Enid M. Hunkeler

Comorbid depression, chronic pain, and disability in primary care.

Objectives: The objectives of this study were to provide estimates of the prevalence and strength of association between major depression and chronic pain in a primary care population and to examine the clinical burden associated with the two conditions, singly and together. Methods: A random sample of Kaiser Permanente patients who visited a primary care clinic was mailed a questionnaire assessing major depressive disorder (MDD), chronic pain, pain-related disability, somatic symptom severity, panic disorder, other anxiety, probable alcohol abuse, and health-related quality of life (HRQL). Instruments included the Patient Health Questionnaire, SF-8, and Graded Chronic Pain Questionnaire. A total of 5808 patients responded (54% of those eligible to participate). Results: Among those with MDD, a significantly higher proportion reported chronic (i.e., nondisabling or disabling) pain than those without MDD (66% versus 43%, respectively). Disabling chronic pain was present in 41% of those with MDD versus 10% of those without MDD. Respondents with comorbid depression and disabling chronic pain had significantly poorer HRQL, greater somatic symptom severity, and higher prevalence of panic disorder than other respondents. The prevalence of probable alcohol abuse/dependence was significantly higher among persons with MDD compared with individuals without MDD regardless of pain or disability level. Compared with participants without MDD, the prevalence of other anxiety among those with MDD was more than sixfold greater regardless of pain or disability level. Conclusions: Chronic pain is common among those with MDD. Comorbid MDD and disabling chronic pain are associated with greater clinical burden than MDD alone. MDD = major depressive disorder; HRQL = health-related quality of life; HMO = health maintenance organization; PHQ = Patient Health Questionnaire; GCPS = Graded Chronic Pain Scale; CP = chronic pain; DCP = disabling chronic pain; GAD = generalized anxiety disorder; SCID = Structured Clinical Interview for DSM-III-R; PRIME-MD = Primary Care Evaluation of Mental Disorders; CI = confidence interval; DSM-IV = Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition; DSM-III-R = Diagnostic and Statistical Manual of Mental Disorders, Third Edition Revised.

The Effectiveness of Depression Care Management on Diabetes-Related Outcomes in Older Patients

