Edward P. Post

DIABETES, DEPRESSION, AND DEATH: A RANDOMIZED CONTROLLED TRIAL OF A DEPRESSION TREATMENT PROGRAM FOR OLDER ADULTS BASED IN PRIMARY CARE (PROSPECT)

OBJECTIVE—We sought to test our a priori hypothesis that depressed patients with diabetes in practices implementing a depression management program would have a decreased risk of mortality compared with depressed patients with diabetes in usual-care practices. RESEARCH DESIGN AND METHODS—We used data from the multisite, practice-randomized, controlled Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT), with patient recruitment from May 1999 to August 2001, supplemented with a search of the National Death Index. Twenty primary care practices participated from the greater metropolitan areas of New York City, New York; Philadelphia, Pennsylvania; and Pittsburgh, Pennsylvania. In all, 584 participants identified though a two-stage, age-stratified (aged 60–74 or ≥75 years) depression screening of randomly sampled patients and classified as depressed with complete information on diabetes status are included in these analyses. Of the 584 participants, 123 (21.2%) reported a history of diabetes. A depression care manager worked with primary care physicians to provide algorithm-based care. Vital status was assessed at 5 years. RESULTS—After a median follow-up of 52.0 months, 110 depressed patients had died. Depressed patients with diabetes in the intervention category were less likely to have died during the 5-year follow-up interval than depressed diabetic patients in usual care after accounting for baseline differences among patients (adjusted hazard ratio 0.49 [95% CI 0.24–0.98]). CONCLUSIONS—Older depressed primary care patients with diabetes in practices implementing depression care management were less likely to die over the course of a 5-year interval than depressed patients with diabetes in usual-care practices.

Depression, cardiovascular disease, diabetes, and two-year mortality among older, primary-care patients

OBJECTIVE Depression is a major contributor to death and disability, but few follow-up studies of depression have been carried out in the primary-care setting. The authors sought to assess whether depression in older patients is associated with increased mortality after a 2-year follow-up interval and to estimate the population-attributable fraction (PAF) of depression on mortality in older primary-care patients. METHODS Longitudinal cohort analysis was carried out in 20 primary-care practices. Participants were identified though a two-stage, age-stratified (60-74 or 75+) depression screening of randomly sampled patients; enrollment included patients who screened positive and a random sample of screened-negative patients. In all, 1,226 persons were assessed at baseline. Vital status at 2 years was the outcome of interest. RESULTS Of 1,226 persons in the sample, 598 were classified as depressed. After 2 years, 64 persons had died. Persons with depression at baseline were more likely to die at the end of the 2-year follow-up interval than were persons without depression, even after accounting for potentially influential covariates such as whether the participant reported a history of myocardial infarction (MI) or diabetes. CONCLUSIONS Among older, primary-care patients over the course of a 2-year follow-up interval, depression contributed as much to mortality as did MI or diabetes.

Improving Medical and Psychiatric Outcomes Among Individuals With Bipolar Disorder: A Randomized Controlled Trial

OBJECTIVES Comorbid medical conditions, notably cardiovascular disease, occur disproportionately among persons with bipolar disorder; yet the quality and outcomes of medical care for these individuals are suboptimal. This pilot study examined a bipolar disorder medical care model (BCM) and determined whether, compared with usual care, individuals randomly assigned to receive BCM care had improved medical and psychiatric outcomes. METHODS Persons with bipolar disorder and cardiovascular disease-related risk factors were recruited from a large Department of Veterans Affairs mental health facility and randomly assigned to receive BCM or usual care. BCM care consisted of four self-management sessions on bipolar disorder symptom control strategies, education and behavioral change related to cardiovascular disease risk factors, and promotion of provider engagement. Primary outcomes were physical and mental health-related quality of life; secondary outcomes included functioning and bipolar symptoms. RESULTS Fifty-eight persons participated. Twenty-seven received BCM care, and 31 received usual care. The mean+/-SD age was 55+/-8 years, 9% were female, 90% were white, and 10% were African American. Repeated-measures analysis was used, and significant differences were observed between the two groups in change in scores from baseline to six months for the 12-Item Short-Form Health Survey (SF-12) subscale for physical health (t=2.01, df=173, p=.04), indicating that the usual care group experienced a decline in physical health over the study period. Change in SF-12 scores also indicated that compared with the usual care group, the BCM group showed improvements in mental health-related quality of life over the six-month study period; however, this finding was not significant. CONCLUSIONS Compared with usual care, BCM care may have slowed the decline in physical health-related quality of life. Further studies are needed to determine whether BCM care leads to long-term positive changes in physical and mental health-related quality of life and reduced risk of cardiovascular disease among persons with bipolar disorder.

Integrating mental health into primary care within the Veterans Health Administration.

The Veterans Health Administration (VHA) has been undertaking a major transformational program of integrating collaborative mental health resources into primary care settings. Key components of the program include colocated collaborative care provided by mental health professionals; care management; and blended programs that combine elements of these two components, whose functions are highly complementary to each other. The program has grown since 2007 from an initiative implementing pilot programs at participating facilities, to a routine expectation of primary care within all VHA medical centers and large community-based outpatient clinics. The national program office supports this VHA initiative in multiple ways, including technical assistance to sites, program and policy development, dissemination of informational tools to facilitate continuous quality improvement, education and training, and partnerships with other existing and emerging VHA programs such as postdeployment health clinics and the patient-centered medical home.

