Implementing collaborative care to reduce depression for rural native American/Alaska native people.

BACKGROUND: The purpose of this study was to identify the effects of Collaborative Care on rural Native American and Alaska Native (AI/AN) patients. METHODS: Collaborative Care was implemented in three AI/AN serving clinics. Clinic staff participated in training and coaching designed to facilitate practice change. We followed clinics for 2 years to observe improvements in depression treatment and to examine treatment outcomes for enrolled patients. Collaborative Care elements included universal screening for depression, evidence-based treatment to target, use of behavioral health care managers to deliver the intervention, use of psychiatric consultants to provide caseload consultation, and quality improvement tracking to improve and maintain outcomes. We used t-tests to evaluate the main effects of Collaborative Care and used multiple linear regression to better understand the predictors of success. We also collected qualitative data from members of the Collaborative Care clinical team about their experience. RESULTS: The clinics participated in training and practice coaching to implement Collaborative Care for depressed patients. Depression response (50% or greater reduction in depression symptoms as measured by the PHQ-9) and remission (PHQ-9 score less than 5) rates were equivalent in AI/AN patients as compared with White patients in the same clinics. Significant predictors of positive treatment outcome include only one depression treatment episodes during the study and more follow-up visits per patient. Clinicians were overall positive about their experience and the effect on patient care in their clinic. CONCLUSIONS: This project showed that it is possible to deliver Collaborative Care to AI/AN patients via primary care settings in rural areas.

Scaling Implementation of Collaborative Care for Depression: Adaptation of the Stages of Implementation Completion (SIC).

Tools to monitor implementation progress could facilitate scale-up of effective treatments. Most treatment for depression, a common and disabling condition, is provided in primary care settings. Collaborative Care Management (CoCM) is an evidence-based model for treating common mental health conditions, including depression, in this setting; yet, it is not widely implemented. The Stages of Implementation Completion (SIC) was adapted for CoCM and piloted in eight rural primary care clinics serving adults challenged by low-income status. The CoCM-SIC accurately assessed implementation effectiveness and detected site variations in performance, suggesting key implementation activities to aid future scale-ups of CoCM for diverse populations.

Comparative effectiveness of safety planning intervention with instrumental support calls (ISC) versus safety planning intervention with two-way text message caring contacts (CC) in adolescents and adults screening positive for suicide risk in emergency departments and primary care clinics: Protocol for a pragmatic randomized controlled trial.

BACKGROUND: Suicide is a leading cause of death in adolescents and adults in the US. Follow-up support delivered when patients return home after an emergency department (ED) or primary care encounter can significantly reduce suicidal ideation and attempts. Two follow-up models to augment usual care including the Safety Planning Intervention have high efficacy: Instrumental Support Calls (ISC) and Caring Contacts (CC) two-way text messages, but they have never been compared to assess which works best. This protocol for the Suicide Prevention Among Recipients of Care (SPARC) Trial aims to determine which model is most effective for adolescents and adults with suicide risk. METHODS: The SPARC Trial is a pragmatic randomized controlled trial comparing the effectiveness of ISC versus CC. The sample includes 720 adolescents (12-17 years) and 790 adults (18+ years) who screen positive for suicide risk during an ED or primary care encounter. All participants receive usual care and are randomized 1:1 to ISC or CC. The state suicide hotline delivers both follow-up interventions. The trial is single-masked, with participants unaware of the alternative treatment, and is stratified by adolescents/adults. The primary outcome is suicidal ideation and behavior, measured using the Columbia Suicide Severity Rating Scale (C-SSRS) screener at 6 months. Secondary outcomes include C-SSRS at 12 months, and loneliness, return to crisis care for suicidality, and utilization of outpatient mental health services at 6 and 12 months. DISCUSSION: Directly comparing ISC and CC will determine which follow-up intervention is most effective for suicide prevention in adolescents and adults.

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.

Collaborative care for depression yields similar improvement among older and younger rural adults.

BACKGROUND: Depressive disorders are among the most prevalent mental health conditions; however, significant barriers to treatment access persist. This study examined differences in depression outcomes between younger and older adults in a large-scale implementation demonstration of the collaborative care model (CoCM). METHODS: Secondary data analysis of a longitudinal, observational implementation demonstration at eight primary care clinics across low-resourced rural or frontier areas of the Western United States. Seven of these clinics were federally qualified health centers. The sample consisted of 3722 younger (18-64 years) and older (65+ years) adult primary care patients diagnosed with unipolar depression. All participants received depression treatment via CoCM, which enhances usual primary care and makes efficient use of specialists by using a behavioral healthcare manager and a psychiatric consultant to support primary care providers. Clinics were followed for up to 27 months. Patients were followed until they completed treatment or dropped out. The Patient Health Questionnaire (PHQ-9) assessed depressive symptoms at baseline (enrollment) and at most follow-up contacts. The primary treatment outcome was a change between a patient's first and last recorded PHQ-9 scores. RESULTS: Across both age groups, there was an average overall reduction of 6.9 points on the PHQ-9. Older adults demonstrated a greater decrease in depression scores of 2.06 points (95% CI -2.98 to -1.14, p < 0.001) on the PHQ-9 compared with younger adults. Estimates were robust when adjusting for gender, race, and clinic. CONCLUSIONS: CoCM resulted in meaningful improvement in depressive symptoms across age groups.

