Outcome Of Depression In Primary Care Research Articles

Use of PHQ-9 for monitoring patients with depression in integrated primary care practices.

The PHQ-9 is a validated, short self-report questionnaire designed to be used in primary care for diagnosis and management of depression. We wished to assess its use for monitoring symptoms in patients being treated for depression. To measure the use of the PHQ-9 in 12 months following an elevated score in adult patients in primary care practices. Retrospective cohort study with descriptive analysis of use of PHQ-9 for follow up; stratified by age category, gender, severity and chronicity of symptoms, and whether referred to integrated behavioral health. EMR data including dates and results of PHQ-9, patient demographics, and referral data. Adults aged 18 and older with a PHQ-9 score of 10 or higher during calendar year 2018. No one was excluded. Primary outcome measure was the number of PHQ-9's done in 12 months following the initial elevated score (index score). Secondary outcome measures are a set of quality measures for depression care related to monitoring with PHQ-9 at 6 and 12 months following index score. Among all patients, mean number of PHQ-9 following index score was 2.1. This was increased for those with chronic symptoms (defined as having an elevated score at least once in calendar year 2017. It was increased slightly as severity of index symptoms increased. It was increased substantially for those referred to integrated behavioral health clinicians in the practices. The PHQ-9 is underutilized as an instrument for monitoring patients who are being treated for depression in primary care. Measurement based care has a strong evidence base and interventions to improve utilization of the PHQ-9 for monitoring are likely to improve depression outcomes in primary care.

Depression Outcomes in Adults Attending Family Practice Were Not Improved by Screening, Stepped-Care, or Online CBT during a 12-Week Study when Compared to Controls in a Randomized Trial.

There is uncertainty regarding possible benefits of screening for depression in family practice, as well as the most effective treatment approach when depression is identified. Here, we examined whether screening patients for depression in primary care, and then treating them with different modalities, was better than treatment-as-usual (TAU) alone. Screening was carried out for depression using the 9-item Patient Health Questionnaire (PHQ-9), with a score of ≥10 indicating significant depressive symptoms. PHQ-9 scores were given to family physicians prior to patients being seen (except for the Control group). Patients (n = 1,489) were randomized to one of four groups. Group #1 were controls (n = 432) in which PHQ-9 was administered, but results were not shared. Group #2 was screening followed by TAU (n = 426). Group #3 was screening followed by both TAU and the opportunity to use an online cognitive behavioral therapy (CBT) treatment program (n = 440). Group #4 utilized an evidence-based Stepped-care pathway for depression (n = 191, note that this was not available at all clinics). Of the study sample 889 (60%) completed a second PHQ-9 rating at 12 weeks. There were no statistically significant differences in baseline PHQ-9 scores between these groups. Compared to baseline, mean PHQ-9 scores decreased significantly in the depressed patients over 12 weeks, but there were no statistically significant differences between any groups at 12 weeks. Thus, for those who were depressed at baseline Control group (Group #1) scores decreased from 15.3 ± 4.2 to 4.0 ± 2.6 (p < 0.001), Screening group (Group #2) scores decreased from 15.5 ± 3.9 to 4.6 ± 3.0 (p < 0.001), Online CBT group (Group #3) scores decreased from 15.4 ± 3.8 to 3.4 ± 2.7 (p < 0.01), and the Stepped-care pathway group (Group #4) scores decreased from 15.3 ± 3.6 to 5.4 ± 2.8 (p < 0.05). In conclusion, these findings from this controlled randomized study do not suggest that using depression screening tools in family practice improves outcomes. They also suggest that much of the depression seen in primary care spontaneously resolves and do not support suggestions that more complex treatment programs or pathways improve depression outcomes in primary care. Replication studies are required due to study limitations.

Universal Depression Screening to Improve Depression Outcomes in Primary Care: Sounds Good, but Where Is the Evidence?

The 2016 recommendation statement by the U.S. Preventive Services Task Force (USPSTF) endorsed screening for depression in the general adult population. The recommendation was mainly based on studies that compared enhanced depression care that included depression screening with usual care. In contrast to the USPSTF recommendation, the 2013 guidelines from the Canadian Task Force on Preventive Health Care (CTFPHC) recommended against routine depression screening. The CTFPHC could not identify any studies comparing depression outcomes of usual care with and without the addition of routine depression screening. In the absence of evidence of clinical benefit, there are concerns that wide adoption of the USPSTF recommendation for universal depression screening would lead to overdiagnosis of depression and an increase in inappropriate prescription of antidepressant medications.

Depression in primary care: Strategies for a psychiatry-scarce environment.

More than an algorithm to guide primary care providers through treatment options, integrated care, also called collaborative care, is a validated, systematic, multidisciplinary approach to depression treatment in primary care. Historically, integrated care emerged in response to a mismatch between a growing demand for mental health treatment and scarce mental healthcare resources. Working together, psychiatrists and primary care providers have demonstrated that the principles and tools of chronic disease management improve depression outcomes in primary care. Currently, most antidepressants are prescribed by primary care providers, but with disappointing rates of full, sustained remission. Primary care patients may derive the greatest benefit from existing depression treatment guidelines when they are melded with an approach informed by integrated care principles. This paper will present established guidelines for pharmacologic management of depression as part of a broader framework for depression treatment in the primary care office.

