Efficacy of Blended Collaborative Care for Patients With Heart Failure and Comorbid Depression: A Randomized Clinical Trial.

Importance: Depression is often comorbid in patients with heart failure (HF) and is associated with worse clinical outcomes. However, depression generally goes unrecognized and untreated in this population. Objective: To determine whether a blended collaborative care program for treating both HF and depression can improve clinical outcomes more than collaborative care for HF only and physicians' usual care (UC). Design, Setting, and Participants: This 3-arm, single-blind, randomized effectiveness trial recruited 756 participants with HF with reduced left ventricular ejection fraction (<45%) from 8 university-based and community hospitals in southwestern Pennsylvania between March 2014 and October 2017 and observed them until November 2018. Participants included 629 who screened positive for depression during hospitalization and 2 weeks postdischarge and 127 randomly sampled participants without depression to facilitate further comparisons. Key analyses were performed November 2018 to March 2019. Interventions: Separate physician-supervised nurse teams provided either 12 months of collaborative care for HF and depression ("blended" care) or collaborative care for HF only (enhanced UC [eUC]). Main Outcomes and Measures: The primary outcome was mental health-related quality of life (mHRQOL) as measured by the Mental Component Summary of the 12-item Short Form Health Survey (MCS-12). Secondary outcomes included mood, physical function, HF pharmacotherapy use, rehospitalizations, and mortality. Results: Of the 756 participants (mean [SD] age, 64.0 [13.0] years; 425 [56%] male), those with depression reported worse mHRQOL, mood, and physical function but were otherwise similar to those without depression (eg, mean left ventricular ejection fraction, 28%). At 12 months, blended care participants reported a 4.47-point improvement on the MCS-12 vs UC (95% CI, 1.65 to 7.28; P = .002), but similar scores as the eUC arm (1.12; 95% CI, -1.15 to 3.40; P = .33). Blended care participants also reported better mood than UC participants (Patient-Reported Outcomes Measurement Information System-Depression effect size, 0.47; 95% CI, 0.28 to 0.67) and eUC participants (0.24; 95% CI, 0.07 to 0.41), but physical function, HF pharmacotherapy use, rehospitalizations, and mortality were similar by both baseline depression and randomization status. Conclusions and Relevance: In this randomized clinical trial of patients with HF and depression, telephone-delivered blended collaborative care produced modest improvements in mHRQOL, the primary outcome, on the MCS-12 vs UC but not eUC. Although blended care did not differentially affect rehospitalization and mortality, it improved mood better than eUC and UC and thus may enable organized health care systems to provide effective first-line depression care to medically complex patients. Trial Registration: ClinicalTrials.gov Identifier: NCT02044211.

A Mind-Body Program for Older Adults With Chronic Low Back Pain: A Randomized Clinical Trial.

IMPORTANCE: Treatment of chronic low back pain (LBP) in older adults is limited by the adverse effects of analgesics. Effective nonpharmacologic treatment options are needed. OBJECTIVE: To determine the effectiveness of a mind-body program at increasing function and reducing pain in older adults with chronic LBP. DESIGN, SETTING, AND PARTICIPANTS: This single-blind, randomized clinical trial compared a mind-body program (n = 140) with a health education program (n = 142). Community-dwelling older adults residing within the Pittsburgh metropolitan area were recruited from February 14, 2011, to June 30, 2014, with 6-month follow-up completed by April 9, 2015. Eligible participants were 65 years or older with functional limitations owing to their chronic LBP (≥11 points on the Roland and Morris Disability Questionnaire) and chronic pain (duration ≥3 months) of moderate intensity. Data were analyzed from March 1 to July 1, 2015. INTERVENTIONS: The intervention and control groups received an 8-week group program followed by 6 monthly sessions. The intervention was modeled on the Mindfulness-Based Stress Reduction program; the control program, on the "10 Keys" to Healthy Aging. MAIN OUTCOMES AND MEASURES: Follow-up occurred at program completion and 6 months later. The score on the Roland and Morris Disability Questionnaire was the primary outcome and measured functional limitations owing to LBP. Pain (current, mean, and most severe in the past week) was measured with the Numeric Pain Rating Scale. Secondary outcomes included quality of life, pain self-efficacy, and mindfulness. Intent-to-treat analyses were conducted. RESULTS: Of 1160 persons who underwent screening, 282 participants enrolled in the trial (95 men [33.7%] and 187 women [66.3%]; mean [SD] age,74.5 [6.6] years). The baseline mean (SD) Roland and Morris Disability Questionnaire scores for the intervention and control groups were 15.6 (3.0) and 15.4 (3.0), respectively. Compared with the control group, intervention participants improved an additional -1.1 (mean, 12.1 vs 13.1) points at 8 weeks and -0.04 (mean, 12.2 vs 12.6) points at 6 months (effect sizes, -0.23 and -0.08, respectively) on the Roland and Morris Disability Questionnaire. By 6 months, the intervention participants improved on the Numeric Pain Rating Scale current and most severe pain measures an additional -1.8 points (95% CI, -3.1 to -0.05 points; effect size, -0.33) and -1.0 points (95% CI, -2.1 to 0.2 points; effect size, -0.19), respectively. The changes in Numeric Pain Rating Scale mean pain measure after the intervention were not significant (-0.1 [95% CI, -1.1 to 1.0] at 8 weeks and -1.1 [95% CI, -2.2 to -0.01] at 6 months; effect size, -0.01 and -0.22, respectively). CONCLUSIONS AND RELEVANCE: A mind-body program for chronic LBP improved short-term function and long-term current and most severe pain. The functional improvement was not sustained, suggesting that future development of the intervention could focus on durability. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01405716.

