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Appendix A Improving Recognition and Quality of Depression Care in Patients with Common Chronic Medical Illnesses Wayne J. Katon, M.D.1 INTRODUCTION Delay of harmful effects of growing older has been called “compression of morbidity” (Fries, 1980), “successful aging” (Rowe and Kahn, 1987), and “healthy aging” (Guralnik and Kaplan, 1989). Both health promotion activities and enhanced management of chronic conditions have been sug- gested as ways to improve successful or healthy aging (Von Korff et al., 2011). Health promotion activities, such as exercise, healthy diet, weight loss, and cessation of smoking, are believed to potentially enhance success- ful aging. Given the high prevalence of chronic illness in aging populations, improving guideline-based management of the most common chronic ill- nesses, such as diabetes, heart disease, asthma and chronic obstructive pul- monary disease (COPD), cancer, and depression, would also have a major public health impact in improving successful aging (Mor, 2005). Depres- sion is unique in that it is as common in the general population as these other chronic conditions but also occurs in high prevalence as a comorbid condition (Katon, 2011). Effective treatment of comorbid depression has been found to reduce functional impairment in patients with diabetes (Ell et al., 2010; Williams et al., 2004), heart disease (Lesperance et al., 2007; Rollman et al., 2009), arthritis (Lin et al., 2003), and chronic pain (Kroenke et al., 2009). However, there are major gaps in the recognition and quality 1 Professor and Vice-Chair, Department of Psychiatry & Behavioral Sciences, Box 356560, University of Washington School of Medicine, Seattle, Washington. 261
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262 LIVING WELL WITH CHRONIC ILLNESS of treatment of depression in aging populations with chronic medical illness (Katon et al., 2004a). Patients with chronic medical illness have been found to have two- to threefold higher rates of major depression compared with age- and gender- matched primary care controls (Katon, 2011). Rates of depression among primary care patients are between 5 and 10 percent (Katon and Schulberg, 1992), whereas prevalence rates of depression in patients with chronic medical illnesses, such as diabetes and coronary artery disease, have been estimated to be 12 to 18 percent (Ali et al., 2006) and 18 to 23 percent, respectively (Schleifer et al., 1989; Spijkerman et al., 2005). Rates of de- pression in complex multicondition aging populations may be as high as 25 percent (McCall et al., 2002). Studies have suggested that there is a bidirectional relationship between depression and such chronic medical illnesses as diabetes, heart disease, and COPD (Figure A-1) (Katon, 2011). Depression often develops in the teen- age years or early adulthood. Predisposing factors to depression include ge- netic factors as well as experiencing childhood adversities, such as the loss of one or both parents, neglect, and abuse (Kendler et al., 2002). Stressful life events in people with these vulnerabilities often precipitate depressive episodes (Caspi et al., 2003). Exposure to childhood adversity also often leads to problems with maladaptive attachment patterns in adult relation- ships, resulting in lack of social support and problems with interpersonal relationships (Bifulco et al., 2002). Lack of support and interpersonal prob- lems may precipitate and prolong depressive episodes (Bifulco et al., 2002). Depression in adolescence and early adulthood is associated with three health behaviors that have been estimated to cause 40 percent of premature mortality in the United States: obesity, smoking, and sedentary lifestyle (Katon et al., 2010c). Psychobiological changes that have been shown to be associated with depression, such as increased cortisol levels, sympathetic nervous system dysregulation, and increased proinflammatory factors, are likely to add to maladaptive health factors in increasing the risk of prema- ture development of chronic illness (Katon, 2011). Once chronic illness develops, comorbid depression is associated with poor self-care (DiMatteo et al., 2000; Lin et al., 2004) and increased risk of adverse outcomes (Lin et al., 2009; van Melle et al., 2004). As Figure A-1 shows, patients with comorbid depression and chronic medical illness often have problems collaborating with physicians and are less likely to adhere to self-care regimens (diet, cessation of smoking, exercise, and tak- ing medications as prescribed) (Katon, 2011). These maladaptive patterns lead to a higher risk of medical complications, increased symptom burden, and worsening function, which can then in turn precipitate or worsen de- pressive episodes. Extensive epidemiological data have shown that, after controlling for
