Guideline-concordant Depression Care Research Articles

Process mapping appointments to identify improvements in care delivered to patients who screen positive for depression

Rationale, aims and objectives After screening positive for depression, many patients do not receive effective medication or maintain optimal contact with practitioners. Our objective was to examine how appointments that patients have after screening positive may affect the delivery of evidence-based and guideline-concordant depression care. Methods We reviewed treatment records for 271 patients who screened positive for depression in primary care across three United States Veterans Health Administration medical facilities. For each patient, we mapped the process of appointments that took place following the positive screen, noting the number of appointments, the service line in which each appointment was held, as well as whether guideline-concordant depression care was in turn received over four months. Results We found that (i) approximately half of the patients who screened positive had no follow-up appointments, (ii) all patients who had two or more follow-up appointments received some – but not necessarily guideline-concordant – mental health treatment, and (iii) there were distinct patterns across the three facilities regarding which service lines’ appointments most often resulted in treatment. Conclusions Our work offers a novel approach of using data on appointments that patients have after screening positive for depression to shed light on current care practices. The number of post-screening appointments can be an informative process measure for improving depression care to become more guideline-concordant. Facilities vary substantially in terms of which service lines they use to attain guideline-concordance, likely due to notable differences in how their primary care, integrated primary care behavioral health, and mental health services are organized.

Quality of depression treatment in Black Americans with major depression and comorbid medical illness

ObjectiveThe objective was to evaluate how comorbid type 2 diabetes (T2DM) and hypertension (HT) influence depression treatment and to assess whether these effects operate differently in a nationally representative community-based sample of Black Americans. MethodsData came from the National Survey of American Life (N=3673), and analysis is limited to respondents who met lifetime criteria for major depression (MD) (N=402). Depression care was defined according to American Psychiatric Association (APA) guidelines and included psychotherapy, pharmacotherapy and satisfaction with services. Logistic regression was used to examine the effects of T2DM and HT on quality of depression care. ResultsOnly 19.2% of Black Americans with MD alone, 7.8% with comorbid T2DM and 22.3% with comorbid HT reported APA-guideline-concordant psychotherapy or antidepressant treatment. Compared to respondents with MD alone, respondents with MD+T2DM/HT were no more or less likely to receive depression care. Respondents with MD+HT+T2DM were more likely to report any guideline-concordant care (odds ratio=3.32; 95% confidence interval, 1.07–10.31). ConclusionsAlthough individuals with MD and comorbid T2DM+HT were more likely to receive depression care, guideline-concordant depression care is low among Black Americans, including those with comorbid medical conditions.

Association of General Medical and Psychiatric Comorbidities With Receipt of Guideline-Concordant Care for Depression

This study described the association of general medical and psychiatric comorbidities with receipt of guideline-concordant depression care. Pharmacy, medical, and behavioral claims and enrollment data from OptumHealth in 2003-2006 were linked for 1,835 adults with a new depression diagnosis or a new antidepressant fill. Multiple logistic regression was used to estimate the association of comorbidities with receipt of guideline-concordant pharmacotherapy, guideline-concordant psychotherapy, and any guideline-concordant therapy. Eleven percent of patients received guideline-concordant psychotherapy; 23%, guideline-concordant pharmacotherapy; and 33%, any guideline-concordant therapy. Having a psychiatric but no medical comorbidity was associated with higher rates of guideline-concordant psychotherapy and overall guideline concordance; conversely, having a general medical but no psychiatric comorbidity was associated with lower rates of guideline-concordant psychotherapy. Comorbidities were associated with the probability of receiving any guideline-concordant therapy, but they were not associated with improved guideline concordance among patients already receiving therapy. Patients with general medical comorbidities may not receive psychotherapy referrals, perhaps because of well-established relationships with their primary care providers.

Association of General Medical and Psychiatric Comorbidities With Receipt of Guideline-Concordant Care for Depression

This study described the association of general medical and psychiatric comorbidities with receipt of guideline-concordant depression care.Pharmacy, medical, and behavioral claims and enrollment data from OptumHealth in 2003-2006 were linked for 1,835 adults with a new depression diagnosis or a new antidepressant fill. Multiple logistic regression was used to estimate the association of comorbidities with receipt of guideline-concordant pharmacotherapy, guideline-concordant psychotherapy, and any guideline-concordant therapy.Eleven percent of patients received guideline-concordant psychotherapy; 23%, guideline-concordant pharmacotherapy; and 33%, any guideline-concordant therapy. Having a psychiatric but no medical comorbidity was associated with higher rates of guideline-concordant psychotherapy and overall guideline concordance; conversely, having a general medical but no psychiatric comorbidity was associated with lower rates of guideline-concordant psychotherapy. Comorbidities were associated with the probability of receiving any guideline-concordant therapy, but they were not associated with improved guideline concordance among patients already receiving therapy.Patients with general medical comorbidities may not receive psychotherapy referrals, perhaps because of well-established relationships with their primary care providers.