Improving mental and physical health outcomes in general healthcare settings: a Gedenkschrift in honor of Wayne Katon, MD (1950-2015).

This special article pays tribute to Wayne Katon, MD (1950-2015) with a Gedenkschrift, or review, of his prolific academic career. Abstracts of all of Dr. Katon's Medline citations were reviewed to develop a narrative of his seminal epidemiological and interventional research findings. Specifically, we describe: (a) how Dr. Katon's clinical work and observational epidemiology and health services research informed and guided interventional studies; (b) the evolution of multidisciplinary interventional trials from primary care-based psychiatric consultation to primary care-based collaborative care for depression to multicondition collaborative care; and (c) how Dr. Katon's research has informed the work of other leading researchers in the field of psychosomatic medicine and helped develop a new generation of researchers at the interface of psychiatry and primary care. For more than three decades, Dr. Katon led a multidisciplinary research team that conducted seminal epidemiological studies and randomized trials and that influenced the thinking and research in the field of psychiatry in a number of areas: (a) the importance and impact of mental disorders presenting in primary care settings and (b) the organization of effective multidisciplinary care for primary care patients with common mental disorders and comorbid medical conditions. Dr. Katon's work revolutionized the care of psychiatric illnesses in primary care and other medical care settings to the benefit of countless patients worldwide.

Value-based financially sustainable behavioral health components in patient-centered medical homes.

Because a high percentage of primary care patients have behavioral problems, patient-centered medical homes (PCMHs) that wish to attain true comprehensive whole-person care will find ways to integrate behavioral health services into their structure. Yet in today's health care environment, the incorporation of behavioral services into primary care is exceptional rather than usual practice. In this article, we discuss the components considered necessary to provide sustainable, value-added integrated behavioral health care in the PCMH. These components are to: (1) combine medical and behavioral benefits into one payment pool; (2) target complex patients for priority behavioral health care; (3) use proactive onsite behavioral "teams;" (4) match behavioral professional expertise to the need for treatment escalation inherent in stepped care; (5) define, measure, and systematically pursue desired outcomes; (6) apply evidence-based behavioral treatments; and (7) use cross-disciplinary care managers in assisting the most complicated and vulnerable. By adopting these 7 components, PCHMs will augment their ability to achieve improved health in their patients at lower cost in a setting that enhances ease of access to commonly needed services.

Treating anxiety in the presence of medical comorbidity: calmly moving forward.

Patients with chronic medical conditions (CMCs) and a comorbid anxiety or mood disorder tend to report more symptoms and experience poorer treatment outcomes compared with those without mental health comorbidity. Although the benefits to be derived from treating depression in patients with CMCs have begun to be quantified, particularly among those with cardiovascular disease, our understanding of the benefits of treating anxiety in patients with CMCs is far less developed. Improving care for patients with CMCs is one of the major challenges facing medicine today because patients with multiple chronic diseases account for most health care costs. Emerging evidence indicates that integrated or "blended" collaborative care strategies that treat both the psychiatric and physical conditions together tend to produce greater improvements in mood symptoms and control of CMCs compared with programs that target the psychiatric condition alone. We review a new report, published in this issue of Psychosomatic Medicine, from the National Institutes of Mental Health-funded multisite Coordinated Anxiety Learning and Management trial, that shines new attention on anxiety disorders and medical comorbidity. We place their findings in context with these new blended care models that are potentially more powerful, scalable, cost-effective, and readily delivered through existing CMC programs.