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FIGURE A-1 Bidirectional interaction between depression and chronic medical disorders. SOURCE: Adapted and reprinted from Biological Pyschiatry, 54, Wayne J. Katon, Clinical health services and relationship between A-1.eps major depression, depressive symptoms, and general medical illness, 216–226, 2003, with permission from Elsevier. 263 bitmap, landscape
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264 LIVING WELL WITH CHRONIC ILLNESS sociodemographic factors and severity of medical illness, patients with comorbid depression and chronic medical illnesses, such as diabetes, coro- nary heart disease (CHD), COPD/asthma, and cancer, also have a higher medical symptom burden (Katon et al., 2007), additive functional impair- ment (Von Korff et al., 2005), higher medical costs (Simon et al., 2005; Sullivan et al., 2002), increased complication and hospitalization rates (Davydow et al., 2011; Lin et al., 2010; van Melle, et al., 2004), and in- creased mortality (Egede et al., 2005; Katon et al., 2005b; Lin et al., 2009, 2010; van Melle et al., 2004; Zhang et al., 2005). Figure A-2 describes the results of comorbid depression on diabetes symptom burden from a 5-year prospective study of approximately 4,800 predominately type 2 diabetes patients enrolled in a large health care system in Washington state. After controlling for sociodemographic factors and severity of medical illness, comorbid major depression in these patients was a stronger predictor of 10 symptoms on a diabetes symptom scale than was number of diabetes complications or HbA1c level (Ludman et al., 2004). In addition, in this cohort of approximately 4,800 patients with diabetes, comorbid depression was associated with more than additive functional impairment (Von Korff et al., 2005), and approximately 50 to 70 percent higher medical costs (Simon et al., 2005). Over the 5-year period, after controlling for socio- demographic factors and the baseline severity of medical illness, patients with comorbid depression and diabetes compared with those with diabetes alone had a 24 percent greater risk of macrovascular complications (Lin et al., 2010), a 36 percent greater risk of microvascular complications (Lin et al., 2010), a twofold increased risk of incident foot ulcers (Williams et al., 2010), a twofold increased risk of dementia (Katon et al., 2010b), and a 50 percent greater risk of mortality (Katon et al., 2005b; Lin et al., 2009), as seen in Table A-1. In considering ways to improve diagnosis and treatment of people with depression and chronic illnesses, it is important to recognize that these are often aging populations. The prevalence of chronic medical illness increases with each decade of life, and approximately 40 percent of Medicare benefi- ciaries have two or more chronic medical illnesses (Hoffman et al., 1996). Aging populations with depression have been found to be significantly less likely to utilize mental health services compared with younger depressed patients (Unützer et al., 2000). This is likely to be due to increased stigma regarding mental illness in aging populations, less access due to insurance issues (i.e., many private mental health specialists do not accept Medicare payments), decreased mobility due to chronic medical illnesses and func- tional decline, and less knowledge about mental illness in this population (Unützer et al., 2000; Van Citters and Bartels, 2004). Among the patients whose depression is recognized in primary care, few receive guideline-level pharmacotherapy or psychotherapy (Druss, 2004; Katon et al., 2004a).
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265 APPENDIX A FIGURE A-2 Relationship of depression and diabetes symptoms. SOURCE: Ludman et al., 2004.