Assessing the Impact of Different Depression Treatment Success Metrics on Organizational Performance.

Objective: The Patient Health Questionnaire-9 (PHQ-9) is commonly used to assess depression symptoms, but its associated treatment success criteria (i.e., metrics) are inconsistently defined. The authors aimed to analyze the impact of metric choice on outcomes and discuss implications for clinical practice and research. Methods: Analyses included three overlapping and nonexclusive time cohorts of adult patients with depression treated in 33 organizations between 2008 and 2018. Average depression improvement rates were calculated according to eight metrics. Organization-level rank orders defined by these metrics were calculated and correlated. Results: The 12-month cohort had higher rates of metrics indicating treatment success than did the 3- and 6-month cohorts; the degree of improvement varied by metric, although all organization-level rank orders were highly correlated. Conclusions: Different PHQ-9 treatment metrics are associated with disparate improvement rates. Organization-level rankings defined by different metrics are highly correlated. Consistency of metric use may be more important than specific metric choice.

Rural clinics implementing collaborative care for low-income patients can achieve comparable or better depression outcomes.

INTRODUCTION: The gap between depression treatment needs and the available mental health workforce is particularly large in rural areas. Collaborative care (CoCM) is an evidence-based approach that leverages limited mental health specialists for maximum population effect. This study evaluates depression treatment outcomes, clinical processes of care, and primary care provider experiences for CoCM implementation in 8 rural clinics treating low-income patients. METHOD: We used CoCM registry data to analyze depression response and remission then used logistic regression to model variance in depression outcomes. Primary care providers reported their experiences with this practice change 18 months following program launch. RESULTS: Participating clinics enrolled 5,187 adult patients, approximately 15% of the adult patient population. Mean PHQ-9 depression score was 16.1 at baseline and 10.9 at last individual measurement, a statistically and clinically significant improvement (SD6.7; 95% CI [4.9, 5.3]). Suicidal ideation also reduced significantly. Multivariate logistic regression predicted the probability of depression response and remission after controlling for several demographic attributes and processes of care, showing a significant amount of variance in outcomes could be explained by clinic, length of time in treatment, and age. Primary care providers reported positive experiences overall. DISCUSSION: Three quarters of participating primary care clinics, adapting CoCM for limited resource settings, exceeded depression response outcomes reported in a controlled research trial and mirrored results of large-scale quality improvement implementations. Future research should examine quality improvement strategies to address clinic-level variation and sustain improvements in clinical outcomes achieved. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Variation In The Effectiveness Of Collaborative Care For Depression: Does It Matter Where You Get Your Care?

Randomized controlled trials have demonstrated that the collaborative care model for depression in primary care is more effective than usual care, but little is known about the effectiveness of this approach in real-world settings. We used patient-reported outcome data from 11,303 patients receiving collaborative care for depression in 135 primary care clinics to examine variations in depression outcomes. The average treatment response across this large sample of clinics was substantially lower than response rates reported in randomized controlled trials, and substantial outcome variation was observed. Patient factors such as initial depression severity, clinic factors such as the number of years of collaborative care practice, and the degree of implementation support received were associated with depression outcomes at follow-up. Our findings suggest that the level of implementation support could be an important influence on the effectiveness of collaborative care model programs.

Care management for depression and osteoarthritis pain in older primary care patients: a pilot study.

OBJECTIVE: To establish the feasibility of and to generate preliminary evidence for the efficacy of a care management program addressing both physical and emotional pain associated with late-life depression and osteoarthritis. METHODS: Treatment development pilot study in three university affiliated primary care clinics. Participants were patients 60 years or older with depression and osteoarthritis pain. The intervention entailed a nurse administered care management program supporting depression and arthritis treatment by primary care physicians. Outcomes include depression, pain severity and functional impairment from pain assessed at baseline and 6 months. RESULTS: Fourteen patients participated in the pilot program. Between baseline and 6 months, mean HSCL-20 depression scores dropped from 1.78 (SD 0.56) to 1.06 (SD 0.59), a standardized effect size of 1.27 (p = 0.004). Pain intensity scores dropped from 5.67 (SD 1.69) to 4.18 (SD 1.98), an effect size of 0.88 (p = 0.021) and pain interference scores dropped from 4.91 (SD 1.75) to 3.49 (SD 2.14), an effect size of 0.81 (p = 0.013). Patients also experienced improvements in self efficacy, in satisfaction with depression care, and in timed 8-m walk and transfer tests. CONCLUSION: The combined intervention was feasible and well-received by patients. Preliminary outcomes are promising and comparisons to an earlier trial of care management for depression alone suggest that the combined program may be equally effective for depression but more effective for pain.

Women's experiences using a nipple shield.

