Kevin D. Hennessy

Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis

CONTEXT To improve the quality of depression management, collaborative care models have been developed from the Chronic Care Model over the past 20 years. Collaborative care is a multicomponent, healthcare system-level intervention that uses case managers to link primary care providers, patients, and mental health specialists. In addition to case management support, primary care providers receive consultation and decision support from mental health specialists (i.e., psychiatrists and psychologists). This collaboration is designed to (1) improve routine screening and diagnosis of depressive disorders; (2) increase provider use of evidence-based protocols for the proactive management of diagnosed depressive disorders; and (3) improve clinical and community support for active client/patient engagement in treatment goal-setting and self-management. EVIDENCE ACQUISITION A team of subject matter experts in mental health, representing various agencies and institutions, conceptualized and conducted a systematic review and meta-analysis on collaborative care for improving the management of depressive disorders. This team worked under the guidance of the Community Preventive Services Task Force, a nonfederal, independent, volunteer body of public health and prevention experts. Community Guide systematic review methods were used to identify, evaluate, and analyze available evidence. EVIDENCE SYNTHESIS An earlier systematic review with 37 RCTs of collaborative care studies published through 2004 found evidence of effectiveness of these models in improving depression outcomes. An additional 32 studies of collaborative care models conducted between 2004 and 2009 were found for this current review and analyzed. The results from the meta-analyses suggest robust evidence of effectiveness of collaborative care in improving depression symptoms (standardized mean difference [SMD]=0.34); adherence to treatment (OR=2.22); response to treatment (OR=1.78); remission of symptoms (OR=1.74); recovery from symptoms (OR=1.75); quality of life/functional status (SMD=0.12); and satisfaction with care (SMD=0.39) for patients diagnosed with depression (all effect estimates were significant). CONCLUSIONS Collaborative care models are effective in achieving clinically meaningful improvements in depression outcomes and public health benefits in a wide range of populations, settings, and organizations. Collaborative care interventions provide a supportive network of professionals and peers for patients with depression, especially at the primary care level.

Translating research into improved outcomes in comprehensive cancer control.

A key question in moving comprehensive cancer control (CCC) plans into action is, to what extent should the knowledge gained from investments in cancer prevention and control research influence the actions taken by states, tribes, and territories during implementation? Underlying this ‘should’ is the assumption that evidence-based approaches (i.e., a public health or clinical intervention or policy that has resulted in improved outcomes when scientifically tested), when implemented in a real-world setting, will increase the likelihood of improved outcomes. This article elucidates the barriers and opportunities for integrating science with practice across the cancer control continuum. However, given the scope of CCC and the substantial investment in generating new knowledge through science, it is difficult for any one agency, on its own, to make a sufficient investment to ensure new knowledge is translated and implemented at a national, state, or local level. Thus, if greater demand for evidence-based interventions and increased resources for adopting them are going to support the dissemination initiatives described herein, new interagency partnerships must be developed to ensure that sufficient means are dedicated to integrating science with service. Furthermore, for these collaborations to increase both in size and in frequency, agency leaders must clearly articulate their support for these collaborative initiatives and explicitly recognize those collaborative efforts that are successful. In this way, the whole (in this context, comprehensive cancer control) can become greater than the sum of its parts.

The National Registry of Evidence-Based Programs and Practices: A Decision-Support Tool to Advance the Use of Evidence-Based Services.

Since its creation in 1996, the National Registry of Evidence-Based Programs and Practices (NREPP) has provided information to the public about the scientific evidence to support a wide array of substance abuse prevention interventions. In the process of expanding NREPP to the domains of substance abuse treatment and to the prevention and treatment of mental illnesses, the Substance Abuse and Mental Health Services Administration (SAMHSA) has explored a variety of mechanisms to enhance the utility of NREPP for multiple audiences. This paper describes the process employed by SAMHSA to evaluate the informational and decision-support needs of various stakeholder audiences and provides a detailed description of the changes to the NREPP system resulting from this process.

An economic and clinical rationale for changing utilization review practices for outpatient psychotherapy

The growth of managed care has led to greater cost consciousness in the financing and delivery of mental health and substnace abuse services. The authors examine whether pressures to reduce the costs associated with mental health and substance abuse treatment have led to the overapplication of a popular managed care strategy, utilization review (UR), to the management of outpatient psychotherpay benefits. Several arguments are presented highlighting why changing outpatient psychotherapy UR practices would be in the best economic and clinical interests of all involved parties, including payers, managed care organizatios, (MCOs), mental health consumers, and providers. A number of alternatives to the aggressive management of outpatient psychotherapy benefits are outlined and discussed.

A Review of Mental Health Interventions in SAMHSA's National Registry of Evidence-Based Programs and Practices

OBJECTIVE This study identified and examined characteristics of mental health interventions listed in a registry of evidence-based behavioral health programs and practices. METHODS Data were from the National Registry of Evidence-Based Programs and Practices (NREPP), which is sponsored by the Substance Abuse and Mental Health Services Administration. All mental health interventions posted as of May 2010 were reviewed. RESULTS A total of 91 interventions were assessed. Over half (57%) focused on promoting mental health rather than on treating mental illness. The implementation materials and trainings for most interventions (52%) were proprietary. Analysis of NREPPs rated dimensions revealed that quality-of-research scores were significantly lower for interventions with exclusively proprietary materials, whereas readiness-for-dissemination scores were significantly lower for interventions with exclusively publicly available materials. CONCLUSIONS NREPP represents a practical tool for organizations seeking to initiate or expand their use of evidence-based services. Periodic studies of listed interventions may help to identify programmatic gaps in NREPP.