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266 LIVING WELL WITH CHRONIC ILLNESS TABLE A-1 Relationship of Depression and Diabetes Symptoms Minor Depression Major Depression Microvascular Complications 1.05 (0.83, 1.33) 1.33 (1.08, 1.65) Macrovascular Complications 1.32 (0.99, 1.75) 1.38 (1.08, 1.78) Mortality (All Cause[s]) 1.23 (0.94, 1.61) 1.53 (1.19, 1.96) Foot Ulcers 1.32 (0.74, 2.35) 1.99 (1.22, 3.24) Dementia — 2.69 (1.77, 4.07) SOURCE: Katon, 2011. PUBLIC HEALTH PLATFORMS TO ENHANCE CARE OF DEPRESSION Given the high prevalence of depression in patients with chronic medi- cal illness and the decreased likelihood of accessing mental health services, it is important to consider possible “public health platforms” that could improve the likelihood of accurate diagnosis and treatment of people with depression and chronic medical illness. Because of the lack of access to traditional mental health services in aging medically ill populations, several recent reports have advocated either developing community-based outreach mental services for frail elderly with multiple chronic illnesses or integrating mental health services into primary care. These recent publications include the surgeon general’s report on men- tal health (HHS, 1999), the report by the Administration on Aging (2001), and the summary of the subcommittee of the President’s New Freedom Commission on Mental Health (Bartels, 2003). COMMUNITY-BASED PUBLIC HEALTH PLATFORMS A recent meta-analysis that evaluated face-to-face psychological ser- vices for adults ages 65 and older with mental illness identified 14 studies, including 5 randomized controlled trials (Van Citters and Bartels, 2004). An interesting finding from this systematic review compared studies that used “gatekeeper models” of recruitment, such as meter readers, building supervisors, or utility workers, with those using medical or social work personnel. Those using gatekeepers tended to identify more socially isolated elderly, such as those living alone and people more often widowed or di- vorced (Van Citters and Bartels, 2004). However, individuals identified by either gatekeepers or medical/mental health personnel had similar mental and physical health services needs. Of the 14 studies reviewed in this meta-analysis, 2 found support for using gatekeepers, such as utility workers, to identify socially isolated ag-
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267 APPENDIX A ing populations with mental illness (Florio and Raschko, 1998; Florio et al., 1998). Other researchers are piloting work with community-based organizations to educate and screen populations for depression, such as churches or adult day care centers (Chung et al., 2010). In all, 12 studies (of which only 5 were randomized controlled trials) found that home- and community-based treatment of psychiatric symptoms were associated with improved psychological status (Van Citters and Bartels, 2004). All five randomized trials (and a more recent sixth trial) reported home-based interventions were associated with improved depressive symptoms, and one reported improved overall psychological symptoms (Banerjee et al., 1996; Blanchard et al., 2002; Ciechanowski et al., 2004; Llewellyn-Jones et al., 1999; Rabins et al., 2000). This review will focus on the evidence from the randomized controlled trials, which focused on depression in socially isolated, often medically frail elderly. Many communities have developed visiting home-based services for aging patients with disabilities that limit mobility. These services are often provided by either social workers or nurses. These frail elderly have been found to have a high prevalence of major depression due to social isola- tion, chronic pain, and lack of access to medical and mental health services (McCall et al., 2002). Research has shown that depression screening that is connected to an organized treatment program, increasing exposure to evidenced-based depression treatment, can significantly improve outcomes of these patients (Banerjee et al., 1996; Blanchard et al., 2002; Ciechanowski et al., 2004; Llewellyn-Jones et al., 1999; Rabins et al., 2000). A recent study randomized 138 patients ages 60 and over with minor depression or dysthmia to the Program to Encourage Active, Rewarding Lives for Seniors (PEARLS) or usual care (Ciechanowski et al., 2004). The PEARLS intervention consisted of problem-solving treatment, social and physical activation, and potential recommendations to patients’ physi- cians regarding antidepressant medications (Ciechanowski et al., 2004). The intervention was provided by social workers who were supervised by psychiatrists employed by Aging and Disability Services, a county-funded home visiting program for frail elderly. Social workers screened clients with the Patient Health Questionnaire-2 (PHQ-2) during routine in-home visits or during telephone calls. Positive scores then led to screening with a structured psychiatric interview, and clients with either minor depression or dysthmia were offered randomization to the study intervention compared with usual care. This intervention significantly increased the percentage of patients with at least a 50 percent decrease in depressive symptoms or remission of depressive symptoms (Ciechanowski et al., 2004). Intervention patients compared with usual care controls also were found to have greater improvement in health-related quality of life and emotional well-being.