Context Many patients have both diabetes and depression. Some hypothesize that treating depression might improve diabetes outcomes. Contribution In this randomized trial, 12 months of depression care management for depressed patients with diabetes improved depression-related outcomes and increased the frequency of exercise. However, care management did not affect diet, diabetes medication adherence, glucose testing, or glycemic control. Cautions The study sample had reasonably good diabetes control at baseline. Whether patients with poorly controlled diabetes would benefit from depression care is not known. The Editors Major depression and dysthymic disorder affect 5% to 10% of older adults seen in primary care settings (1-3). Late-life depression is often chronic or recurrent (4-6) and is associated with substantial suffering, functional impairment, and diminished health-related quality of life (7). Diabetes mellitus affects 7.8% of all adults and almost 1 in 5 of those age 60 years and older (8). Individuals with diabetes mellitus have a 2-fold higher rate of major depression than those without diabetes (9, 10). Depression adversely affects the course of coexisting medical illness, contributing to increased symptom burden, functional impairment, and mortality (11, 12). For patients with diabetes mellitus, depression is associated with decreased glycemic control and increased number of micro- and macrovascular complications (13, 14). The mechanism of effect is not understood but may be related to depression-induced abnormalities in neuroendocrine and neurotransmitter function or decreased self-care behaviors (15-20). Integrating evidence-based depression care for persons with diabetes may improve both depression and diabetes outcomes. Three small randomized, controlled trials have studied the effect of treatment for depression on affective and glycemic outcomes in patients with depression and diabetes mellitus (21-23). These studies have consistently shown improvements in affective outcomes, but effects on glycemic control have been mixed. Primary care physicians are well positioned to provide integrated care for depression and diabetes mellitus but face many barriers. Controlled trials report that treatment for depression is efficacious in approximately 70% of persons who complete treatment compared with 30% of those who receive placebo (24). However, these results are difficult to replicate in routine primary care practice. Barriers to high-quality care include suboptimal recognition; inconsistent treatment with lack of close follow-up and monitoring; and organizational barriers, such as brief visits, poor integration with specialty mental health care, competing clinical priorities, and lack of decision support systems (25-27). Simple interventions, such as depression screening and physician education, have little impact on these barriers and patient outcomes (28-30). Treatment models that use a depression specialist working collaboratively with primary care physicians have shown clinically important improvement in patient outcomes (31-37). We recently reported robust effects of such a model for older adults with major depression or dysthymia (37). In this preplanned analysis, we evaluate the effects on affective and diabetes-specific outcomes. If effective care for depression also benefits adherence to self-care regimens, functional status, and other medical illness outcomes, it would add powerful quality-of-care and economic incentives for the dissemination and maintenance of these models. In addition, if effective care for depression improves self-care behaviors, it may also positively affect other chronic medical illnesses with important self-care components. For this prespecified subgroup analysis, we focused on older adults with clinical depression and coexisting diabetes mellitus. We hypothesized that the collaborative care intervention would improve affective symptoms, functional status, self-care behaviors, and glycemic control. In addition, we hypothesized that effects on glycemic control would be greatest for patients with baseline hemoglobin A1c values of 8.0% or greater. Methods The Improving MoodPromoting Access to Collaborative Treatment (IMPACT) study is a multisite randomized, controlled trial of a collaborative care intervention program for late-life depression in primary care (37, 38). Institutional review boards at participating sites approved study protocols, and all participants gave written informed consent. Patients Seven study sites representing 8 diverse health care organizations with a total of 18 primary care clinics in 5 states participated in the study. From July 1999 to August 2001, depressed older adults were recruited through referrals from primary care practitioners and other clinic staff or through systematic depression screening with a 2-item depression screener adapted from the Primary Care Evaluation of Mental Disorders (39). Of the 2190 patients referred to the study, 308 (14%) declined the initial eligibility screening or additional interviews, 54 (3%) had incomplete initial screenings, and 202 (9%) were ineligible because they were younger than 60 years of age or they did not plan to use the participating clinic over the coming 12 months. Of the 32908 patients approached for screening, 5246 (16%) declined the initial screening or follow-up interviews. A total of 1791 (5%) of the initial screenings were incomplete and 23233 (71%) of those screened were not eligible because they did not have one of the core depression symptoms (95%) or because of logistic reasons such as lack of transportation or access to a telephone (5%). The remaining 1626 (74%) of those referred and 2638 (8%) of those screened completed a computer-assisted structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), to assess whether patients met research diagnostic criteria for major depression or dysthymia (40). Inclusion criteria were age 60 years or older, plans to use one of the participating clinics as the main source of general medical care in the coming year, and a diagnosis of current major depression or dysthymic disorder according to the structured clinical interview for DSM-IV. Otherwise eligible persons were excluded because of a current drinking problem (a score of 2 on the CAGE questionnaire) (41), a history of bipolar disorder or psychosis (38), ongoing treatment with a psychiatrist, or severe cognitive impairment defined by a score less than 3 on a 6-item cognitive screener (42). We identified 2102 eligible older adults with major depression or dysthymic disorder, of whom 1801 (86%) enrolled in the study. As part of the structured baseline interview, enrolled patients were asked Has a doctor or another health care worker diagnosed you with or treated you for high blood sugar or diabetes in the past 3 years? The 417 patients who endorsed this question are the focus of the diabetes-specific analyses. After the baseline interview, we randomly assigned participants to the IMPACT intervention or usual care. The randomization was stratified by recruitment method (screening or referral) and clinic. Randomization information was contained in a set of numbered, sealed envelopes for each stratum that were used sequentially for newly enrolled patients at each clinic (38). Diagnoses were communicated to enrolled patients and their primary care physicians. Intervention Patients in the intervention group received a 20-minute educational videotape and a booklet about late-life depression and were encouraged to have an initial visit with a depression care manager at the primary care clinic (43, 44). Care managers were nurses or psychologists who were trained for the study as a depression clinical specialist (38, 45). During the initial visit, the depression clinical specialist conducted a clinical and psychosocial history, reviewed the educational materials, and discussed patient preferences for depression treatment (antidepressant medications or psychotherapy). New patients and patients needing treatment plan adjustments were discussed with a supervising team psychiatrist and a liaison primary care physician during a weekly team meeting. The depression clinical specialist then worked with the patient and his or her regular primary care provider to establish a treatment plan according to an evidence-based treatment algorithm (38). The IMPACT algorithm suggested an initial choice of an antidepressant (usually a selective serotonin reuptake inhibitor) or a course of Problem-Solving Treatment in Primary Care (PST-PC), which consisted of 6 to 8 brief sessions of structured psychotherapy for depression, delivered by the depression clinical specialist in primary care (46-49). For patients who were already receiving antidepressant medications but who were still depressed, the recommendation for partial responders was to increase the dose or augment the antidepressant with a trial of PSTPC; the recommendation for nonresponders was to switch to a different medication or use a trial of PSTPC. Depression clinical specialists also encouraged patients to increase behavioral activation and referred them to additional health or social services, as clinically indicated. The intervention did not specifically address diabetes mellitus or other coexisting medical illnesses. As care managers, depression clinical specialists attempted to follow patients for up to 12 months; they monitored treatment response with the Primary Care Evaluation of Mental Disorders Patient Health Questionnaire (50) and a Web-based clinical information system (51). During the acute treatment phase, in-person or telephone follow-up contacts were suggested at least every other week. Patients who recovered from depression ( 50% reduction in the Patient Health Questionnaire score and <3 of 9 symptoms of major depression) were engaged in developing a relapse prevention plan and were then follo

