Bea Herbeck Belnap

The Bypassing the Blues Treatment Protocol: Stepped Collaborative Care for Treating Post-CABG Depression

Objective: To present the design of the Bypassing the Blues (BtB) study to examine the impact of a collaborative care strategy for treating depression among patients with cardiac disease. Coronary artery bypass graft (CABG) surgery is one of the most common and costly medical procedures performed in the US. Up to half of post-CABG patients report depressive symptoms, and they are more likely to experience poorer health-related quality of life (HRQoL), worse functional status, continued chest pains, and higher risk of cardiovascular morbidity independent of cardiac status, medical comorbidity, and the extent of bypass surgery. Methods: BtB was designed to enroll 450 post-CABG patients from eight Pittsburgh-area hospitals including: (1) 300 patients who expressed mood symptoms preceding discharge and at 2 weeks post hospitalization (Patient Health Questionnaire (PHQ-9) ≥10); and (2) 150 patients who served as nondepressed controls (PHQ-9 <5). Depressed patients were randomized to either an 8-month course of nurse-delivered telephone-based collaborative care supervised by a psychiatrist and primary care expert, or to their physicians’ “usual care.” The primary hypothesis will test whether the intervention can produce an effect size of ≥0.5 improvement in HRQoL at 8 months post CABG, as measured by the SF-36 Mental Component Summary score. Secondary hypotheses will examine the impact of our intervention on mood symptoms, cardiovascular morbidity, employment, health services utilization, and treatment costs. Results: Not applicable. Conclusions: This effectiveness trial will provide crucial information on the impact of a widely generalizable evidence-based collaborative care strategy for treating depressed patients with cardiac disease.

Comparison of Electronic Physician Prompts versus Waitroom Case-Finding on Clinical Trial Enrollment

BackgroundRecruiting patients into clinical research protocols is challenging. Electronic medical record (EMR) systems capable of prompting clinicians may facilitate enrollment.ObjectiveTo compare an EMR-based clinician prompt versus a wait-room-based case-finding strategy at enrolling patients into a clinical trial.DesignCross-sectional comparison of recruitment data from two trials to treat anxiety disorders in primary care. Both studies utilized similar enrollment criteria, intervention strategies, and the same four practice sites and EMR system.ParticipantsPatients referred by their (primary care physicians) PCPs in response to an EMR prompt (recruited 1/2005–10/2006), and patients enrolled by research assistants stationed in practice waiting rooms (7/2000–4/2002).MeasurementsReferral counts, patients’ baseline sociodemographic and clinical characteristics.ResultsOver a 22-month period, EMR-prompted PCPs referred 794 patients and 176 (22%) met study inclusion criteria and enrolled, compared to 8,095 patients approached by wait room-based recruiters of whom 193 (2.4%) enrolled. Subjects enrolled by EMR-prompted PCPs were more likely to be non-white (23% vs 5%; P < 0.001), male (28% vs 18%; P = 0.03), and have higher anxiety levels than those recruited by wait-room recruiters (P < 0.0001).ConclusionsEMR systems prompting clinicians to refer patients with specific characteristics are an efficient recruitment tool with critical implications for increasing minority participation in clinical research.

Pain interference impacts response to treatment for anxiety disorders

Background: Anxiety disorders and pain are commonly comorbid, though little is known about the effect of pain on the course and treatment of anxiety. Methods: This is a secondary analysis of a randomized controlled trial for anxiety treatment in primary care. Participants with panic disorder (PD) and/or generalized anxiety disorder (GAD) (N=191; 81% female, mean age 44) were randomized to either their primary‐care physicians usual care or a 12‐month course of telephone‐based collaborative care. Anxiety severity, pain interference, health‐related quality of life, health services use, and employment status were assessed at baseline, and at 2‐, 4‐, 8‐, and 12‐month follow‐up. We defined response to anxiety treatment as a 40% or greater improvement from baseline on anxiety severity scales at 12‐month follow‐up. Results: The 39% who reported high pain interference at baseline had more severe anxiety (mean SIGH‐A score: 21.8 versus 18.0, P<.001), greater limitations in activities of daily living, and more work days missed in the previous month (5.8 versus 4.0 days, P=.01) than those with low pain interference. At 12‐month follow‐up, high pain interference was associated with a lower likelihood of responding to anxiety treatment (OR=.28; 95% CI=.12–.63) and higher health services use (26.1% with ≥1 hospitalization versus 12.0%, P<.001). Conclusions: Pain that interferes with daily activities is prevalent among primary care patients with PD/GAD and associated with more severe anxiety, worse daily functioning, higher health services use, and a lower likelihood of responding to treatment for PD/GAD. Depression and Anxiety, 2009.