Effect of Depression Care on Outcomes in COPD Patients With Depression

Although depression among COPD patients is a common problem with important consequences for the management of COPD and overall outcomes, the proportion of those who receive guideline-concordant depression care is low. Guideline-concordant depression care is associated with fewer depressive symptoms and lower risk for psychiatric hospitalization; however, it is unknown whether guideline-concordant depression care favorably impacts COPD-related outcomes for patients with both conditions. This retrospective cohort study investigated 5,517 veterans with COPD who experienced a new treatment episode for depression. Guideline-concordant depression care was defined as having an adequate supply of antidepressant medication and sufficient follow-up care. Multivariate methods were used to examine the relationship between the receipt of guideline-concordant depression care and (1) COPD-related hospitalization and (2) all-cause mortality 2 years after the depression episode, while controlling for care setting and other covariates. There was no association between the receipt of guideline-concordant depression care and COPD-related hospitalization (odds ratio [OR], 0.98) or all-cause mortality (OR, 0.95). However, patients seen in mental health settings during their depressive episode had 30% lower odds of 2-year mortality than patients seen in primary care. For patients with COPD and depression, interacting with a mental health professional may be an important intervention. However, receiving guideline-concordant depression care, as outlined in common quality monitors, was not significantly associated with decreased hospitalization or mortality. These findings suggest that more referrals to specialty care or better care coordination with mental health specialty care may lead to a significant reduction in mortality risk for these patients.

Clinician Burden and Depression Treatment: Disentangling Patient- and Clinician-Level Effects of Medical Comorbidity

Efforts to improve primary care depression treatment have assessed strategies across heterogeneous groups of patients, but few have examined clinician-level influences on depression treatment. To examine clinician characteristics that affect depression treatment in primary care settings, using multilevel ordinal regression modeling to disentangle patient- from clinician-level effects. Secondary analysis from the Quality Improvement in Depression Study dataset. The participants were 1,023 primary care patients with depression who reported on treatment in the 6-month follow-up and whose clinicians (n = 158) had at least 4 patients in the study. Primary outcome variable was depression treatment intensity, derived from assessment of concordance with AHCPR depression treatment guidelines based on patient-reported data on their treatment. Primary independent variable was clinical practice burden for treating depression, derived from patient- and clinician-reported composite measures tested for significant association with clinician-reported practice burden. Clinicians who treat patients with more chronic medical comorbidities perceive less burden from treating depressed patients in their practice (Spearman's rho = -.30, p < .05). Clinicians who treat patients with more chronic medical comorbidities also provide greater intensity of depression treatment (adjusted OR = 1.44, p = .02), even after adjusting for the effects of patient-level chronic medical comorbidities (adjusted OR = 0.95, p = .45). Clinicians who provide more chronic care also provide greater depression treatment intensity, suggesting that clinicians who care for complex patients can integrate depression care into their practice. Targeting interventions to these clinicians to enhance their ability to provide guideline-concordant depression care is a worthwhile endeavor and deserves further investigation.

The Effect of Adherence to Practice Guidelines on Depression Outcomes

Few studies have assessed clinician adherence to depression practice guidelines and the relationship between clinician adherence and depression outcomes. To estimate how frequently specific guideline recommendations are followed and to assess whether following guideline recommendations is linked to improved depression outcomes. Observational analysis of data collected from 1996 to 1998 in 3 randomized clinical trials. 45 primary care practices in 13 U.S. states. 1131 primary care patients with depression. Expert panel methods were used to develop a patient survey-based index that measured adherence to clinical practice guidelines on depression. Rates of adherence to the 20 indicators that form the index were evaluated. Multivariable regression that controlled for case mix was used to assess how index scores predicted continuous and dichotomous depression measures at 12, 18, and 24 months. Quality of care was high (clinician adherence > or =79%) for 6 indicators, including primary care clinician detection of depression. Quality of care was low (adherence, 20% to 38%) for 8 indicators, including management of suicide risk (3 indicators), alcohol abuse (2 indicators), and elderly patients; assessment of symptoms and history of depression; and treatment adjustment for patients who did not respond to initial treatment. Greater adherence to practice guidelines significantly predicted fewer depressive symptoms on continuous measures (P < 0.001 for 12 months, P < 0.01 for 18 months, and P < 0.001 for 24 months) and dichotomous measures (P < 0.05 for 18 and 24 months). Data are based on patient self-report. Possible changes in practice since 1998 may limit the generalizability of the findings. Adherence to guidelines was high for one third of the recommendations that were measured but was very low for nearly half of the measures, pointing to specific needs for quality improvement. Guideline-concordant depression care appears to be linked to improved outcomes in primary care patients with depression.