Ya Fen Chan

Quality Improvement With Pay-for-Performance Incentives in Integrated Behavioral Health Care

OBJECTIVES We evaluated a quality improvement program with a pay-for-performance (P4P) incentive in a population-focused, integrated care program for safety-net patients in 29 community health clinics. METHODS We used a quasi-experimental design with 1673 depressed adults before and 6304 adults after the implementation of the P4P program. Survival analyses examined the time to improvement in depression before and after implementation of the P4P program, with adjustments for patient characteristics and clustering by health care organization. RESULTS Program participants had high levels of depression, other psychiatric and substance abuse problems, and social adversity. After implementation of the P4P incentive program, participants were more likely to experience timely follow-up, and the time to depression improvement was significantly reduced. The hazard ratio for achieving treatment response was 1.73 (95% confidence interval=1.39, 2.14) after the P4P program implementation compared with pre-program implementation. CONCLUSIONS Although this quasi-experiment cannot prove that the P4P initiative directly caused improved patient outcomes, our analyses strongly suggest that when key quality indicators are tracked and a substantial portion of payment is tied to such quality indicators, the effectiveness of care for safety-net populations can be substantially improved.

Course of depression, mental health service utilization and treatment preferences in women receiving chemotherapy for breast cancer.

OBJECTIVE This prospective study aimed to estimate the prevalence and course of depression during chemotherapy in women with Stage I-III breast cancer, identify potential risk factors for depression and determine which treatments for depression were being used and which were most preferred. METHOD Thirty-two women were followed over consecutive chemotherapy infusions, with 289 assessments conducted altogether (mean, 9.0 assessments/subject). Current depression, anxiety, physical symptoms and mental health service use were recorded during each assessment. A linear mixed effects model was used to identify factors associated with depression. Patients also ranked depression treatment preferences. We referred patients with more severe depression for treatment. RESULTS Clinically significant depression was identified in 37.5% of patients. Depression severity tended to peak at 12-14 weeks and 32 or more weeks of chemotherapy. Depression severity was associated with anxiety severity, physical symptom burden, non-White race, receiving ones first chemotherapy regimen, Adriamycin-Cytoxan chemotherapy and chemotherapy duration. Most (65.5%) patients preferred evidence-based treatments for depression, and 66.7% of depressed patients were using such treatments. CONCLUSIONS Depression is common in women receiving chemotherapy for breast cancer. Most patients prefer evidence-based depression treatments. We recommend regular screening for depression during chemotherapy to ensure adequate detection and patient-centered treatment.

Prevalence of Symptoms of Depression and Anxiety in Adults With Cystic Fibrosis Based on the PHQ-9 and GAD-7 Screening Questionnaires

OBJECTIVE To examine the prevalence of symptoms of depression and anxiety among patients with cystic fibrosis (CF) who were followed up at the University of Washington Adult CF clinic and to identify sociodemographic and clinical factors associated with symptoms. METHODS A total of 178 adults with CF were asked to complete the Patient Health Questionnaire-9 for depression and General Anxiety Disorder-7 for anxiety when clinically stable. Clinically significant symptoms of depression and anxiety were defined in the following 2 ways: (1) symptom definition-presence of moderate-to-severe symptoms based on the questionnaires and (2) composite definition-symptom definition or the use of psychiatric medications to manage symptoms. Associations between Patient Health Questionnaire-9 and General Anxiety Disorder-7 scores with sociodemographic (gender, age, age of CF diagnosis, vocation, and spousal status) and clinical factors (forced expiratory volume in 1 second, body mass index, and CF-related diabetes on insulin) were examined. RESULTS Of 178 patients, 153 (85%) completed the screening questionnaires. Based on the symptom definition, 7% of patients had symptoms of depression and 5% had symptoms of anxiety. Using the composite definition, 22% of patients had symptoms of depression and 10% had symptoms of anxiety. Based on the Patient Health Questionnaire-9, 5% of patients reported suicidal thoughts. In multiple linear regression analysis, only forced expiratory volume in 1 second % predicted was independently associated with Patient Health Questionnaire-9 depression scores, and no sociodemographic or clinical factors were associated with General Anxiety Disorder-7 anxiety scores. CONCLUSIONS We conclude that all adults with CF should be screened for symptoms of depression and anxiety given the difficulty in identifying strong clinical risk factors and the unexpected high rates of suicidal ideation.

Referral for substance abuse treatment and depression improvement among patients with co-occurring disorders seeking behavioral health services in primary care.

