to enhanced usual care. Given relative low burden on nursing staff, depression care management may be an important component of routine home health practices producing long-term reduction in SI among high-risk patients. Copyright © 2015 John Wiley & Sons, Ltd.

Changes in HIV Outcomes Following Depression Care in a Resource-Limited Setting: Results from a Pilot Study in Bamenda, Cameroon.

BackgroundLittle is known about how improved depression care affects HIV-related outcomes in Africa. In a sample of depressed HIV patients in a low income, sub-Saharan country, we explored how implementing measurement-based antidepressant care (MBC) affected HIV outcomes over 4 months of antidepressant treatment.MethodsAs part of a project adapting MBC for use in Cameroon, we enrolled 41 depressed HIV patients on antiretroviral therapy in a pilot study in which a depression care manager (DCM) provided an outpatient HIV clinician with evidence-based decision support for antidepressant treatment. Acute depression management was provided for the first 12 weeks, with DCM contact every 2 weeks and HIV clinician appointments every 4 weeks. We measured HIV clinical and psychiatric outcomes at 4 months.ResultsParticipants were moderately depressed at baseline (mean Patient Health Questionnaire [PHQ] score = 14.4, range 13.1, 15.6). All HIV clinical outcomes improved by four month follow-up: mean (range) CD4 count improved from 436 (2, 860) to 452 (132, 876), mean (range) log-viral load decreased from 4.02 (3.86, 4.17) to 3.15 (2.81, 3.49), the proportion with virologic suppression improved from 0% to 18%, mean (range) HIV symptoms decreased from 6.4 (5.5, 7.3) to 3.1 (2.5, 3.7), the proportion reporting good or excellent health improved from 18% to 70%, and the proportion reporting any missed ARV doses in the past month decreased from 73% to 55%. Concurrently, psychiatric measures improved. The mean (range) PHQ score decreased from 14.4 (13.1, 15.6) to 1.6 (0.8, 2.4) and 90% achieved depression remission, while mean maladaptive coping style scores decreased and mean adaptive coping scores and self-efficacy scores improved.ConclusionIn this pilot study of an evidence-based depression treatment intervention for HIV-infected patients in Cameroon, a number of HIV behavioral and non-behavioral health outcomes improved over 4 months of effective depression treatment. These data are consistent with the hypothesis that better depression care can lead to improved HIV outcomes.

Multimorbidity, Depression, and Mortality in Primary Care: Randomized Clinical Trial of an Evidence-Based Depression Care Management Program on Mortality Risk.

Two-thirds of older adults have two or more medical conditions that often take precedence over depression in primary care. We evaluated whether evidence-based depression care management would improve the long-term mortality risk among older adults with increasing levels of medical comorbidity. Longitudinal analyses of the practice-randomized Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT). Twenty primary care practices randomized to intervention or usual care. The sample included 1204 older primary care patients completing the Charlson Comorbidity Index (CCI) and other interview questions at baseline. For 2 years, a depression care manager worked with primary care physicians to provide algorithm-based care for depression, offering psychotherapy, increasing the antidepressant dose if indicated, and monitoring symptoms, medication adverse effects, and treatment adherence. Depression status based on clinical interview, CCI to evaluate medical comorbidity, and vital status at 8 years (National Death Index). In the usual care condition, patients with the highest levels of medical comorbidity and depression were at increased risk of mortality over the course of the follow-up compared to depressed patients with minimal medical comorbidity [hazard ratio 3.02 (95% CI, 1.32 to 8.72)]. In contrast, in intervention practices, patients with the highest level of medical comorbidity and depression compared to depressed patients with minimal medical comorbidity were not at significantly increased risk [hazard ratio 1.73 (95% CI, 0.86 to 3.96)]. Nondepressed patients in intervention and usual care practices had similar mortality risk. Depression management mitigated the combined effect of multimorbidity and depression on mortality. Depression management should be integral to optimal patient care, not a secondary focus.

The effect of antidepressant treatment on HIV and depression outcomes: results from a randomized trial.