The design and methods of the aging successfully with pain study.

Chronic low back pain (CLBP) is widespread among older adults (≥ 65 years) and is often treated inadequately. With a rapidly growing aging population, CLBP will increase and so will the demand for treatment. We believe that mind-body therapies can help to meet this demand. We present the methodology of a randomized, controlled clinical trial of 300 individuals with CLBP aged 65 years or older. The specific aims are, 1) to determine the effectiveness of a mindfulness meditation program in increasing function and reducing pain among older adults with CLBP, and 2) to evaluate the impact of mindfulness meditation on neuropsychological performance in older adults with CLBP. The intervention program is modeled on the Mindfulness-Based Stress Reduction Program (MBSR) and the control is adapted from the 10 Keys to Healthy Aging. We will measure self-reported and objectively measured physical function and include a variety of measures to assess pain intensity and pain interference and psychological function. Our primary hypothesis is that the MBSR program will be more effective than the 10 Keys program in increasing function and decreasing pain. The proposed study represents the first large, well-controlled, comprehensive examination of the effects of a mind-body program on older adults with chronic pain.

Comorbid mental health symptoms and heart diseases: can health care and mental health care professionals collaboratively improve the assessment and management?

On the basis of current epidemiological and clinical research, this article describes how mental health symptoms are associated with heart disease, a major chronic condition that occurs primarily in middle and late life. The article describes the culturally and historically important link between heart and mind. It then describes depression and anxiety, both as manifestations of heart disease and as contributors to the disease prognosis. In addition to discussing risk factors, the article discusses factors that protect against the co-occurrence of mental health problems and heart disease such as positive attitudes, coping mechanisms, social supports, and spirituality. Further, the article highlights issues concerning the clinical assessment of mental health symptoms and interventions to address them. Finally, it summarizes the collaborative chronic care model, in which health care professionals-including medical, mental health, gerontological, and community social workers-assess and manage patients with comorbid mental health symptoms and heart disease.

A mind-body program for older adults with chronic low back pain: results of a pilot study.

OBJECTIVES: Determine the impact of an 8-week mindfulness meditation program on disability, psychological function, and pain severity in community-dwelling older adults with chronic low back pain, and to test the education control program for feasibility. DESIGN: Randomized controlled trial. Participants. Forty community-dwelling older adults with moderate low back pain or greater for at least the previous 3 months. Intervention. Participants were randomized to an 8-week meditation program or an 8-week education control program. OUTCOME MEASURES: Disability, psychological function, and pain severity were assessed. The same measures were obtained for both groups at baseline, at the end of the program, and 4 months after program completion. RESULTS: Sixteen participants (80%) completed the meditation program and 19 (95%) completed the education program. Both the meditation and control group improved on measures of disability, pain, and psychological function, both at program completion and 4-month follow-up. The differences between the two groups did not reach statistical significance. The meditation group practiced mindfulness meditation a mean of 5 days/week (range 1-7) and mean of 31 minutes/session (range 22-48). At 4 months follow-up 14/16 (88%) participants continued to meditate. CONCLUSION: Both the intervention group and the education control group improved on outcome measures suggesting both programs had a beneficial effect. Participants continued to meditate on 4-month follow-up. The control program was feasible but not inert. Piloting the control program in mind-body research can inform the design of larger clinical trials.

Translating evidence-based depression management services to community-based primary care practices.

Randomized controlled trials have demonstrated the efficacy and cost-effectiveness of using treatment models for major depression in primary care settings. Nonetheless, translating these models into enduring changes in routine primary care has proved difficult. Various health system and organizational barriers prevent the integration of these models into primary care settings. This article discusses barriers to introducing and sustaining evidence-based depression management services in community-based primary care practices and suggests organizational and financial solutions based on the Robert Wood Johnson Foundation Depression in Primary Care Program. It focuses on strategies to improve depression care in medical settings based on adaptations of the chronic care model and discusses the challenges of implementing evidence-based depression care given the structural, financial, and cultural separation between mental health and general medical care.