Effects of Mental Health Benefits Legislation A Community Guide Systematic Review

CONTEXT Health insurance benefits for mental health services typically have paid less than benefits for physical health services, resulting in potential underutilization or financial burden for people with mental health conditions. Mental health benefits legislation was introduced to improve financial protection (i.e., decrease financial burden) and to increase access to, and use of, mental health services. This systematic review was conducted to determine the effectiveness of mental health benefits legislation, including executive orders, in improving mental health. EVIDENCE ACQUISITION Methods developed for the Guide to Community Preventive Services were used to identify, evaluate, and analyze available evidence. The evidence included studies published or reported from 1965 to March 2011 with at least one of the following outcomes: access to care, financial protection, appropriate utilization, quality of care, diagnosis of mental illness, morbidity and mortality, and quality of life. Analyses were conducted in 2012. EVIDENCE SYNTHESIS Thirty eligible studies were identified in 37 papers. Implementation of mental health benefits legislation was associated with financial protection (decreased out-of-pocket costs) and appropriate utilization of services. Among studies examining the impact of legislation strength, most found larger positive effects for comprehensive parity legislation or policies than for less-comprehensive ones. Few studies assessed other mental health outcomes. CONCLUSIONS Evidence indicates that mental health benefits legislation, particularly comprehensive parity legislation, is effective in improving financial protection and increasing appropriate utilization of mental health services for people with mental health conditions. Evidence was limited for other mental health outcomes.

Predictors of the Decision to Adopt Motivational Interviewing in Community Health Settings

The purpose of this study is to concurrently examine the impact of individual and organizational characteristics on the decision to adopt the evidence-based practice (EBP) motivational interviewing (MI) among directors and staff (n = 311) in community health organizations (n = 92). Results from hierarchical linear modeling indicated that, at the individual level, attitudes toward EBPs and race each predicted directors’ decisions to adopt, while gender predicted staff’s decisionmaking. At the organizational level, organizational climate was inversely associated with both staff’s and directors’ decisions to adopt MI. Organizational barriers to implementing EBPs and use of reading materials and treatment manuals were related to directors’ decision to adopt. Type of organization and staff attributes were associated with staff’s decision to adopt. These findings underscore the need to tailor dissemination and implementation strategies to address differences between directors and staff in the adoption of EBPs.

Increasing adoption of comparative effectiveness research in community behavioral health: methodology.

Increased efforts in comparative effectiveness research (CER) (comparing various health care intervention and treatment options) are being used to inform health care delivery. While CER research itself is an important step in developing best practices in health care, it is not enough to ensure success. The knowledge must also be successfully disseminated to increase adoption and implementation of practices. To ensure the greatest benefits of successful interventions, it is essential to understand which dissemination strategies are effective and under what conditions. This article provides the background and methodology used in a large-scale, 2-year study aimed at determining how knowledge gained from CER research may be most effectively disseminated to those responsible for delivering behavioral health services. The study takes an important step toward addressing the gaps in dissemination and translation of CER.

Evaluation of a randomized intervention to increase adoption of comparative effectiveness research by community health organizations.

This randomized controlled trial examined the influence of two strategies (informational packets alone and in conjunction with Webinars) aimed at increasing the adoption of motivational interviewing (MI), a patient-centered behavioral health practice supported by evidence from comparative effectiveness studies, among community health organizations responsible for delivering mental and behavioral health services. Data were obtained from 311 directors and staff across 92 community organizations. Hierarchical linear modeling was used to examine changes in decision to adopt MI. The mediating effects of multiple contextual variables were also examined. Results showed that both strategies positively influenced the decision to adopt. The positive impact on decision to adopt was significantly greater among individuals that received informational packets in conjunction with Webinars. Baseline attitudes toward evidence-based practices and pressures for change appeared to mediate this effect.

Datapoints: Reported Mental Health Specialty Care in the 2010 HealthStyles Survey

O measure of progress in reducing negative attitudes toward people with mental illness is the extent to which members of the general public who report having a mental health condition seek specialist care. To examine this issue more closely, we analyzed adult responses to the 2010 edition of the HealthStyles Survey. The survey is a large, private proprietary, national mail panel marketing survey conducted annually to assess attitudes and beliefs about chronic and infectious disease and behaviors, exposure to health information and to health communication campaigns, and self-reported symptoms, risk factors, diseases, and disorders (1). The survey is designed to be representative of the U.S. population, and the 2010 survey data were weighted to match the 2009 Current Population Survey estimates for age, sex, marital status, education, and race-ethnicity. The 2010 survey was mailed to 6,255 respondents; the response rate was 67% (4,184 individuals age 18 and over). Most respondents agreed with statements that a person with mental illness would improve if given treatment and support (68%) and that treatment can help people with mental illness lead a normal life (65%). A subset of respondents (24%) self-reported having one or more of eight listed mental health conditions in the past year. Among those with a self-reported mental health condition, approximately 42% reported having more than one mental health condition. For those with either a single condition or multiple conditions, depression and anxiety were the most prevalent, accounting for almost 80% of all conditions in both groups. Figure 1 presents data about respondents with one or more self-reported mental health conditions who reported visiting a mental health specialty provider in the previous year and the extent of these visits. Only 17% of those with one self-reported condition and 46% of those with multiple self-reported conditions saw a mental health provider during the previous year. Further, among those who visited a mental health provider, most made fewer than six visits. Among those with a single condition who sought treatment, 79% reported six or fewer visits. Among those with multiple conditions, 58% reported six or fewer visits. Reported Mental Health Specialty Care in the 2010 HealthStyles Survey