Depression is a major barrier to HIV treatment outcomes. To test whether antidepressant management decision support integrated into HIV care improves antiretroviral adherence and depression morbidity. Pseudo-cluster randomized trial. Four US infectious diseases clinics. HIV-infected adults with major depressive disorder. Measurement-based care (MBC) - depression care managers used systematic metrics to give HIV primary-care clinicians standardized antidepressant treatment recommendations. Primary - antiretroviral medication adherence (monthly unannounced telephone-based pill counts for 12 months). Primary time-point - 6 months. Secondary - depressive severity, depression remission, depression-free days, measured quarterly for 12 months. From 2010 to 2013, 149 participants were randomized to intervention and 155 to usual care. Participants were mostly men, Black, non-Hispanic, unemployed, and virally suppressed with high baseline self-reported antiretroviral adherence and depressive severity. Over follow-up, no differences between arms in antiretroviral adherence or other HIV outcomes were apparent. At 6 months, depressive severity was lower among intervention participants than usual care [mean difference -3.7, 95% confidence interval (CI) -5.6, -1.7], probability of depression remission was higher [risk difference 13%, 95% CI 1%, 25%), and suicidal ideation was lower (risk difference -18%, 95% CI -30%, -6%). By 12 months, the arms had comparable mental health outcomes. Intervention arm participants experienced an average of 29 (95% CI: 1-57) more depression-free days over 12 months. In the largest trial of its kind among HIV-infected adults, MBC did not improve HIV outcomes, possibly because of high baseline adherence, but achieved clinically significant depression improvements and increased depression-free days. MBC may be an effective, resource-efficient approach to reducing depression morbidity among HIV patients.

Development and Evaluation of a Fidelity Instrument for PEARLS.

This manuscript describes the development and the preliminary evaluation of a fidelity instrument for the Program for Encouraging Active and Rewarding Lives (PEARLS), an evidence-based depression care management (DCM) program. The objective of the study was to find an effective, practical, multidimensional approach to measure fidelity of PEARLS programs to the original, research-driven PEARLS protocol in order to inform program implementation at various settings nationwide. We conducted key informant interviews with PEARLS stakeholders, and held focus groups with former PEARLS clients, to identify core program components. These components were then ranked using a Q-sort process, and incorporated into a brief instrument. We tested the instrument at two time points with PEARLS counselors, other DCM program counselors, and non-DCM program counselors (n = 56) in six states. Known-groups method was used to compare findings from PEARLS programs, other DCM programs, and non-DCM programs. We asked supervisors of the counselors to complete the fidelity instrument on behalf of their counselors to affirm the validity of the results. We examined the association of PEARLS program fidelity with individual client outcomes. Program for Encouraging Active and Rewarding Lives providers reported the highest fidelity scores compared to DCM program providers and non-DCM program providers. The sample size was too small to yield significant results on the comparison between counselor experience and fidelity. Scores varied between PEARLS counselors and their supervisors. PEARLS program fidelity was not significantly correlated with client outcomes, suggesting that other implementation factors may have influenced the outcomes and/or that the instrument needs refinement. Our findings suggest that providers may be able to use the instrument to assess PEARLS program fidelity in various settings across the country. However, more rigorous research is needed to evaluate instrument effectiveness.

Developing a clinical pathway for the identification and management of anxiety and depression in adult cancer patients: an online Delphi consensus process.

People with cancer and their families experience high levels of psychological morbidity. However, many cancer services do not routinely screen patients for anxiety and depression, and there are no standardized clinical referral pathways. This study aimed to establish consensus on elements of a draft clinical pathway tailored to the Australian context. A two-round Delphi study was conducted to gain consensus among Australian oncology and psycho-oncology clinicians about the validity of 39 items that form the basis of a clinical pathway that includes screening, assessment, referral and stepped care management of anxiety and depression in the context of cancer. The expert panel comprised 87 multidisciplinary clinician members of the Australian Psycho-oncology Co-operative Research Group (PoCoG). Respondents rated their level of agreement with each statement on a 5-point Likert scale. Consensus was defined as >80% of respondents scoring within 2 points on the Likert scale. Consensus was reached for 21 of 39 items, and a further 15 items approached consensus except for specific contextual factors, after two Delphi rounds. Formal screening for anxiety and depression, a stepped care model of management and recommendations for inclusion of length of treatment and time to review were endorsed. Consensus was not reached on items related to roles and responsibilities, particularly those not applicable across cancer settings. This study identified a core set of evidence- and consensus-based principles considered essential to a stepped care model of care incorporating identification, referral and management of anxiety and depression in adult cancer patients.