Challenges of Implementing Depression Care Management in the Primary Care Setting

Empirical evidence shows that care management is an effective tool for improving depression treatment in primary care patients. However, several conceptual and practical issues have not been sufficiently addressed. This article explores questions concerning the scope of care management services within the chronic illness care model; optimal ways to identify depressed patients in the primary care setting; responsibilities and desirable qualifications of depression care managers; the location and manner in which care managers interact with patients; costs of services provided by care managers; and the level of supervision by mental health specialists that is necessary to ensure quality care.

Optimism, response to treatment of depression, and rehospitalization after coronary artery bypass graft surgery.

Objective Optimism has been associated with a lower risk of rehospitalization after coronary artery bypass graft (CABG) surgery, but little is known about how optimism affects treatment of depression in post-CABG patients. Methods Using data from a collaborative care intervention trial for post-CABG depression, we conducted exploratory post hoc analyses of 284 depressed post-CABG patients (2-week posthospitalization score in the 9-item Patient Health Questionnaire ≥10) and 146 controls without depression who completed the Life Orientation Test – Revised (full scale and subscale) to assess dispositional optimism. We classified patients as optimists and pessimists based on the sample-specific Life Orientation Test – Revised distributions in each cohort (full sample, depressed, nondepressed). For 8 months, we assessed health-related quality of life (using the 36-item Short-Form Health Survey) and mood symptoms (using the Hamilton Rating Scale for Depression [HRS-D]) and adjudicated all-cause rehospitalization. We defined treatment response as a 50% or higher decline in HRS-D score from baseline. Results Compared with pessimists, optimists had lower baseline mean HRS-D scores (8 versus 15, p = .001). Among depressed patients, optimists were more likely to respond to treatment at 8 months (58% versus 27%, odds ratio = 3.02, 95% confidence interval = 1.28–7.13, p = .01), a finding that was not sustained in the intervention group. The optimism subscale, but not the pessimism subscale, predicted treatment response. By 8 months, optimists were less likely to be rehospitalized (odds ratio = 0.54, 95% confidence interval = 0.32–0.93, p = .03). Conclusions Among depressed post-CABG patients, optimists responded to depression treatment at higher rates. Independent of depression, optimists were less likely to be rehospitalized by 8 months after CABG. Further research should explore the impact of optimism on these and other important long-term post-CABG outcomes.

Longitudinal Trends in Hazardous Alcohol Consumption Among Women With Human Immunodeficiency Virus Infection, 1995–2006

Hazardous alcohol consumption among women with human immunodeficiency virus (HIV) infection is associated with several adverse health and behavioral outcomes, but the proportion of HIV-positive women who engage in hazardous drinking over time is unclear. The authors sought to determine rates of hazardous alcohol consumption among these women over time and to identify factors associated with this behavior. Subjects were 2,770 HIV-positive women recruited from 6 US cities who participated in semiannual follow-up visits in the Womens Interagency HIV Study from 1995 to 2006. Hazardous alcohol consumption was defined as exceeding daily (> or =4 drinks) or weekly (>7 drinks) consumption recommendations. Over the 11-year follow-up period, 14%-24% of the women reported past-year hazardous drinking, with a slight decrease in hazardous drinking over time. Women were significantly more likely to report hazardous drinking if they were unemployed, were not high school graduates, had been enrolled in the original cohort (1994-1995), had a CD4 cell count of 200-500 cells/mL, were hepatitis C-seropositive, or had symptoms of depression. Approximately 1 in 5 of the women met criteria for hazardous drinking. Interventions to identify and address hazardous drinking among HIV-positive women are urgently needed.

The impact of pain and depression on recovery after coronary artery bypass grafting.