Long term outcomes from the IMPACT randomised trial for depressed elderly patients in primary care

Abstract Objective To determine the long term effectiveness of collaborative care management for depression in late life. Design Two arm, randomised, clinical trial; intervention one year and follow-up two years. Setting 18 primary care clinics in eight US healthcare organisations. Patients 1801 primary care patients aged 60 and older with major depression, dysthymia, or both. Intervention Patients were randomly assigned to a 12 month collaborative care intervention (IMPACT) or usual care for depression. Teams including a depression care manager, primary care doctor, and psychiatrist offered education, behavioural activation, antidepressants, a brief, behaviour based psychotherapy (problem solving treatment), and relapse prevention geared to each patients needs and preferences. Main outcome measures Interviewers, blinded to treatment assignment, conducted interviews in person at baseline and by telephone at each subsequent follow up. They measured depression (SCL-20), overall functional impairment and quality of life (SF-12), physical functioning (PCS-12), depression treatment, and satisfaction with care. Results IMPACT patients fared significantly (P < 0.05) better than controls regarding continuation of antidepressant treatment, depressive symptoms, remission of depression, physical functioning, quality of life, self efficacy, and satisfaction with care at 18 and 24 months. One year after IMPACT resources were withdrawn, a significant difference in SCL-20 scores (0.23, P < 0.0001) favouring IMPACT patients remained. Conclusions Tailored collaborative care actively engages older adults in treatment for depression and delivers substantial and persistent long term benefits. Benefits include less depression, better physical functioning, and an enhanced quality of life. The IMPACT model may show the way to less depression and healthier lives for older adults.

Improving primary care for depression in late life: the design of a multicenter randomized trial.

Background.Late life depression can be successfully treated with antidepressant medications or psychotherapy, but few depressed older adults receive effective treatment. Research Design. A randomized controlled trial of a disease management program for late life depression. Subjects.Approximately 1,750 older adults with major depression or dysthymia are recruited from seven national study sites. Intervention.Half of the subjects are randomly assigned to a collaborative care program where a depression clinical specialist supervised by a psychiatrist and a primary care expert supports the patient’s regular primary care provider to treat depression. Intervention services are provided for 12 months using antidepressant medications and Problem Solving Treatment in Primary Care according to a stepped care protocol that varies intervention intensity according to clinical needs. The other half of the subjects are assigned to care as usual. Evaluation.Subjects are independently assessed at baseline, 3 months, 6 months, 12 months, 18 months, and 24 months. The evaluation assesses the incremental cost-effectiveness of the intervention compared with care as usual. Specific outcomes examined include care for depression, depressive symptoms, health-related quality of life, satisfaction with depression care, health care costs, patient time costs, market and nonmarket productivity, and household income. Conclusions.The study blends methods from health services and clinical research in an effort to protect internal validity while maximizing the generalizability of results to diverse health care systems. We hope that this study will show the cost-effectiveness of a new model of care for late life depression that can be applied in a range of primary care settings.

Recruitment in the Coronary Artery Disease Risk Development in Young Adults (Cardia) study

Coronary Artery Disease Risk Development in Young Adults (CARDIA) is a longitudinal study designed to trace the development of risk factors for coronary heart disease in 5100 individuals 18-30 years old. The study will compare, by cross-sectional and longitudinal analyses, trends and processes involved in risk factor development by sex, race, age, and other sociodemographic characteristics. Participants for the approximately 4 1/2-hour baseline examination were randomly selected and recruited by telephone from census tracts in Minneapolis and Chicago, by telephone exchanges within the Birmingham city limit, and from lists of the Kaiser-Permanente Health Plan membership in Oakland and Berkeley. A major issue was the desirability of sampling approximately equal numbers by age, race, sex, and education as compared with sampling numbers representative of the population base. The recruitment goal of 5100 was achieved on schedule.