Depression care management for adults older than 60 years in primary care clinics in urban China: a cluster-randomised trial

China's national health policy classifies depression as a chronic disease that should be managed in primary care settings. In some high-income countries use of chronic disease management principles and primary care-based collaborative-care models have improved outcomes for late-life depression; however, this approach has not yet been tested in China. We aimed to assess whether use of a collaborative-care depression care management (DCM) intervention could improve outcomes for Chinese adults with depression aged 60 years and older. Between Jan 17, 2011, [corrected] and Nov 30, 2013, we did a cluster-randomised trial in patients from primary care centre clinics in Shangcheng district of Hangzhou city in eastern China. We randomly assigned (1:1) clinics to either DCM (involving training for physicians in use of treatment guidelines, training for primary care nurses to function as care managers, and consultation with psychiatrists as support) or to give enhanced care as usual to all eligible patients aged 60 years and older with major depressive disorder. Clinics were chosen randomly for inclusion from all primary care clinics in the district by computer algorithm and then randomly allocated depression care interventions remotely by computer algorithm. Physicians, study personnel, and patients were not masked to clinic assignment. Our primary outcome was difference in Hamilton Depression Rating Scale (HAMD) score using data for clusters at baseline and 3, 6, and 12 month follow-up in a mixed-effects model of the intention-to-treat population. We originally aimed to analyse outcomes at 24 months, however the difference between groups at 12 months was large and funding was insufficient to continue to 24 months, therefore we decided to end the trial at 12 months. This trial is registered with ClinicalTrials.gov, number NCT01287494. Of 34 primary care clinics in Shangcheng district, 16 were randomly chosen. We randomly assigned eight clinics to the DCM intervention (164 patients enrolled) and eight primary care clinics to enhanced care as usual (162 patients). There were no major differences in baseline demographic and clinical variables between the groups of patients for each intervention. Over the 12 months, patients in clinics assigned to DCM had a significantly greater reduction in HAMD score than did those in practices assigned to enhanced care as usual (estimated between group difference -6·5 [95% CI -7·1 to -5·9]; Cohen's d 0·8 [95% CI 0·8-0·9]; p<0·0001). The intercluster correlation for change in HAMD total score was 0·07 (95% CI 0·06-0·08). There were no study-related adverse events in either group. Clinical outcomes of Chinese adults older than 60 years who had major depression were improved when their primary care clinic used DCM. Primary care-based collaborative management of depression is promising to address this pressing public health need in China. National Institutes of Health, Program for New Century Excellent Talents in Universities of China, Ministry of Education, China.

The Relationships Between Vascular Risk, Cognition and Outcome in Late-Life Psychotic Depression

difficulties, and baseline depression scores. We assessed risk of discharge to hospital (according to Medicare hospitalization claims) in the 30-day and 60-day periods following start of care. Results: Of 755 total eligible patients, 195 (25.8%) patients were hospitalized during the 60-day study period. At 30 days from start of care, 68 (15.5%) CAREPATH patients and 69 (22.0%) usual care patients were hospitalized. The 30-day risk of hospitalization among CAREPATH patients was approximately 30% lower compared to usual care (adjusted Relative Risk (RR) 1⁄4 0.70, p1⁄4.020). At 60 days from start of care, 103 (23.5%) CAREPATH patients were hospitalized and 92 (29.4%) usual care patients were hospitalized. The 60-day risk of hospitalization remained approximately 20% lower among CAREPATH patients (RR1⁄40.79, p1⁄4.055). Using cox proportional hazards models to account for individual differences in time at-risk, the risk of hospitalization was approximately 34% lower (adjusted Hazard Ratio (HR) 1⁄4 0.66, p1⁄4.015) among CAREPATH patients after 30 days, and approximately 29% lower (HR 1⁄4 0.71, p1⁄4.019) after 60 days. Conclusions: Patients receiving CAREPATH depression care were significantly less likely to experience acute care hospitalization during 30-day and 60-day Medicare home health episodes. Results suggest that depression care management may be an important element of routine home health and post-acute care practices, not only to treat depression but to reduce risk of adverse outcomes and associated medical costs.

