Bradford Felker

Effectiveness of Collaborative Care Depression Treatment in Veterans' Affairs Primary Care

AbstractOBJECTIVE: To compare collaborative care for treatment of depression in primary care with consult-liaison (CL) care. In collaborative care, a mental health team provided a treatment plan to the primary care provider, telephoned patients to support adherence to the plan, reviewed treatment results, and suggested modifications to the provider. In CL care, study clinicians informed the primary care provider of the diagnosis and facilitated referrals to psychiatry residents practicing in the primary care clinic. DESIGN: Patients were randomly assigned to treatment model by clinic firm. SETTING: VA primary care clinic. PARTICIPANTS: One hundred sixty-eight collaborative care and 186 CL patients who met criteria for major depression and/or dysthymia. MEASUREMENTS: Hopkins Symptom Checklist (SCL-20), Short Form (SF)-36, Sheehan Disability Scale. MAIN RESULTS: Collaborative care produced greater improvement than CL in depressive symptomatology from baseline to 3 months (SCL-20 change scores), but at 9 months there was no significant difference. The intervention increased the proportion of patients receiving prescriptions and cognitive behavioral therapy. Collaborative care produced significantly greater improvement on the Sheehan at 3 months. A greater proportion of collaborative care patients exhibited an improvement in SF-36 Mental Component Score of 5 points or more from baseline to 9 months. CONCLUSIONS: Collaborative care resulted in more rapid improvement in depression symptomatology, and a more rapid and sustained improvement in mental health status compared to the more standard model. Mounting evidence indicates that collaboration between primary care providers and mental health specialists can improve depression treatment and supports the necessary changes in clinic structure and incentives.

The association between depressive symptoms and health status in patients with chronic pulmonary disease

This study evaluated the association between depressive symptoms and health related quality of life (HRQoL) in patients with chronic pulmonary disease using both general and disease-specific HRQoL measures. A cross-sectional analysis of HRQoL measures completed by patients enrolled in the Department of Veteran Affairs Ambulatory Care Quality Improvement Project. 1252 patients with chronic pulmonary disease screened positive for emotional distress and returned the Hopkins Symptom Checklist-20 (SCL-20). 733 of 1252 had a score of 1.75 or greater on the SCL-20 indicating significant depressive symptoms. Depressive symptoms were associated with statistically significantly worse general and pulmonary health as reflected by lower scores on all sub-scales of both the Medical Outcomes Short Form-36 and the Seattle Obstructive Lung Disease Questionnaire. In fact, 11% to 18% of the variance in physical function sub-scales was attributed to depressive symptoms alone. Patients with chronic pulmonary disease and depressive symptoms reported significantly more impaired functioning and worse health status when compared to those patients without depressive symptoms. Because there are highly effective treatments for depression, selective screening of patients with chronic pulmonary disease for depression may identify a group that could potentially benefit from treatment interventions.

Using evidence-based quality improvement methods for translating depression collaborative care research into practice.

OBJECTIVE Translating Initiatives in Depression into Effective Solution (TIDES) aimed to translate research-based collaborative care for depression into an approach for the Veterans Health Administration (VA). SITES: Three multistate administrative regions and seven of their medium-sized primary care practices. INTERVENTION Researchers assisted regional leaders in adapting research-based depression care models using evidence-based quality improvement (EBQI) methods. EVALUATION We evaluated model fidelity and impacts on patients. Trained nurse depression care managers collected data on patient adherence and outcomes. RESULTS Among 72% (128) of the 178 patients followed in primary care with depression care manager assistance during the 3-year study period, mean PHQ-9 scores dropped from 15.1 to 4.7 (p < .001). A total of 87% of patients achieved a PHQ-9 score lower than 10 (no major depression). 62% achieved a score lower than six (symptom resolution). Care managers referred 28% (50) TIDES patients to mental health specialty (MHS). In the MHS-referred group, mean PHQ-9 scores dropped from 16.4 to 9.0 (p < .001). A total of 58% of MHS-referred patients achieved a PHQ-9 score lower than 10, and 40%, a score less than 6. Over the 2 years following the initial development phase reported here, national policymakers endorsed TIDES through national directives and financial support. CONCLUSIONS TIDES developed an evidence-based depression collaborative care prototype for a large health care organization (VA) using EBQI methods. As expected, care managers referred sicker patients to mental health specialists; these patients also improved. Overall, TIDES achieved excellent overall patient outcomes, and the program is undergoing national spread.