This study examined the relationship between substance treatment referrals and depression improvement among 2,373 participants with concurrent substance use and depressive disorders enrolled in an integrated behavioral health program. Three groups of substance treatment referral status were identified: accessed treatment (n=780), declined treatment (n=315), and no referral for treatment (n=1278). The primary outcome is improvement in depressive symptoms (PHQ-9<10 or ≥50% reduction). Using propensity score adjustments, patients accessing substance treatment were significantly more likely to achieve depression improvement than those who declined receiving treatment services (hazard ratio (HR)=1.82, 95% confidence interval (CI): 1.50-2.20, p<0.001) and those without a referral for treatment (HR=1.13, 95% CI: 1.03-1.25, p=0.014). Each 1 week delay in initiating a referral was associated with a decreased likelihood of depression improvement (HR=0.97, 95% CI: 0.96-0.98, p<0.001). Study findings highlight the need of enhancing early treatment contact for co-occurring substance use disorders in primary care.

The Relationship Between Depressive/Anxiety Symptoms During Pregnancy/Postpartum and Sexual Life Decline after Delivery

INTRODUCTION Several factors have been found to be independently associated with decline in sexual activity after delivery. However, the association between depression in pregnancy/postpartum and sexual problems is less clear. AIM To prospectively evaluate the relationship between depressive/anxiety symptoms (DAS) during the perinatal period and sexual life in the postpartum period. METHODS A prospective cohort study conducted between May 2005 and March 2007 included 831 pregnant women recruited from primary care clinics of the public sector in São Paulo, Brazil. Four groups with DAS during antenatal and postpartum periods were identified using the Self Report Questionnaire (SRQ-20): absence of both antenatal and postpartum DAS; presence of antenatal DAS only; presence of postpartum DAS only; and presence of both antenatal and postpartum DAS. The primary outcome was perception of sexual life decline (SLD) before and after pregnancy/delivery. Crude and adjusted risk ratios (RR), with 95% confidence intervals (95% CI), were calculated using Poisson regression to examine the associations between DAS and SLD. MAIN OUTCOME MEASURE The main outcome measure of this study is the perception of SLD before and after pregnancy/delivery. RESULTS SLD occurred in 21.1% of the cohort. In the multivariable analysis, the following variables were independently associated with SLD: DAS during both pregnancy and postpartum (RR: 3.17 [95% CI: 2.18-4.59]); DAS during only the postpartum period (RR: 3.45 [95% CI: 2.39-4.98]); a previous miscarriage (RR: 1.54 [95% CI: 1.06-2.23]); and maternal age (RR: 2.11 [95% CI: 1.22-3.65]). CONCLUSIONS Postpartum women with DAS have an increased likelihood for SLD up to 18 months after delivery. Efforts to improve the rates of recognition and treatment of perinatal depression/anxiety in primary care settings have the potential to preserve sexual functioning for low-income mothers.

Substance Screening and Referral for Substance Abuse Treatment in an Integrated Mental Health Care Program

OBJECTIVE This study examined rates of substance screening and referral for substance abuse treatment as part of an integrated care program providing mental health services to low-income patients in primary care. METHODS Adults (N=11,150) who were enrolled in the program between 2008 and 2010 were included. Primary outcomes included substance screening rates, treatment referral rates, and correlates of accessing recommended treatment. RESULTS A total of 7,513 (67%) participants were screened for substance abuse. Among the 2,856 (38%) participants with a positive screen, 1,344 (47%) were referred for treatment. After adjustment for covariates, accessing recommended treatment was associated with past substance abuse treatment history, alcohol use, heavy drug use, posttraumatic stress disorder, and number of follow-up contacts with a care manager. CONCLUSION This study of a vulnerable population highlights missed opportunities for identifying and referring patients in primary care to substance abuse treatment.

The Role of the Integrated Care Psychiatrist in Community Settings: A Survey of Psychiatrists’ Perspectives

OBJECTIVE The objective of this study was to describe the work and experiences of psychiatrists practicing integrated care in the community. METHODS Consulting psychiatrists working in integrated care participated in an online survey about their experiences, opinions, and advice. Results were analyzed with quantitative and qualitative methods. RESULTS A convenience sample of 52 psychiatrists from around the country who were working in integrated care responded. Respondents reported that they address a wide variety of clinical problems with a range of treatment strategies. Most reported positive experiences, which were summarized in four themes: working in a patient-centered care model, working with a team, the psychiatrists role as educator, and opportunities for growth and innovation. CONCLUSIONS The survey documented the experiences of psychiatrists working in integrated care. Findings suggest that integrated care teams allow consulting psychiatrists to leverage their expertise to reach a large number of patients in a variety of practice settings.

The presentation, recognition and management of bipolar depression in primary care.

