Collaborative Depression Care Management and Disparities in Depression Treatment and Outcomes

Abstract

Context Collaborative depression care management (DCM), by addressing barriers disproportionately affecting patients of racial/ethnic minority and low education, may reduce disparities in depression treatment and outcomes. Objective To examine the effect of DCM on treatment disparities by education and ethnicity among older depressed primary care patients. Design, Setting and Participants Analysis of data from a randomized controlled trial known as PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial). This analysis included patients from 20 primary care practices, 60 or older, and with major depression (n=396). We conducted model-based analysis to estimate potentially differential intervention effects by education, independent of those by ethnicity (and vice versa). Intervention Algorithm-based recommendations to physicians and care management by depression care managers. Main Outcome Measures Antidepressant use, depressive symptoms and intensity of DCM over 2 years Results The PROSPECT intervention had a larger and more lasting effect among less-educated patients. At month 12, the intervention increased the rate of adequate antidepressant use by 14.2 percentage points (pps) [95% confidence interval (CI): 1.7, 26.4] among the no-college group, compared with a null effect among the college-educated (−9.2 pps [95% CI: −25.0, 2.7]); at month 24, the intervention reduced depressive symptoms by 2.6 points on the Hamilton Depression Rating Scale [95% CI: −4.6, −0.4] among no-college patients, 3.8 points [95% CI: −6.8, −0.4] more than among the college group. The intervention benefitted non-Hispanic whites more than minority patients. Intensity of DCM received by minorities was 60-70% of that by whites after the initial phase, but did not differ by education. Conclusions The PROSPECT intervention substantially reduced disparities by patient education, but failed to mitigate racial/ethnic disparities, in depression treatment and outcomes. Incorporation of culturally-tailored strategies in DCM models may be needed in order to extend their benefits to minorities.

Life stressors and resources and the 23-year course of depression

“…Our results suggest that after initially seeking treatment, these individuals continue to experience a worse course of depression over a long follow-up period. Collaborative depression care management, which incorporates use of a care coordinator, has shown promise in improving depression outcomes among individuals with low education and those who experience other barriers to effective treatment (Bao et al, 2011).…”

Receipt of High Risk Medications among Elderly Enrollees in Medicare Advantage Plans

“…28 That racial minority status is associated with lower use of mental health services may also explain the slightly lower risk of HRM use in blacks and other non-white groups. [29][30][31] More research is needed to better elucidate the process by which these gender and racial differences arise.…”

Social Inequalities in Early Antidepressant Discontinuation

“…For example, programs of therapeutic education especially tailored for this population should be developed, as they have been for treatment of other illnesses (57,58). Previous American studies have shown that depression care management programs (involving a care manager who conducts patient assessment, education, follow-ups, and care coordination) can be effective in reducing social inequalities in depression treatment and outcomes (50,59); such programs should be tested elsewhere to reduce social inequalities in depression management.…”

“…General practitioners may find it more difficult to diagnose depression and assess its severity among these patients (45)(46)(47)(48)(49). Moreover, low-SES patients may manage their illness and adhere to treatment poorly; they may have a greater expectation, for example, that the drug will work immediately, although it takes several weeks for antidepressants to become effective (50). Social inequalities in patientphysician communication, as shown in other health fields (26,51,52), may worsen this situation.…”