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268 LIVING WELL WITH CHRONIC ILLNESS This home-based PEARLS program was also recently tested in 80 patients with comorbid depression and epilepsy (Ciechanowski et al., 2010). Patients with epilepsy have extremely high rates of depression and markedly higher rates of suicide compared with other medical populations (Ciechanowski et al., 2010). The PEARLS intervention was delivered by master’s-level counselors and compared with usual primary care and was found to significantly decrease depressive symptoms and suicidality over a 12-month period (Ciechanowski et al., 2010). Rabins et al., examined in a randomized controlled trial the effect of a multidisciplinary care protocol and nurse-based outreach to 298 seniors living in public housing (Rabins et al., 2000). Among the six housing sites, residents in three buildings were randomized to receive the intervention and three buildings were randomized to usual care. The intervention group had significantly more improvement in overall general psychological symp- toms as well as depression symptoms compared with controls (Rabins et al., 2000). The intervention had two key components: (1) identification of potential patients by gatekeepers (managers, social workers, janitors) and (2) evaluation and treatment by a psychiatric nurse supervised by a psychia- trist. A limitation of this protocol was the lack of a standardized treatment. Llewellyn-Jones and colleagues examined the effect of a multidisci- plinary treatment program provided primarily by a general practitioner in 220 elderly people living in a residential facility (Llewellyn-Jones et al., 1999). The intervention group had significantly greater improvement in de- pressive symptoms compared with controls (Llewellyn-Jones et al., 1999). The shared care intervention program involved multidisciplinary consulta- tion and collaboration, training of several practitioners and caretakers in detection and management of depression, and depression-related health education and activity programs for residents. The control group received routine care. Blanchard and colleagues tested a screening and multidisciplinary mul- timodal intervention in 96 elderly people living at home with minor or major depression (Blanchard et al., 2002). The intervention involved a psychiatrist interview, presentation of results to a multidisciplinary geriatric psychiatry team, and a nurse interventionist working closely with a general practitioner to implement recommendations made by the team (Blanchard et al., 2002). Controls received standard or usual care. The intervention group showed greater improvement in depressive symptoms than controls at 3 months. Limitations include lack of control for baseline factors and a lag between initial assessment and the start of the intervention. Banerjee and colleagues tested a home-based intervention for depres- sion with 69 people ages 65 and over who received home care and were de- pressed (Banerjee et al., 1996). Members of the intervention group received a package of care that was developed by a community psychogeriatric team
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269 APPENDIX A and implemented by one psychiatrist. Controls received care as usual by a general practitioner. Patients in the intervention group were significantly more likely to have recovered from depression at 6 months compared with controls (Banerjee et al., 1996). The home-based programs for frail elderly that utilized nurses as case managers and/or geriatric multidisciplinary teams often also evaluated medical conditions and geriatric risk factors, such as potential for falls and poor nutrition. PRIMARY CARE PLATFORMS Large observational studies have found that severity of medical illness was a predictor of chronicity of depression symptoms in aging popula- tions with chronic medical illness (Kennedy et al., 1991). Therefore, a key research question is whether evidenced-based psychotherapeutic and phar- macological treatment approaches that have been found to be efficacious in depressed patients without chronic medical illness would be as effective in those with depression and comorbid conditions, such as diabetes, CHD, or cancer. Several systematic reviews have found that antidepressants are more effective than placebo in patients with depression and chronic medical ill- ness (Gill and Hatcher 2000; van der Feltz-Cornelis et al., 2010). Systematic reviews have also found that evidence-based psychotherapies, such as cog- nitive behavioral therapy, were more effective than supportive, nonspecific theories in treatment of depression in patients with comorbid medical ill- ness (van der Feltz-Cornelis et al., 2010). Most of these trials of antidepres- sant medication or psychotherapy were small, with fewer than 100 patients, and they often selected patients with less severe medical illness and limited psychiatric comorbidities (Gill and Hatcher, 2000; van der Feltz-Cornelis et al., 2010). A key question has been how to deliver evidence-based depression treatment to the large populations of patients with chronic conditions across a range of severity. Since most patients with comorbid depression and chronic medical illness are seen by primary care physicians and/or medical specialists, integrating depression services into these systems of care is a logical way to deliver mental health services to larger populations. Collaborative care models have been shown to be effective in improv- ing the quality of depression care and depression outcomes compared with usual primary care in a wide range of primary care populations, from adolescent (Asarnow et al., 2005) through geriatric populations (Unützer et al., 2002). Collaborative care programs integrate an allied health pro- fessional, such as a nurse or social worker, into primary care to support behavioral and pharmacological treatments initiated by primary care pro-