Compliance and Drop Out Rates Among Minority Patients in Collaborative Care Management for Depression

Treatment compliance continues to be a challenge in chronic disease management. Depression is not an exception with low treatment engagement seen particularly among minority population. The collaborative care model (CCM) has been shown to potentially improve treatment engagement in this group. We conducted a retrospective study aimed at comparing treatment engagement in CCM, measured by compliance and drop-out rates, between minority and non-minority groups. Using the registry, records of patients eligible for CCM from March 2008 until August 2013 were reviewed. Both 6 month compliance and drop-out rates were compared between Caucasian and minority (non-Caucasian) patients followed under CCM. Treatment compliance between minority patients enrolled in CCM and those in usual care (UC) was also evaluated. Of 624 minority patients eligible for CCM, 38.6% (N=241) enrolled; the rest stayed in UC. Compliance with 6 month follow-up was 61.8% (n=149) among minority patients in CCM vs. 12.3% (n=47) in UC (p value =0.0001). Within CCM, compliance was lower in minority group than in Caucasians although not statistically significant (p value=0.058). Six month drop-out rate from CCM was significantly higher in minority patients compared to Caucasians (36.1% vs. 27.9%, p value=0.011). While CCM appear to improve compliance with depression treatment among minority patients, treatment engagement in this population group remains a challenge as reflected by lower compliance and higher dropout rate. Identifying barriers to treatment retention and re-evaluating CCM process to address these barriers are key elements to successful implementation of this model in depression management among minority patients.

Effect of Depression Care Management on Acute Hospitalization Risk Among Medicare Home Health Patients: The CAREPATH Trial

Acute care hospitalizations among home-health care (HHC) patients are significant and costly adverse outcomes, but there are few evidence-based interventions to reduce risk of hospitalization in HHC. Depression is common among home health patients, is often inadequately treated, and increases risk of hospitalization and other adverse outcomes. The purpose of this study was to evaluate the effectiveness of a depression care management intervention in reducing risk of acute care hospitalization among older HHC patients.

Guideline concordant detection and management of depression among Alaska Native and American Indian people in primary care

BackgroundA tribal health organization in Alaska implemented a primary care depression screening, detection and management initiative amongst 55,000 Alaska Native/American Indian people (AN/AIs).Objectives(a) To describe the proportion of AN/AIs screening positive for depression with depression noted or diagnosed and proportion with guideline concordant management and (b) to assess whether management varied by patient and provider factors.Research designSecondary analysis of electronic and paper medical record information of 400 AN/AIs.MeasuresProvider variables, patient demographics and patient clinical factors were electronically queried. Manual chart audits assessed depression notation, diagnoses and management within 12 weeks of positive screening. Multilevel ordinal logistic modelling assessed management by patient and provider factors.ResultsA depression diagnosis was present in 141 (35%) charts and 151 (38%) had depressive symptoms noted. Detection was higher among AN/AIs with moderate and severe depression (p<0.001). In total, 258 patients (66%) received guideline concordant management, 32 (8%) had some management, and 110 (28%) received no management. Younger patient age and increased provider tenure increased odds of management.ConclusionsMost AN/AIs screening positive for depression received initial guideline concordant management. Additional outreach to older patients and additional support for providers newer to practices appears warranted.

Home health care nurse interactions with homebound geriatric patients with depression and disability.

Building therapeutic nurse-patient relationships is pivotal to the provision of optimum nurse care management for geriatric home health care (HHC) patients. However, little is known about which strategies most effectively treat older adult HHC patients with concomitant depression and disability. This qualitative descriptive study was conducted in two parts to explore the issue further. The first part involved interviews regarding HHC nurse perceptions of geriatric depression and disability care management. The second part, which is the focus of the current analysis, describes HHC nurses' use of care management and therapeutic during home visits. Observation of nurse-patient interactions involved 25 nurses home visits to HHC patients 60 and older who had depression and disability. Drawing on clinical knowledge and interpersonal skills, nurses built relationships and fostered trust. However, despite their disabilities to make these connections, multiple missed opportunities occurred for nurses to engage in more productive interactions. Four training components to support improvement of nurse-patient therapeutic relationships are described and recommended.

