Collaborative Care for Patients with Depression and Chronic Illnesses

Abstract

BACKGROUND Patients with depression and poorly controlled diabetes, coronary heart disease, or both have an increased risk of adverse outcomes and high health care costs. We conducted a study to determine whether coordinated care management of multiple conditions improves disease control in these patients. METHODS We conducted a single-blind, randomized, controlled trial in 14 primary care clinics in an integrated health care system in Washington State, involving 214 participants with poorly controlled diabetes, coronary heart disease, or both and coexisting depression. Patients were randomly assigned to the usual-care group or to the intervention group, in which a medically supervised nurse, working with each patient’s primary care physician, provided guideline-based, collaborative care management, with the goal of controlling risk factors associated with multiple diseases. The primary outcome was based on simultaneous modeling of glycated hemoglobin, low-density lipoprotein (LDL) cholesterol, and systolic blood-pressure levels and Symptom Checklist–20 (SCL-20) depression outcomes at 12 months; this modeling allowed estimation of a single overall treatment effect. RESULTS As compared with controls, patients in the intervention group had greater overall 12-month improvement across glycated hemoglobin levels (difference, 0.58%), LDL cholesterol levels (difference, 6.9 mg per deciliter [0.2 mmol per liter]), systolic blood pressure (difference, 5.1 mm Hg), and SCL-20 depression scores (difference, 0.40 points) (P<0.001). Patients in the intervention group also were more likely to have one or more adjustments of insulin (P = 0.006), antihypertensive medications (P<0.001), and antidepressant medications (P<0.001), and they had better quality of life (P<0.001) and greater satisfaction with care for diabetes, coronary heart disease, or both (P<0.001) and with care for depression (P<0.001). CONCLUSIONS As compared with usual care, an intervention involving nurses who provided guideline-based, patient-centered management of depression and chronic disease significantly improved control of medical disease and depression. (Funded by the National Institute of Mental Health; ClinicalTrials.gov number, NCT00468676.)

Associations Between Antidepressant Adherence and Shared Decision-Making, Patient–Provider Trust, and Communication Among Adults with Diabetes: Diabetes Study of Northern California (DISTANCE)

“…Research has shown that adherence to antidepressant medications is improved when treatment is provided in the context of a team-based collaborative care model. 32,33 Our findings are consistent with research demonstrating that models of care that are effective in improving antidepressant adherence provide opportunities for an enhanced relationship between a patient and his/her primary care team through frequent contacts, outreach, and support by care managers, as well as psychoeducation and care coordination. An extension of the chronic care model, the 'health literate care model', applies a 'universal precautions' framework in advocating for the institutionalization of practices at both the level of individual providers and the healthcare system, many of which are intended to promote trust and foster improved patient-provider relationships.…”

Provider Patient-Sharing Networks and Multiple-Provider Prescribing of Benzodiazepines

“…Patients with psychiatric illness often present with other medical conditions; the need for an integrated care approach that promotes collaboration among psychiatrists, PCPs, and other medical professionals caring for these patients is well recognized. 29,30 One strategy that has been proven effective in a number of randomized controlled trials is a collaborative care plan that implements active follow-up by a non-physician care manager or nurse, who proactively monitors patients' progress and facilitates care coordination with their physicians. [30][31][32] While the initial costs of setting up such an intervention may be high, in the long term, they are offset by the reduced need for medical care.…”

Symptoms of Depression in Survivors of Severe Sepsis: A Prospective Cohort Study of Older Americans

“…Furthermore, since premorbid depression appears to convey considerable risk for substantial symptoms of depression in the aftermath of severe sepsis, hospital programs that target older patients surviving severe sepsis with a prior history of depression—whether or not formally diagnosed—for careful monitoring of their subsequent mental health may improve outcomes. Studies of interventions that combine screening and treatment for comorbid depression and medical conditions in older adults have demonstrated reductions in depressive symptoms, 62 as well as improved physical functioning and medical outcomes. 62,63 …”

“…Studies of interventions that combine screening and treatment for comorbid depression and medical conditions in older adults have demonstrated reductions in depressive symptoms, 62 as well as improved physical functioning and medical outcomes. 62,63 …”