Depression Treatment in a Sample of 1,801 Depressed Older Adults in Primary Care

OBJECTIVES: To examine rates and predictors of lifetime and recent depression treatment in a sample of 1,801 depressed older primary care patients

Improving depression care for older, minority patients in primary care

Objective:Few older minorities receive adequate treatment of depression in primary care. This study examines whether a collaborative care model for depression in primary care is as effective in older minorities as it is in nonminority elderly patients in improving depression treatment and outcomes. Study Design:A multisite randomized clinical trial of 1801 older adults comparing collaborative care for depression with treatment as usual in primary care. Twelve percent of the sample were black (n = 222), 8% were Latino (n = 138), and 3% (n = 53) were from other minority groups. We compared the 3 largest ethnic groups (non-Latino white, black, and Latino) on depression severity, quality of life, and mental health service use at baseline, 3, 6, and 12 months after randomization to collaborative care or usual care. Principal Findings:Compared with care as usual, collaborative care significantly improved rates and outcomes of depression care in older adults from ethnic minority groups and in older whites. At 12 months, intervention patients from ethnic minorities (blacks and Latinos) had significantly greater rates of depression care for both antidepressant medication and psychotherapy, lower depression severity, and less health-related functional impairment than usual care participants (64%, 95% confidence interval [CI] 55–72 versus 45%, CI 36–55, P = 0.003 for antidepressant medication; 37%, CI 28–47 versus 13%, CI 6–19, P = 0.002 for psychotherapy; mean = 0.9, CI 0.8–1.1 versus mean = 1.4, CI 1.3–1.5, P < 0.001 for depression severity, range 0–4; mean = 3.7, CI 3.2–4.1, versus mean = 4.7, CI 4.3–5.1, P < 0.0001 for functional impairment, range 0–10). Conclusions:Collaborative Care is significantly more effective than usual care for depressed older adults, regardless of their ethnicity. Intervention effects in ethnic minority participants were similar to those observed in whites.

Depression and Comorbid Illness in Elderly Primary Care Patients: Impact on Multiple Domains of Health Status and Well-being

PURPOSE Our objective was to examine the relative association of depression severity and chronicity, other comorbid psychiatric conditions, and coexisting medical illnesses with multiple domains of health status among primary care patients with clinical depression. METHODS We collected cross-sectional data as part of a treatment effectiveness trial that was conducted in 8 diverse health care organizations. Patients aged 60 years and older (N = 1,801) who met diagnostic criteria for major depression or dysthymia participated in a baseline survey. A survey instrument included questions on sociodemographic characteristics, depression severity and chronicity, neuroticism, and the presence of 11 common chronic medical illnesses, as well as questions screening for panic disorder and posttraumatic stress disorder. Measures of 4 general health indicators (physical and mental component scales of the SF-12, Sheehan Disability Index, and global quality of life) were included. We conducted separate mixed-effect regression linear models predicting each of the 4 general health indicators. RESULTS Depression severity was significantly associated with all 4 indicators of general health after controlling for sociodemographic differences, other psychological dysfunction, and the presence of 11 chronic medical conditions. Although study participants had an average of 3.8 chronic medical illnesses, depression severity made larger independent contributions to 3 of the 4 general health indicators (mental functional status, disability, and quality of life) than the medical comorbidities. CONCLUSIONS Recognition and treatment of depression has the potential to improve functioning and quality of life in spite of the presence of other medical comorbidities.

Treatment of depression improves physical functioning in older adults

Objectives: To determine the effect of collaborative care management for depression on physical functioning in older adults.

HOME BLOOD PRESSURE MONITORING : EFFECT ON USE OF MEDICAL SERVICES AND MEDICAL CARE COSTS

The objective of this study was to determine whether a hypertension management program in which patients monitor their own blood pressure (BF) at home can reduce costs without compromising BP control. The prospective, randomized, controlled 1-year clinical trial was conducted at four medical centers of the Kaiser Permanente Medical Care Program in the San Francisco Bay Area. Of 467 patients with uncomplicated hypertension who were referred by their physicians, 37 declined to participate in the study; 215 were randomly assigned to a Usual Care (UC) group and 215 to a Home BP group. Twenty-five UC patients and 15 Home BP patients did not return for year-end BP measurements. Patients in the UC group were referred back to their physicians. Patients in the Home BP group were trained to measure their own BP and return the readings by mail. Patients were given a standard procedure to follow in case of unusually high or low BP readings at home. The number and type of outpatient medical services used were obtained from patient medical records for the study year and the prior year. Costs of care for hypertension were calculated by assigning relative value units to each outpatient service. Trained technicians measured each patients BP at entry into the study and 1 year later. Home BP patients made 1.2 fewer hypertension-related office visits than UC patients during the study year (95% confidence interval (CI): 0.8,1.7). Mean adjusted cost for physician visits, telephone calls, and laboratory tests associated with hypertension care was