A Statewide Effort to Implement Collaborative Care for Depression: Reach and Impact for All Patients With Depression.

BACKGROUND: Little is known about the reach and impact of collaborative care for depression outside of clinical trials. OBJECTIVE: The objective of this study was to examine the effect of a collaborative care intervention for depression on the rates of depression diagnosis, use of specific depression codes, and treatment intensification. RESEARCH DESIGN: Evaluation of a staggered, multiple baseline implementation initiative. SUBJECTS: Patients receiving depression care in primary care clinics throughout Minnesota from February 2008 through March 2011. MEASURES: Data regarding depression diagnosis rates and codes, and measures of antidepressant intensification were provided by health insurers. RESULTS: Depression Improvement Across Minnesota: Offering a New Direction (DIAMOND) affected neither rates of depression recognition nor use of depression diagnostic codes, and the overall reach of DIAMOND was disappointingly small. Patients in DIAMOND had more episodes of treatment intensification than non-DIAMOND patients, but we were unable to account for depression severity in our analysis. CONCLUSIONS: DIAMOND did not affect depression recognition or diagnostic coding, but may have affected treatment intensification. Our results suggest that even strongly evidence-based interventions may have little contamination effects on patients not enrolled in the new care model.

Barriers to improving primary care of depression: perspectives of medical group leaders.

Using clinical trials, researchers have demonstrated effective methods for treating depression in primary care, but improvements based on these trials are not being implemented. This might be because these improvements require more systematic organizational changes than can be made by individual physicians. We interviewed 82 physicians and administrative leaders of 41 medical groups to learn what is preventing those organizational changes. The identified barriers to improving care included external contextual problems (reimbursement, scarce resources, and access to/communication with specialty mental health), individual attitudes (physician and patient resistance), and internal care process barriers (organizational and condition complexity, difficulty standardizing and measuring care). Although many of these barriers are challenging, we can overcome them by setting clear priorities for change and allocating adequate resources. We must improve primary care of depression if we are to reduce its enormous adverse social and economic impacts.

Minnesota 10 by 10. Reducing morbidity and mortality in people with serious mental illnesses.

Persons with schizophrenia, schizoaffective disorder, and bipolar affective disorder in Minnesota are dying much younger than their age- and sex-matched cohorts. A new initiative, MN 10 By 10, is designed to engage key constituencies in addressing modifiable risk factors in order to lengthen these individuals' lives.

Relationship between the presence of practice systems and the quality of care for depression.

A valid measure of practice systems for improving chronic disease care is needed as a guide for both improvement and public accountability. We tested whether a new survey measure of the presence of practice systems (the PPC-R) is associated with performance measure rates for depression among 40 medical groups in Minnesota. These PPC-R scores were compared with standardized medical group measures of antidepressant persistence. Only 54% of potentially important systems were present, and there was high variability. However, there was a positive correlation between systems and quality on the 90-day measure of antidepressant persistence, both overall (r = .33, P = .04) and for the Chronic Care Model domains of decision support (r = .38, P = .02) and delivery system redesign (r = .31, P = .05). Thus, practice systems overall and several domains of the Chronic Care Model appear to be associated with higher quality care for depression. This questionnaire may help practices identify particular systems to improve.

Facilitating Action for Suicide Prevention by Learning Health Care Systems.

The Mental Health Research Network (MHRN), funded by the National Institute of Mental Health to serve as a national laboratory to improve mental health care, includes researchers embedded in 13 health systems in 15 states. This column describes practice changes and effectiveness and exploratory research undertaken by MHRN partners when they found a sustained elevated risk of suicide attempts among patients who reported suicidal ideation on the nine-item Patient Health Questionnaire. Challenges described include finding common ground between what health care systems and funding agencies find compelling, choosing study designs that balance research and clinical tensions, and implementing studies in ways that minimize disruption to health systems. The authors conclude that the greatest benefit to working collaboratively with care system partners is the opportunity to improve care and to simultaneously measure the impact of change.

Follow-up and follow-through of depressed patients in primary care: the critical missing components of quality care.

Certainly we could improve our identification, diagnosis, and initial treatment approaches to the large numbers of depressed patients we see in primary care. However, until we have established the kind of systematic follow-up and follow-through that the US Preventive Services Task Force said is a prerequisite for its recommendation to routinely screen for depression, none of these earlier actions will make much difference. Recently, a number of controlled trials of innovative approaches to care management have demonstrated clearly how much patient outcomes are improved when systematic follow-up is in place. The problem is that there are few examples of such systems in real clinical practices. This article describes the main components of such a systematic approach.