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270 LIVING WELL WITH CHRONIC ILLNESS viders (Gilbody et al., 2006). These allied health professionals are trained to provide patient education about common mental disorders, proactively track clinical symptoms using such rating scales as the Patient Health Ques- tionnaire-9 (PHQ-9), support adherence to medications, and provide brief evidence-based forms of psychotherapy, such as problem-solving, cognitive behavioral, or interpersonal therapy (Gilbody et al., 2006). Collaborative care teams also usually include a consulting psychiatrist who provides caseload-focused supervision for a panel of patients treated in primary care. The psychiatrist advises primary care providers about diagnostic and therapeutic approaches if patients are not improving with initial treatments, and they may provide in-person consultation for selected patients with per- sistent symptoms or diagnostic complexity. Collaborative care models have been tested in over 40 primary care–based randomized controlled trials and have been shown to be more effective than usual primary care in improving quality of depression care and depression and functional outcomes for up to 2 years (Gilbody et al., 2006). In recent years collaborative care approaches have also been tested in patients with depression and chronic medical illness. Three collaborative care trials have been completed in primary care patients with comorbid depression and diabetes (Ell et al., 2010; Katon et al., 2004b; Williams et al., 2004). In each of these trials, intervention patients were provided with a psychiatrically supervised case manager who offered an initial choice of problem-solving treatment (PST) or antidepressant medication (Ell et al., 2010; Katon et al., 2004b; Williams et al., 2004). Patients were treated with stepped care principles so if they did not respond to therapy, a medication could be added, or if they did not respond to an initial medication, another medication could be tried or PST could be added. Collaborative care was shown to improve quality of depression care, depression outcomes, func- tioning, and patient satisfaction with care compared with usual care (Ell et al., 2010; Katon et al., 2004b; Williams et al., 2004). Moreover, collabora- tive care compared with usual care was shown to be associated with savings in total medical costs in each of these three randomized controlled trials (Hays et al., 2011; Katon et al., 2006; Simon et al., 2007). The IMPACT trial randomized 1,801 aging patients with major de- pression and/or dysthymia from 8 health care organizations to collab- orative care and usual care. These patients had a mean of four chronic medical illnesses. Compared with usual primary care, collaborative care was associated with improved quality of depressive care and functional and depression outcomes over a 2-year period (Katon et al., 2005a). In IMPACT, the cost of collaborative care was offset by savings in medical costs over a 2-year period (Katon et al., 2005a). In one of the above dia- betes depression collaborative care trials and in the IMPACT trial, long- term costs were examined and showed continued cost savings for up to
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271 APPENDIX A 5 years compared with usual primary care (Katon et al., 2008a; Unützer et al., 2008). Two trials of collaborative care have also been shown to improve quality of care and outcomes in cardiac patients compared with usual care. Rollman and colleagues tested a telephone-based depression collaborative care model delivered by nurses working with patients’ primary care provid- ers to enhance antidepressant medication treatment, patient education, and behavioral activation (Rollman et al., 2009). In 302 postcoronary bypass graft patients with comorbid depression, this intervention was associated with significant improvements in depression symptoms and mental health functioning over an 8-month period compared with usual care (Rollman et al., 2009). Davidson and colleagues tested a depression collaborative care model that gave patients a choice of starting treatment with pharmaco- therapy or problem-solving treatment in 157 patients persistently depressed for 3 months after an acute coronary event (Davidson et al., 2010). Collab- orative care compared with usual primary care was shown to significantly improve depressive symptoms over a 1-year period (Davidson et al., 2010). Four collaborative care trials have also been tested in patients with co- morbid depression and cancer (Ell et al., 2008; Fann et al., 2009; Kroenke et al., 2010; Strong et al., 2008). Fann and colleagues