Bipolar disorder is a mood disorder characterized by episodes of major depression and mania or hypomania. Most patients experience chronic symptoms of bipolar disorder approximately half of the time, most commonly subsyndromal depressive symptoms or a full depressive episode with concurrent manic symptoms. Consequently, patients with bipolar depression are often misdiagnosed with major depressive disorder. Individual patient characteristics and population screening tools may be helpful in improving recognition of bipolar depression in primary care. Health risk behaviors including tobacco use, sedentary activity level and weight gain are highly prevalent in patients with bipolar disorder, as are the comorbid chronic diseases such as diabetes mellitus and cardiovascular disease. Patients with bipolar illness have about an eight-fold higher risk of suicide and a two-fold increased risk of death from chronic medical illnesses. Recognition of bipolar depression and its associated health risk behaviors and chronic medical problems can lead to the use of appropriate interventions for patients with bipolar disorder, which differ in important ways from the treatments used for major depressive disorder. The above topics are reviewed in detail in this article.

Variations in depression care and outcomes among high-risk mothers from different racial/ethnic groups.

UNLABELLED PURPOSE. To examine variations in depression care and outcomes among high-risk pregnant and parenting women from different racial/ethnic groups served in community health centres. METHODS As part of a collaborative care programme that provides depression treatment in primary care clinics for high-risk mothers, 661 women with probable depression (Patient Health Questionnaire-9 ≥ 10), who self-reported race/ethnicity as Latina (n = 393), White (n = 126), Black (n = 75) or Asian (n = 67), were included in the study. Primary outcomes include quality of depression care and improvement in depression. A Cox proportional hazard model adjusting for sociodemographic and clinical characteristics was used to examine time to treatment response. RESULTS We observed significant differences in both depression processes and outcomes across ethnic groups. After adjusting for other variables, Blacks were found to be significantly less likely to improve than Latinas [hazard ratio (HR): 0.53, 95% confidence interval (CI): 0.44-0.65]. Other factors significantly associated with depression improvement were pregnancy (HR: 1.52, 95% CI: 1.27-1.82), number of clinic visits (HR: 1.26, 95% CI: 1.17-1.36) and phone contacts (HR: 1.45, 95% CI: 1.32-1.60) by the care manager in the first month of treatment. After controlling for depression severity, having suicidal thoughts at baseline was significantly associated with a decreased likelihood of depression improvement (HR: 0.75, 95% CI: 0.67-0.83). CONCLUSIONS In this racially and ethnically diverse sample of pregnant and parenting women treated for depression in primary care, the intensity of care management was positively associated with improved depression. There was also appreciable variation in depression outcomes between Latina and Black patients.

Pain in primary care patients with bipolar disorder.

Birgenheir et al [1] found that a chart diagnosis of a chronic pain condition occurred approximately two times as often in veterans with a documented diagnosis of bipolar disorder compared to those without bipolar disorder. These findings are important for addressing the overall health of patients with bipolar disorder [1]. The authors noted that the veteran population was a limitation of their study. In an effort to expand the authors’ findings, we will describe our previously unreported findings on pain in primary care patients with bipolar disorder. We identified 740 primary care patients with bipolar disorder receiving care between January 2008 and December 2011in the Washington State Mental Health Integration Program (MHIP), a state wide clinical program serving patients with co-occurring medical and mental health needs in over 140 community health centers [2]. Cases of bipolar disorder were defined as having both the presence of a semi-structured Composite International Diagnostic Interview Version 3.0 [3] consistent with bipolar disorder and a clinician-documented bipolar disorder diagnosis. All patients enrolled in MHIP are assessed with baseline symptom questions, including a question about pain phrased as, “Is the patient being treated for a chronic pain condition, or does s/he describe pain that happens regularly and that interferes with daily functioning?”. We defined the presence of pain as answering “yes” to this question. Additional details of MHIP and of primary care patients with bipolar disorder treated in MHIP are described elsewhere [4]. The mean age of patients with bipolar disorder in MHIP was 39 years (S.D. 10.6), and 44% (n=326) were women. 641 of the 740 (87%) patients with bipolar disorder responded to the pain question. Almost half of the total patients with bipolar disorder (n=338, 46%) endorsed either current treatment for a pain condition or regular pain interfering with daily functioning. Other findings included a mean Patient Health Questionnaire 9 (PHQ-9) score of 18.1 (SD 5.9), suicidal ideation based on a score of 1 or more on item 9 of the PHQ-9 in 58% of patients, and significant psychosocial impairment, such as lack of a support person, in many patients with bipolar disorder [4]. We found that a high percentage of primary care patients with bipolar disorder enrolled in a collaborative care treatment program endorsed current pain symptoms or functional impairment related to pain. A previous report on patients enrolled in MHIP prior to October 31, 2010, showed that chronic pain was significantly associated with suicidal ideation measured by the