Initiation of Primary Care-Mental Health Integration Programs in the VA Health System: Associations With Psychiatric Diagnoses in Primary Care

Background:Providing collaborative mental health treatment within primary care settings improves depression outcomes and may improve detection of mental disorders. Few studies have assessed the effect of collaborative mental health treatment programs on diagnosis of mental disorders in primary care populations. In 2008, many Department of Veterans Affairs (VA) facilities implemented collaborative care programs, as part of the VAs Primary Care–Mental Health Integration (PC-MHI) program. Objectives:To assess the prevalence of diagnosed mental health conditions among primary care patient populations in association with PC-MHI programs, overall and for patient subpopulations that may be less likely to receive mental health treatment. Research Design:Using a difference-in-differences analysis, we evaluated whether the rates of psychiatric diagnoses among primary care patient populations at 294 VA facilities changed from fiscal year (FY)07 to FY08, and whether trends differed at facilities with PC-MHI encounters in FY08. Subgroup analyses examined whether trends differed by patient age and race/ethnicity. Subjects, Measures, and Results:From FY07 to FY08, the prevalence of diagnosed depression, anxiety, post-traumatic stress disorder, and alcohol abuse increased more in the 137 facilities with PC-MHI program encounters than in the 157 facilities without these encounters. Increases were more likely among patients who were younger (18–64) and white. Conclusions:Initiation of PC-MHI programs was associated with elevated diagnosis patterns, which may enhance recognition of mental health needs among primary care patients. Increases in diagnosis prevalence were not uniform across patient subgroups. Further research is needed on treatment processes and outcomes for individuals receiving services in PC-MHI programs.

Quality of Care for Cardiovascular Disease-related Conditions in Patients with and without Mental Disorders

ObjectiveWe compared the quality of care for cardiovascular disease (CVD)-related risk factors for patients diagnosed with and without mental disorders.MethodsWe identified all patients included in the fiscal year 2005 (FY05) VA External Peer Review Program’s (EPRP) national random sample of chart reviews for assessing quality of care for CVD-related conditions. Using the VA’s National Psychosis Registry and the National Registry for Depression, we assessed whether patients had received diagnoses of serious mental illness (schizophrenia, bipolar disorder, or other psychoses) or depression during FY05. Using multivariable logistic regression and generalized estimating equation analyses, we assessed patient and facility factors associated with receipt of guideline concordant care for hypertension (total N = 24,016), hyperlipidemia (N = 46,430), and diabetes (N = 10,943).ResultsOverall, 70% had good blood pressure control, 90% received a cholesterol (hyperlipidemia) screen, 77% received a retinal exam for diabetes, and 63% received recommended renal tests for diabetes. After adjustment, compared to patients without SMI or depression, patients with SMI were less likely to be assessed for CVD risk factors, notably hyperlipidemia (OR = 0.58; p < 0.001), and less likely to receive recommended follow-up assessments for diabetes: foot exam (OR = 0.68; p < 0.001), retinal exam (OR = 0.65; p < 0.001), or renal testing (OR = 0.64; p < 0.001). Patients with depression were also significantly less likely to receive adequate quality of care compared to non-psychiatric patients, although effects were smaller than those observed for patients with SMI.ConclusionsQuality of care for major chronic conditions associated with premature CVD-related mortality is suboptimal for VA patients with SMI, especially for procedures requiring care by a specialist.

Randomized controlled trial to assess reduction of cardiovascular disease risk in patients with bipolar disorder: the Self-Management Addressing Heart Risk Trial (SMAHRT).

OBJECTIVES Persons with bipolar disorder experience a disproportionate burden of medical conditions, notably cardiovascular disease (CVD), leading to impaired functioning and premature mortality. We hypothesized that the Life Goals Collaborative Care (LGCC) intervention, compared to enhanced usual care, would reduce CVD risk factors and improve physical and mental health outcomes in US Department of Veterans Affairs patients with bipolar disorder. METHOD Patients with an ICD-9 diagnosis of bipolar disorder and ≥ 1 CVD risk factor (N = 118) enrolled in the Self-Management Addressing Heart Risk Trial, conducted April 2008-May 2010, were randomized to LGCC (n = 58) or enhanced usual care (n = 60). Life Goals Collaborative Care included 4 weekly self-management sessions followed by tailored contacts combining health behavior change strategies, medical care management, registry tracking, and provider guideline support. Enhanced usual care included quarterly wellness newsletters sent during a 12-month period in addition to standard treatment. Primary outcome measures included systolic and diastolic blood pressure, nonfasting total cholesterol, and physical health-related quality of life. RESULTS Of the 180 eligible patients identified for study participation, 134 were enrolled (74%) and 118 completed outcomes assessments (mean age = 53 years, 17% female, 5% African American). Mixed effects analyses comparing changes in 24-month outcomes among patients in LGCC (n = 57) versus enhanced usual care (n = 59) groups revealed that patients receiving LGCC had reduced systolic (β = -3.1, P = .04) and diastolic blood pressure (β = -2.1, P = .04) as well as reduced manic symptoms (β = -23.9, P = .01). Life Goals Collaborative Care had no significant impact on other primary outcomes (total cholesterol and physical health-related quality of life). CONCLUSIONS Life Goals Collaborative Care, compared to enhanced usual care, may lead to reduced CVD risk factors, notably through decreased blood pressure, as well as reduced manic symptoms, in patients with bipolar disorder. TRIAL REGISTRATION ClinicalTrials.gov identifier: NCT00499096.