An informal, retrospective telephone survey of 202 breastfeeding women was conducted over an 8-month period of time, assessing patients' perceptions regarding use of a silicone nipple shield. Women used the shield most frequently because of flat nipples (62%). Other reasons for shield use included the infant's disorganized suck (43%), sore nipples (23%), engorgement (15%), prematurity (12%), short frenulum (1%), and other reasons (1%). Forty-six percent of the women gave more than 1 reason for using a shield. Sixty-seven percent of the women continued to breastfeed after transitioning off the nipple shield. Median duration of nipple shield use for this group of women was 2 weeks. Thirty-three percent of the women who used the nipple shield with every breastfeeding breastfed from 1 day to 15 months. Five percent of women used the shield on only one side from 1 day to 9 months.

Effects of a mail and telephone intervention on breast health behaviors.

This study evaluated a mail and telephone intervention to improve breast health behaviors while maintaining quality of life. Women recruited from the general public were randomized to a stepped-intensity intervention consisting of mailings, telephone calls, and counseling (if requested or appropriate given a woman's genetic risk for breast cancer) or to a delayed treatment control group. Outcomes (mammography screening and quality of life) were measured at baseline in a telephone survey and again at a 12-month follow-up period. Women in the intervention group significantly increased screening mammography uptake by 12% and quality of life by 5.3 scale points compared to control participants. Changes in knowledge of breast cancer, genetic testing, and cancer worry all significantly predicted intervention changes. This successful intervention can help women make better breast health choices without causing increased worry.

Long-term cost effects of collaborative care for late-life depression.

OBJECTIVE: To determine the long-term effects on total healthcare costs of the Improving Mood: Promoting Access to Collaborative Treatment (IMPACT) program for late-life depression compared with usual care. STUDY DESIGN: Randomized controlled trial with enrollment from July 1999 through August 2001. The IMPACT trial, conducted in primary care practices in 8 delivery organizations across the United States, enrolled 1801 depressed primary care patients 60 years or older. Data are from the 2 IMPACT sites for which 4-year cost data were available. Trial enrollment across these 2 health maintenance organizations was 551 patients. METHODS: Participants were randomly assigned to the IMPACT intervention (n = 279) or to usual primary care (n = 272). Intervention patients had access to a depression care manager who provided education, behavioral activation, support of antidepressant medication management prescribed by their regular primary care provider, and problem-solving treatment in primary care for up to 12 months. Care managers were supervised by a psychiatrist and a primary care provider. The main outcome measures were healthcare costs during 4 years. RESULTS: IMPACT participants had lower mean total healthcare costs ($29 422; 95% confidence interval, $26 479-$32 365) than usual care patients ($32 785; 95% confidence interval, $27 648-$37 921) during 4 years. Results of a bootstrap analysis suggested an 87% probability that the IMPACT program was associated with lower healthcare costs than usual care. CONCLUSION: Compared with usual primary care, the IMPACT program is associated with a high probability of lower total healthcare costs during a 4-year period.

Effects of breast cancer risk counseling for sexual minority women.

Sexual minority women (lesbian and bisexual) represent a vulnerable group regarding their breast health. The participants in this study were 150 women aged 18-74 recruited via public announcements in mainstream and sexual minority communities in the greater Seattle metropolitan area. Potential participants were recruited to participate in a randomized trial of a breast cancer risk counseling intervention for sexual minority women. The counseling intervention produced significant reductions in perceived risk of breast cancer, anxieties and fears about breast cancer at 6 and 24 months, and increases in breast screening rates at 24 months in the intervention arm, compared with the control arm participants. These data add to the growing body of knowledge on sexual minority women's health and point to areas of community action and future research.

Comparing sexual minority status across sampling methods and populations.

The health of sexual minority women (SMW) has recently received research attention. Previous research into the health of SMW (e.g., lesbians, bisexuals, transgendered women) used a mixture of sampling methods, many of which were poorly documented and difficult to understand. The results of these previous studies do not present a consistent pattern of findings, possibly due to differences in sampling methods. The present study compared the characteristics ofSMWacross four survey sampling methods, three in the same geographic area. Differences were found among groups of SMW by sampling method, including in demographic data (e.g., level of education) and personal health data (e.g., rates of regular mammography screening). These findings provided a possible explanation for the variety of findings in the published literature and identified rigorous sampling methods that can be used in future research.

Comparing women of differing sexual orientations using population-based sampling.

OBJECTIVES: Area probability sampling was used to conduct a women's health survey in Boston, MA. Sexual minority women (SMW) and heterosexual adult women were compared on a variety of health-related measures. METHODS: SMW-rich census tracts were identified and mapped onto zip code boundaries. Eligible respondents were women 18 and older who lived within the defined area, who were able to complete a personal interview or self-administered questionnaire in English. Differences in significant health-related outcomes by sexual orientation were examined. RESULTS: SMW and heterosexual women differed on access to health care and utilization of screening tests. There were no significant differences in smoking rates, eating less calories or fat, and intentions to follow mammography recommendations. CONCLUSIONS: In certain respects, study results are congruent with previous non-probability surveys, while in others the results are different. It is likely that real differences exist in some health-related variables by sexual orientation category.