Peer Influence on Change in Employer Appraisal of Depression Care Management Products

Peer Influence on Change in Employer Appraisal of Depression Care Management Products

Improving home-based providers’ communication to primary care providers to enhance care coordination

Objectives: Health care system fragmentation is a pervasive problem. Research has not delineated concrete behavioral strategies to guide providers to communicate with personnel in other organizations to coordinate care. We addressed this gap within a particular context: home-based providers delivering depression care management (DCM) to older adults requiring coordination with primary care personnel. Our objective was to pilot test a communication protocol (‘BRIDGE – BRinging Inter-Disciplinary Guidelines to Elders’) in conjunction with DCM.Method: In an open pilot trial (N = 7), home-based providers delivered DCM to participants. Following the BRIDGE protocol, home-based providers made scripted telephone calls and sent structured progress reports to personnel in participants’ primary care practices with concise information and requests for assistance. Home-based providers documented visits with participants, contacts to and responses from primary care personnel. A research interviewer assessed participant outcomes [Symptom Checklist-20 (depressive symptoms), World Health Organization Disability Assessment Schedule-12, satisfaction] at baseline, three months, and six months.Results: Over 12 months, home-based providers made 2.4 telephone calls and sent 6.3 faxes to other personnel, on average per participant. Primary care personnel responded to 18 of 22 requests (81.8%; 2 requests dropped, 2 ongoing), with at least one response per participant. Participants’ depressive symptoms and disability improved significantly at both post-tests with large effect sizes (d ranged 0.73–2.3). Participants were satisfied.Conclusion: Using BRIDGE, home-based providers expended a small amount of effort to communicate with primary care personnel, who responded to almost all requests. Larger scale research is needed to confirm findings and potentially extend BRIDGE to other client problems, professions, and service sectors.

Clinical Effectiveness of Integrating Depression Care Management Into Medicare Home Health

ImportanceAmong older home health care patients, depression is highly prevalent, is often inadequately treated, and contributes to hospitalization and other poor outcomes. Feasible and effective interventions are needed to reduce this burden of depression.ObjectiveTo determine whether, among older Medicare Home Health recipients who screen positive for depression, patients of nurses receiving randomization to an intervention have greater improvement in depressive symptoms during 1 year than patients receiving enhanced usual care.Design, Setting, and ParticipantsThis cluster randomized effectiveness trial conducted at 6 home health care agencies nationwide assigned nurse teams to an intervention (12 teams) or to enhanced usual care (9 teams). Between January 13, 2009, and December 6, 2012, Medicare Home Health patients 65 years and older who screened positive for depression on routine nursing assessments were recruited, underwent assessment, and were followed up at 3, 6, and 12 months by research staff blinded to intervention status. Patients were interviewed at home and by telephone. Of 502 eligible patients, 306 enrolled in the study.InterventionsThe Depression Care for Patients at Home (Depression CAREPATH) trial requires nurses to manage depression at routine home visits by weekly symptom assessment, medication management, care coordination, education, and goal setting. Nurses’ training totaled 7 hours (4 onsite and 3 via the web). Researchers telephoned intervention team supervisors every other week.Main Outcomes and MeasuresDepression severity, assessed by the 24-item Hamilton Scale for Depression (HAM-D).ResultsThe 306 participants were predominantly female (69.6%), were racially/ethnically diverse (18.0% black and 16.0% Hispanic), and had a mean (SD) age of 76.5 (8.0) years. In the full sample, the intervention had no effect (P = .13 for intervention × time interaction). Adjusted HAM-D scores (Depression CAREPATH vs control) did not differ at 3 months (10.5 vs 11.4, P = .26) or at 6 months (9.3 vs 10.5, P = .12) but reached significance at 12 months (8.7 vs 10.6, P = .05). In the subsample with mild depression (HAM-D score, <10), the intervention had no effect (P = .90), and HAM-D scores did not differ at any follow-up points. Among 208 participants with a HAM-D score of 10 or higher, the Depression CAREPATH demonstrated effectiveness (P = .02), with lower HAM-D scores at 3 months (14.1 vs 16.1, P = .04), at 6 months (12.0 vs 14.7, P = .02), and at 12 months (11.8 vs 15.7, P = .005).Conclusion and RelevanceHome health care nurses can effectively integrate depression care management into routine practice. However, the clinical benefit seems to be limited to patients with moderate to severe depression.Trial Registrationclinicaltrials.gov Identifier: NCT01979302

Depression Care Manager Key to Integrated Care Success

Depression Care Manager Key to Integrated Care Success

Intervention impact on depression product appraisal and purchasing behavior by employers: a randomized trial.