Access to and satisfaction with care comparing patients with and without serious mental illness.

Objectives: We compared perceived access to and satisfaction with health care between patients diagnosed with serious mental illness (SMI: schizophrenia or bipolar disorder) and among those with no SMI diagnosis. Method: We conducted a national, cross-sectional study of VA patients in Fiscal Year (FY) 1999 (N=7,187) who completed the VAs Large Health Survey of Veteran Enrollees (LHSV) section on access and satisfaction and either received a diagnosis of schizophrenia or bipolar disorder, or did not and were randomly selected from the general non-SMI VA patient population (non-SMI group). We compared the probability of perceived poor access and dissatisfaction using multivariable logistic regression adjusting for patient covariates. Results: Compared to non-SMI patients, patients diagnosed with bipolar disorder were more likely to report difficulty in receiving care they needed (adjusted OR =1.36, p < .05) or seeing a specialist (adjusted OR=1.44, p < .001). Patients diagnosed with schizophrenia were more likely to report dissatisfaction, including thoroughness by their provider (adjusted OR=1.37, p < .001) and the providers explanation of problems (adjusted OR=1.54, p < .001) compared to non-SMI patients. Conclusions: Patients diagnosed with bipolar disorder reported greater problems with access to health care, while those diagnosed with schizophrenia were less satisfied with the process of care.

Collaborative Depression Care Management and Disparities in Depression Treatment and Outcomes

CONTEXT Collaborative depression care management (DCM), by addressing barriers disproportionately affecting patients of racial/ethnic minority and low education, may reduce disparities in depression treatment and outcomes. OBJECTIVE To examine the effects of DCM on treatment disparities by education and race/ethnicity in older depressed primary care patients. DESIGN Analysis of data from the randomized controlled trial Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT). SETTING Twenty primary care practices. PARTICIPANTS A total of 396 individuals 60 years or older with major depression. We conducted model-based analysis to estimate potentially differential intervention effects by education, independent of those by race/ethnicity (and vice versa). INTERVENTION Algorithm-based recommendations to physicians and care management by care managers. MAIN OUTCOME MEASURES Antidepressant use, depressive symptoms, and intensity of DCM over 2 years. RESULTS The PROSPECT intervention had a larger and more lasting effect in less-educated patients. At month 12, the intervention increased the rate of adequate antidepressant use by 14.2 percentage points (pps) (95% confidence interval [CI], 1.7 to 26.4 pps) in the no-college group compared with a null effect in the college-educated group (-9.2 pps [95% CI, -25.0 to 2.7 pps]); at month 24, the intervention reduced depressive symptoms by 2.6 pps on the Hamilton Depression Rating Scale (95% CI, -4.6 to -0.4 pps) in no-college patients, 3.8 pps (95% CI, -6.8 to -0.4) more than in the college group. The intervention benefitted non-Hispanic white patients more than minority patients. Intensity of DCM received by minorities was 60% to 70% of that received by white patients after the initial phase but did not differ by education. CONCLUSIONS The PROSPECT intervention substantially reduced disparities by patient education but did not mitigate racial/ethnic disparities in depression treatment and outcomes. Incorporation of culturally tailored strategies in DCM models may be needed to extend their benefits to minorities. TRIAL REGISTRATION clinicaltrials.gov Identifier for PROSPECT NCT00279682.

Prevalence, comorbidity, and prognosis of mental health among US veterans

OBJECTIVES We evaluated the association of mental illnesses with clinical outcomes among US veterans and evaluated the effects of Primary Care-Mental Health Integration (PCMHI). METHODS A total of 4 461 208 veterans were seen in the Veterans Health Administrations patient-centered medical homes called Patient Aligned Care Teams (PACT) in 2010 and 2011, of whom 1 147 022 had at least 1 diagnosis of depression, posttraumatic stress disorder (PTSD), substance use disorder (SUD), anxiety disorder, or serious mental illness (SMI; i.e., schizophrenia or bipolar disorder). We estimated 1-year risk of emergency department (ED) visits, hospitalizations, and mortality by mental illness category and by PCMHI involvement. RESULTS A quarter of all PACT patients reported 1 or more mental illnesses. Depression, SMI, and SUD were associated with increased risk of hospitalization or death. PTSD was associated with lower odds of ED visits and mortality. Having 1 or more contact with PCMHI was associated with better outcomes. CONCLUSIONS Mental illnesses are associated with poor outcomes, but integrating mental health treatment in primary care may be associated with lower risk of those outcomes.