Self-Rated Health and Long-Term Prognosis of Depression

Indicators of prognosis should be considered to fully inform clinical decision making in the treatment of depression. This study examines whether self-rated health predicts long-term depression outcomes in primary care. Our analysis was based on the first 5 years of a prospective 10-year cohort study underway since January 2005 conducted in 30 randomly selected Australian primary care practices. Participants were 789 adult patients with a history of depressive symptoms. Main outcome measures include risks, risk differences, and risk ratios of major depressive syndrome (MDS) on the Patient Health Questionnaire. Retention rates during the 5 years were 660 (84%), 586 (74%), 560 (71%), 533 (68%), and 517 (66%). At baseline, MDS was present in 27% (95% CI, 23%-30%). Cross-sectional analysis of baseline data showed participants reporting poor or fair self-rated health had greater odds of chronic illness, MDS, and lower socioeconomic status than those reporting good to excellent self-rated health. For participants rating their health as poor to fair compared with those rating it good to excellent, risk ratios of MDS were 2.10 (95% CI, 1.60-2.76), 2.38 (95% CI, 1.77-3.20), 2.22 (95% CI, 1.70-2.89), 1.73 (95% CI, 1.30-2.28), and 2.15 (95% CI, 1.59-2.90) at 1, 2, 3, 4, and 5 years, after accounting for missing data using multiple imputation. After adjusting for age, sex, multimorbidity, and depression status and severity, self-rated health remained a predictor of MDS up to 5 years. Self-rated health offers family physicians an efficient and simple way to identify patients at risk of poor long-term depression outcomes and to inform therapeutic decision making.

Implementation outcomes of evidence-based quality improvement for depression in VA community based outpatient clinics

BackgroundCollaborative-care management is an evidence-based practice for improving depression outcomes in primary care. The Department of Veterans Affairs (VA) has mandated the implementation of collaborative-care management in its satellite clinics, known as Community Based Outpatient Clinics (CBOCs). However, the organizational characteristics of CBOCs present added challenges to implementation. The objective of this study was to evaluate the effectiveness of evidence-based quality improvement (EBQI) as a strategy to facilitate the adoption of collaborative-care management in CBOCs.MethodsThis nonrandomized, small-scale, multisite evaluation of EBQI was conducted at three VA Medical Centers and 11 of their affiliated CBOCs. The Plan phase of the EBQI process involved the localized tailoring of the collaborative-care management program to each CBOC. Researchers ensured that the adaptations were evidence based. Clinical and administrative staff were responsible for adapting the collaborative-care management program for local needs, priorities, preferences and resources. Plan-Do-Study-Act cycles were used to refine the program over time. The evaluation was based on the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) Framework and used data from multiple sources: administrative records, web-based decision-support systems, surveys, and key-informant interviews.ResultsAdoption: 69.0% (58/84) of primary care providers referred patients to the program. Reach: 9.0% (298/3,296) of primary care patients diagnosed with depression who were not already receiving specialty care were enrolled in the program. Fidelity: During baseline care manager encounters, education/activation was provided to 100% (298/298) of patients, barriers were assessed and addressed for 100% (298/298) of patients, and depression severity was monitored for 100% (298/298) of patients. Less than half (42.5%, 681/1603) of follow-up encounters during the acute stage were completed within the timeframe specified. During the acute phase of treatment for all trials, the Patient Health Questionnaire (PHQ9) symptom-monitoring tool was used at 100% (681/681) of completed follow-up encounters, and self-management goals were discussed during 15.3% (104/681) of completed follow-up encounters. During the acute phase of treatment for pharmacotherapy and combination trials, medication adherence was assessed at 99.1% (575/580) of completed follow-up encounters, and side effects were assessed at 92.4% (536/580) of completed follow-up encounters. During the acute phase of treatment for psychotherapy and combination trials, counseling session adherence was assessed at 83.3% (239/287) of completed follow-up encounters. Effectiveness: 18.8% (56/298) of enrolled patients remitted (symptom free) and another 22.1% (66/298) responded to treatment (50% reduction in symptom severity). Maintenance: 91.9% (10/11) of the CBOCs chose to sustain the program after research funds were withdrawn.ConclusionsProvider adoption was good, although reach into the target population was relatively low. Fidelity and maintenance were excellent, and clinical outcomes were comparable to those in randomized controlled trials. Despite the organizational barriers, these findings suggest that EBQI is an effective facilitation strategy for CBOCs.Trial registrationClinical trial # NCT00317018.