Hopelessness and suicidal ideation in Iraq and Afghanistan war veterans reporting subthreshold and threshold posttraumatic stress disorder

We examined hopelessness and suicidal ideation in association with subthreshold and threshold posttraumatic stress disorder (PTSD) in a sample of Iraq and Afghanistan War Veterans (U.S., N = 275) assessed within a specialty VA postdeployment health clinic. Veterans completed paper-and-pencil questionnaires at intake. The military version of the PTSD Checklist was used to determine PTSD levels (No PTSD; subthreshold PTSD; PTSD), and endorsement of hopelessness or suicidal ideation were used as markers of elevated suicide risk. Veterans were also asked if they received mental health treatment in the prior 6 months. Veterans reporting subthreshold PTSD were 3 times more likely to endorse these markers of elevated suicide risk relative to the Veterans without PTSD. We found no significant differences in likelihood of endorsing hopelessness or suicidal ideation comparing subthreshold and threshold PTSD groups, although the subthreshold PTSD group was less likely to report prior mental health treatment. Clinicians should be attentive to suicide risk in returned Veterans reporting both subthreshold and threshold PTSD.

Implementing collaborative care for depression treatment in primary care: A cluster randomized evaluation of a quality improvement practice redesign

BackgroundMeta-analyses show collaborative care models (CCMs) with nurse care management are effective for improving primary care for depression. This study aimed to develop CCM approaches that could be sustained and spread within Veterans Affairs (VA). Evidence-based quality improvement (EBQI) uses QI approaches within a research/clinical partnership to redesign care. The study used EBQI methods for CCM redesign, tested the effectiveness of the locally adapted model as implemented, and assessed the contextual factors shaping intervention effectiveness.MethodsThe study intervention is EBQI as applied to CCM implementation. The study uses a cluster randomized design as a formative evaluation tool to test and improve the effectiveness of the redesign process, with seven intervention and three non-intervention VA primary care practices in five different states. The primary study outcome is patient antidepressant use. The context evaluation is descriptive and uses subgroup analysis. The primary context evaluation measure is naturalistic primary care clinician (PCC) predilection to adopt CCM.For the randomized evaluation, trained telephone research interviewers enrolled consecutive primary care patients with major depression in the evaluation, referred enrolled patients in intervention practices to the implemented CCM, and re-surveyed at seven months.ResultsInterviewers enrolled 288 CCM site and 258 non-CCM site patients. Enrolled intervention site patients were more likely to receive appropriate antidepressant care (66% versus 43%, p = 0.01), but showed no significant difference in symptom improvement compared to usual care. In terms of context, only 40% of enrolled patients received complete care management per protocol. PCC predilection to adopt CCM had substantial effects on patient participation, with patients belonging to early adopter clinicians completing adequate care manager follow-up significantly more often than patients of clinicians with low predilection to adopt CCM (74% versus 48%%, p = 0.003).ConclusionsDepression CCM designed and implemented by primary care practices using EBQI improved antidepressant initiation. Combining QI methods with a randomized evaluation proved challenging, but enabled new insights into the process of translating research-based CCM into practice. Future research on the effects of PCC attitudes and skills on CCM results, as well as on enhancing the link between improved antidepressant use and symptom outcomes, is needed.Trial RegistrationClinicalTrials.gov: NCT00105820

Characteristics of Deployed Operation Iraqi Freedom Military Personnel Who Seek Mental Health Care

INTRODUCTION This study reports on the feasibility of using validated mental health screening instruments for deployed Operation Iraqi Freedom military personnel. METHODS For a 3-month period in 2005, all service members (N=296) who initially presented to the U.S. Military Hospital Kuwait mental health clinic completed an intake questionnaire that gathered demographic information and contained validated instruments to screen for mental disorders and functional impairment. RESULTS A total of 19% of the sample subjects screened positive for post-traumatic stress disorder-related symptoms, 35% for a major depressive disorder, and 11% for severe misuse of alcohol. Significant levels of distress and functional impairment were reported by 58% of the sample. Women represented a disproportionately high percentage of those presenting for care (27%). CONCLUSIONS Screening instruments were well accepted and useful in detecting psychopathological conditions and functional impairment. Female service members might represent a high-risk group. These results are useful for those caring for service members during or after deployment.

Added Burden of Mental Disorders on Health Status Among Patients With Chronic Obstructive Pulmonary Disease

OBJECTIVE Patients with chronic obstructive pulmonary disease (COPD) and comorbid mental disorders are known to have worse health status. The association between these variables remains complex and poorly understood. We sought to better understand the association between COPD severity, mental disorders (depression/anxiety), and health status. METHOD This cross-sectional study compared participants without COPD or with mild COPD (n = 162) to those with moderate (n = 25), severe (n = 38), and very severe (n = 26) COPD. We recruited participants from a primary care and a pulmonary clinic at a veterans affairs medical center between July 2001 until September 2002. We used the Patient Health Questionnaire to screen for depression and anxiety and the Posttraumatic Stress Disorder Checklist to screen for posttraumatic stress disorder. Health status was assessed with the veterans version of the Medical Outcomes Study 36-item Short-Form Health Survey (SF-36) and the Shortness of Breath Questionnaire (SOBQ). RESULTS COPD severity was associated with worse physical status and dyspnea as measured by the SF-36 physical component summary and the SOBQ but was not associated with worse mental status as measured by the SF-36 mental component summary. At each level of COPD severity, participants with mental disorders had worse health status and dyspnea as measured by the SF-36 physical component summary, mental component summary, and SOBQ. Significant linear trends with COPD severity were associated with increased prevalence of any depressive disorder, major depressive disorder, and nonpanic/non-PTSD anxiety disorders (all tests for linear trend, P < .01). CONCLUSIONS Independent of COPD severity, comorbid mental disorders were associated with worse health status and dyspnea. Studies are needed to determine whether patients with comorbid mental disorders may have more significant improvement in physical symptoms and functioning if providers focus more on psychiatric conditions.