Objective: To describe the relationship between pain and depression on recovery after coronary artery bypass grafting (CABG). Methods: A secondary data analysis on 453 depressed and nondepressed post-CABG patients enrolled in a randomized, controlled, effectiveness trial of telephone-delivered collaborative care for depression. Outcome measures were collected from March 2004 to September 2007 and included pain, physical function, and mood symptoms. Results: Depressed patients (baseline Patient Health Questionnaire-9 score ≥10) versus those without depression reported significantly worse pain scores on the 36-Item Short Form Health Survey Bodily Pain Scale at baseline and up to 12 months post-CABG, p < .05. Among patients with depression, those who received collaborative care reported significantly better pain scores at each time point between 2 and 12 months post-CABG versus depressed patients randomized to the usual care control group, p < .05. Regardless of intervention status, depressed participants with at least moderate pain at baseline reported significantly lower functional status (measured by the Duke Activity Status Index) at 8 and 12 months versus depressed patients with none or mild pain, p < .05. Depressed patients with at least moderate pain at baseline were also significantly less likely to show improvement of depressive symptoms throughout the course of follow-up versus depressed patients with little or no pain, p < .05. These findings controlled for age, gender, education, race, comorbid conditions, and baseline pain diagnosis. Conclusions: Depression and pain seem to influence functional recovery post-CABG. The relationship between these two conditions and 12-month outcomes should be considered by clinicians when planning treatment. HTN = hypertension; CVA = cerebral vascular accident; COPD = chronic obstructive pulmonary disease; CHF = chronic heart failure; PHQ = Patient Health Questionnaire; HRS-D = Hamilton Rating Scale-Depression; DASI = Duke Activity Status Index; NSAIDs = nonsteroidal antiinflammatory drug.

Generalized Anxiety Disorder Severity Scale Validation in Older Adults

OBJECTIVES The Generalized Anxiety Disorder Severity Scale (GADSS) is a validated measure of Generalized Anxiety Disorder (GAD) symptom severity. Given the high prevalence of GAD in the elderly and the need for a validated scale to assess GAD severity in this age group, the authors examined the psychometric properties of the GADSS in the elderly. DESIGN, SETTING, PARTICIPANTS The authors examined a sample of 134 elderly subjects (age 60 and above) who met diagnostic criteria for current GAD, 33 healthy elderly comparison subjects (age 60 and above) and 186 younger subjects (age 18-60) diagnosed with GAD. RESULTS The GADSS had a high internal consistency in the elderly subjects (raw Cronbachs alpha = 0.76). Pearson correlations showed a significant positive correlation between GADSS, Hamilton Rating Scale for Anxiety and Penn State Worry Questionnaire. Pearson correlations showed an inverse significant correlation between GADSS and the Medical Outcome Study SF-36. There was no correlation between GADSS and Mini Mental State Examination or Cumulative Illness Rating Scale for Geriatrics. CONCLUSIONS The results showed a good convergent, concurrent, and discriminant validity of the GADSS when used for elderly with GAD. The authors conclude that GADSS is a valid measure of GAD symptom severity in older adults.

The Bypassing the Blues trial: collaborative care for post-CABG depression and implications for future research.

Depressive symptoms are reported by up to one-half of patients following coronary artery bypass graft (CABG) surgery, and are associated with numerous adverse outcomes, including poorer health-related quality of life, worse functional status, and delayed recovery. Strategies to detect and then manage depression in CABG patients and in cardiac populations are of great interest given the potential for depression treatment to reduce cardiovascular morbidity. Yet, many tested interventions have had little or no effect on mood symptoms in cardiac patients. “Collaborative care” is a safe and proven-effective strategy for treating depression in concert with patients’ primary care physicians; however, it had not been tested previously in patients with cardiac disease. This article presents the design and main outcome findings from the National Institutes of Health–funded Bypassing the Blues study, the first trial to examine the impact of a collaborative care strategy for treating depression among patients with cardiac disease, and our efforts to improve upon and expand the model for testing in other cardiac conditions.

The Role of Clinical Information Technology in Depression Care Management

We examine the literature on the growing application of clinical information technology in managing depression care and highlight lessons learned from Robert Wood Johnson Foundation’s national program “Depression in Primary Care-Incentives Demonstrations.” Several program sites are implementing depression care registries. Key issues discussed about implementing registries include using a simple yet functional format, designing registries to track multiple conditions versus depression alone (i.e., patient-centric versus disease-centric registries) and avoiding violations of patient privacy with the advent of more advanced information technologies (e.g., web-based formats). Finally, we discuss some implications of clinical information technology for healthcare practices and policy makers.