Improving Antidepressant Adherence and Depression Outcomes in Primary Care: The Treatment Initiation and Participation (TIP) Program

To test the impact of a novel psychosocial intervention to improve antidepressant adherence and depression outcomes among older adults prescribed pharmacotherapy by their primary care physician (PCP). A randomized controlled pilot study was conducted to examine the usefulness of the Treatment Initiation and Participation (TIP) program as an intervention to improve antidepressant adherence and depression outcomes. The study was conducted at two primary care clinics in New York city: one clinic served geriatric adults and the second clinic served a diverse group of mixed aged adults. The sample consisted of adults aged 60 years and older with major depression who were recommended antidepressant therapy by their PCPs. All participants were prescribed antidepressant therapy and randomly assigned to either the intervention (TIP) or the treatment as usual (TAU) group. The TIP intervention identifies and targets psychological barriers to depression care, especially stigma, as well as fears and misconceptions of depression and its treatment. TIP participants are encouraged to develop a treatment goal and create an adherence strategy. Study participants were assessed at entry, 6, 12, and 24 weeks later. Adherence was measured based on self-report with chart verification. Depression severity was measured using the Hamilton Depression Rating Scale. Participants in TIP were significantly more adherent to their antidepressant pharmacotherapy at all assessment time points and had a significantly greater decrease in depressive symptoms than older adults who received TAU. The results provide support for the usefulness of TIP as a brief intervention to improve adherence to depression medication treatment provided in primary care settings.

Follow-Up Visits by Provider Specialty for Patients With Major Depressive Disorder Initiating Antidepressant Treatment

This study examined the association between provider specialty and guideline-concordant care after the initiation of antidepressant treatment. Medical and prescription claims were analyzed from adults newly diagnosed as having major depressive disorder who initiated antidepressant treatment. Follow-up visits during the first 90 days after the index prescription were identified, and an indicator for receipt of guideline-concordant care (three or more visits) was created. Logistic regression models were used, and propensity score matching techniques were applied. Sensitivity analyses were conducted to investigate how results differed by varying the approach to identify follow-up visits. The study included 4,102 patients, and only 31% received guideline-concordant follow-up visits. Patients receiving their initial prescription from psychiatrists were nearly five times as likely as patients receiving their initial prescription from primary care providers to receive guideline-concordant follow-up care (odds ratio=4.6, 95% confidence interval=3.9-5.4). Routine care for antidepressant management falls short of guideline recommendations, especially in primary care.

Treating Depressed Workers Improves Work Productivity

Although organized screening and care management programs improve depression outcomes in primary care, employers purchasing health benefits have not

Systematic review of multifaceted interventions to improve depression care

Objective Depression is a prevalent high-impact illness with poor outcomes in primary care settings. We performed a systematic review to determine to what extent multifaceted interventions improve depression outcomes in primary care and to define key elements, patients who are likely to benefit and resources required for these interventions. Method We searched Medline, HealthSTAR, CINAHL, PsycINFO and a specialized registry of depression trials from 1966 to February 2006; reviewed bibliographies of pertinent articles; and consulted experts. Searches were limited to the English language. We included 28 randomized controlled trials that: (a) involved primary care patients receiving acute-phase treatment; (b) tested a multicomponent intervention involving a patient-directed component; and (c) reported effects on depression severity. Pairs of investigators independently abstracted information regarding (a) setting and subjects, (b) components of the intervention and (c) outcomes. Results Twenty of 28 interventions improved depression outcomes over 3–12 months (an 18.4% median absolute increase in patients with 50% improvement in symptoms; range, 8.3–46%). Sustained improvements at 24–57 months were demonstrated in three studies addressing acute-phase and continuation-phase treatments. All interventions involved care management and required additional resources or staff reassignment to implement; interventions were delivered exclusively or predominantly by telephone in 16 studies. The most commonly used intervention features were: patient education and self-management, monitoring of depressive symptoms and treatment adherence, decision support for medication management, a patient registry and mental health supervision of care managers. Other intervention features were highly variable. Conclusion There is strong evidence supporting the short-term benefits of care management for depression; critical elements for successful programs are emerging.

Improving Care for Depression: There's No Free Lunch

Primary care clinicians know depression well, yet diagnostic and treatment failures are common. In answer to the pressing need to do better, the elegant study by Dobscha and colleagues in this issu...

Major depression and its correlates in primary care settings in six countries

Few published studies address depression outcomes in primary care from a cross-cultural perspective. To define baseline factors associated with 9-month clinical outcomes across six countries. Adults meeting criteria for current major depression were recruited from primary care clinics in Australia, Brazil, Israel, Spain, Russia and the USA; 968 patients were assessed at the 9-month follow-up. Predictors of complete remission were examined using logistic regression with a hierarchical model. Rates of complete remission in the six sites ranged from 25% to 48%. Logistic regression using pooled data showed that education, key life events and the Quality of Life Depression Scale score at baseline were the final predictors of complete remission, adjusting for centres, socio-demographic data, severity of depression, comorbidity and general quality of life. Variationin predictors across sites was not statistically significant. The two major findings of this study were the low proportion of people achieving complete remission at follow-up across the six sites, and that some baseline characteristics (education, Quality of Life Depression Scale score and key life events) are modest predictors of outcome in depression.

Interventions that improve the quality of depression care

Interventions that improve the quality of depression care