VA Puget Sound Telemental Health Service to rural veterans: a growing program.

The VA Puget Sound Health Care System Telemental Health program connects veterans with psychologists, psychiatrists, and social workers via live clinical video teleconferencing. Providers deliver care to veterans in rural Veteran Affairs medical centers, community-based outpatient clinics and residences, and thus, increase access to specialty mental health care for rural and medically underserved veteran communities.

A pilot trial of telephone-based collaborative care management for PTSD among Iraq/Afghanistan war veterans

BACKGROUND Collaborative care and care management are cornerstones of Primary Care-Mental Health Integration (PC-MHI) and have been shown to reduce depressive symptoms. Historically, the standard of Veterans Affairs (VA) collaborative care was referring patients with posttraumatic stress disorder (PTSD) to specialty care. Although referral to evidence-based specialty care is ideal, many veterans with PTSD do not receive such care. To address this issue and reduce barriers to care, VA currently recommends veterans with PTSD be offered treatment within PC-MHI as an alternative. The current project outlines a pilot implementation of an established telephone-based collaborative care model-Translating Initiatives for Depression into Effective Solutions (TIDES)-adapted for Iraq/Afghanistan War veterans with PTSD symptoms (TIDES/PTSD) seen in a postdeployment primary care clinic. MATERIALS AND METHODS Structured medical record extraction and qualitative data collection procedures were used to evaluate acceptability, feasibility, and outcomes. RESULTS Most participants (n=17) were male (94.1%) and white (70.6%). Average age was 31.2 (standard deviation=6.4) years. TIDES/PTSD was successfully implemented within PC-MHI and was acceptable to patients and staff. Additionally, the total number of care manager calls was positively correlated with number of psychiatry visits (r=0.63, p<0.05) and amount of reduction in PTSD symptoms (r=0.66, p<0.05). Overall, participants in the pilot reported a significant reduction in PTSD symptoms over the course of the treatment (t=2.87, p=0.01). CONCLUSIONS TIDES can be successfully adapted and implemented for use among Iraq/Afghanistan veterans with PTSD. Further work is needed to test the effectiveness and implementation of this model in other sites and among veterans of other eras.

The va psychiatry-primary care education initiative

Received June 1, 2006; revised August 23, 2006; accepted March 2, 2007. Dr. Rohrbaugh is affiliated with the Department of Psychiatry at Yale University and with the VA Connecticut Healthcare System; Dr. Felker is affiliated with the Department of Psychiatry at the University of Washington and with the VA Washington Healthcare System. Dr. Kosten is affiliated with the Baylor College of Medicine in Houston and the VA National Substance Use Disorders Quality Enhancement Research Initiative. Address correspondence to Robert M. Rohrbaugh, M.D., Yale School of Medicine, Department of Psychiatry, 300 George St., Suite 901, Room 24, New Haven, CT 06511; Robert.rohrbaugh@yale.edu (e-mail). Copyright 2009 Academic Psychiatry The medical care needs of patients with psychiatric disorders have received increasing attention over the past decade (1–5). However, many psychiatric residency training programs continue to offer little training in primary medical care beyond the Accreditation Council for Graduate Medical Education (ACGME) required minimum of 4 months. This exposure often takes place during internship on inpatient medical units for severely ill patients. Residents in psychiatry may sense little connection between this type of medical training and the medical skills they need to counsel patients or to integrate medical care into their own practice. During this time, the U.S. Department of Veterans Affairs (VA) reorganized its health care priorities from an inpatient-based model to an emphasis on outpatient primary care. In 1996 VA leadership in mental health began planning the Psychiatry Primary Care Education (PsyPCE) initiative to encourage psychiatric resident education at the interface of psychiatry and primary care. Veterans Affairs leadership did not determine the content of the education program, encouraging a variety of programs to be developed. The PsyPCE initiative therefore provided a national laboratory to explore models for enhancing primary care education in psychiatric residency training (6, 7). In this article we review these programs to determine common elements that could be considered for a model program. We also report on resident knowledge, satisfaction, and practice behavior following implementation of the PsyPCE intervention in one representative program.