BackgroundEmployers can purchase high quality depression products that provide the type, intensity and duration of depression care management shown to improve work outcomes sufficiently for many employers to achieve a return on investment. The purpose of this randomized controlled trial was to test an intervention to encourage employers to purchase a high quality depression product for their workforce.MethodsTwenty nine organizations recruited senior health benefit professional members representing public or private employers who had not yet purchased a depression product for all 100+ workers in their company. The research team used randomization blocked by company size to assign eligible employers to: (1) a presentation encouraging employers to purchase a high quality depression product accompanied by a scientifically-derived return on investment estimate, or (2) a presentation encouraging employers to work with their most subscribed health plan to improve depression treatment quality indicators. Two hundred ninety three employers (82.3% of 356) completed baseline data immediately before learning that 140 employers had been randomized to the evidence-based (EB) depression product presentation and 153 had been randomized to the usual care (UC) depression treatment quality indicator presentation. Analysis of 250 (85.3% of 293) employers who completed web-based interviews at 12 and/or 24 months was conducted to determine presentation impact on depression product appraisal and purchasing behavior.ResultsThe intervention had no impact on depression product appraisal in 232 subjects (F = 2.36, p = .07) or depression product purchasing (chisquare = 1.82, p = .44) in 250 subjects. Depression product appraisal increased in companies with greater health benefit generosity whose benefit professionals were male. Depression product purchasing behavior increased in small companies compared to large companies, companies who knew a vendor that sold depression products at baseline, companies with greater health benefit risk taking, and companies with less politicalization of health care benefit decision making.ConclusionsPolicy makers need to build innovative bridges to the employer community to convince them to purchase evidence-based benefits, even when benefits offer potential financial savings.Trial registrationClinical Trials Registration Number: NCT01013220.

Collaborative treatment of late-life depression in primary care (GermanIMPACT): study protocol of a cluster-randomized controlled trial.

BackgroundDepression is not a normal side effect of aging, however it is one of the most prevalent mental health issues in later life, imposing a tremendous burden on patients, their families, and the healthcare system. We describe the experimental implementation of a collaborative, stepped-care model for the treatment of late-life depression (GermanIMPACT trial) in the German primary care context. GermanIMPACT was developed as an adaptation of a successful and widely used American model. The aim of the study is to evaluate the model’s applicability to the German primary care setting and its cost-effectiveness.Methods/DesignThe study will be conducted as a cluster-randomized controlled trial comparing the development of depressive symptoms in primary care patients who either receive treatment as usual (control arm) or treatment according to the GermanIMPACT model (intervention arm). In two German cities (Freiburg and Hamburg), a total of 60 general practice offices will be selected and randomized. Each general practice office will be asked to enroll five patients into the trial who are 60 years of age or older and who show moderate depressive symptoms in the scope of a diagnosed depressive episode, recurrent depressive disorder, or dysthymia. General practices in the control arm will provide treatment as usual; general practices in the intervention arm will work closely with a specially trained care manager and a supervising mental health specialist. Evidence-based elements of the treatment plan manual include patient education, identification and integration of positive activities into the daily routine, relapse prevention, and training of problem-solving techniques as needed. The intervention period per patient will be one year. Data will be collected at baseline, 6, and 12 months. Primary outcome is the patient-reported change of depressive symptoms (Patient Health Questionnaire, PHQ-9). Secondary outcomes include measures of quality of life, anxiety, depression-related behavior, problem-solving skills, resilience, and an overall economic evaluation of the program.DiscussionThe GermanIMPACT trial will provide evidence about the effectiveness, feasibility, and cost-effectiveness of collaborative stepped care in treating late-life depression in German primary care. Positive results will be a first step toward integrating specialized depression care managers into the primary care setting.Trial registrationGerman Clinical Trials Register: DRKS00003589 (September 2012).