examined results from the 215 patients with depression and cancer enrolled in the IMPACT trial (Fann et al., 2009). Patients randomized to collaborative care had significant improvements in depressive symptoms and functioning and en- hanced quality of life compared with those randomized to usual care (Fann et al., 2009). Strong and colleagues randomized 200 patients with comor- bid depression and cancer to collaborative care and usual care (Strong et al., 2008). Collaborative care involved a nurse-delivered intervention that included a choice of either problem-solving treatment or antidepressant medication provided by the patient’s primary care physician. Patients in the intervention group have improved depression, anxiety, and fatigue outcomes compared with usual care over a 12-month period (Strong et al., 2008). Kroenke and colleagues tested a collaborative care approach for 405 patients with cancer with either comorbid depression, significant persistent pain, or both (Kroenke et al., 2010). The intervention was a telephone- based care management program that provided education about pain and depression, and a stepped medication algorithm for both pain and depres- sion based on patient symptoms measured on standard scales (Kroenke et al., 2010). Nurses were supervised weekly by both pain and psychiatric specialists and medication recommendations were communicated by nurse managers to patients’ primary care physicians. Intervention patients had significant decreases in both pain and depressive symptoms compared with usual care controls over a 12-month period.
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274 LIVING WELL WITH CHRONIC ILLNESS flaws; when analyses were restricted to more robust trials, there was a moderate but nonsignificant beneficial effect of exercise compared with nonexercise control groups (Mead et al., 2008). A critique of these studies is that, although many of the enrolled patients had mild depression based on a depression rating scale score, most would not meet criteria for major depression or dysthymia. A more recent systematic review included only studies in which a clinical diagnosis of depression was made. That review found a short-term mild significant effect of exercise on depression com- pared with nonexercise control groups (Krogh et al., 2011). However, there was limited evidence of a beneficial long-term effect, with the trials lasting more than 10 weeks no longer showing significant effects. A key critique of exercise trials has been the potential lack of generaliz- ability to populations of depressed patients. Symptoms of depression, such as lack of motivation and energy, will probably limit the ability of many patients to enroll in these studies. Thus, even if exercise has a modest effect in ameliorating symptoms of depression, it is likely to have only mild effects on decreasing prevalence of serious depression in populations. Several small trials have suggested that yoga and meditation may have beneficial effects on depression. These trials need replication in larger num- bers of patients meeting criteria for major depression or dysthymia. HEALTH POLICY CHANGES THAT COULD IMPROVE QUALITY AND OUTCOMES OF DEPRESSION CARE Berwick has emphasized that major organizational changes will be nec- essary for medical care systems to adapt existing primary care and medical specialty services to optimize care of patients with chronic illnesses, such as depression or diabetes (Berwick et al., 2003). These changes include investing in clinical information systems, such as registries to help track the quality and outcomes of care in specific populations; linking these sys- tems to medical records; and designing decision support systems that will develop and implement treatment guidelines in a timely manner (Berwick et al., 2003). Organizational changes will also be needed to create delivery systems, such as depression management teams to implement more frequent systematic follow-up and monitoring of outcomes, promote integration of mental health specialty care into primary care, and develop self-manage- ment tool-kits for patients and providers. Economic incentives and regulatory changes will be needed to imple- ment these costly changes in care. As Berwick has emphasized, “For most organizations, investment on this scale is a strategic issue and will only be undertaken if the market—employers and government purchasers, princi- pally and consumers secondarily—permits and rewards these strategies” (Berwick et al., 2003).
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275 APPENDIX A Key “demand side” levers include increasing community, consumer, and employer demand for integrating evidence-based changes in systems of care, aligning financial models of care to defray the costs of reorganiz- ing health services to provide “collaborative care, and developing new Health Plan Employer Data Information Set (HEDIS) depression perfor- mance criteria that evidence suggests are linked with improved outcomes” (Katon and Seelig, 2008b). Increasing demand will necessitate education of consumer groups, employers, and insurers about cost-effective models to improve depression care, including information on how these models may decrease overall medical costs in patients with comorbid medical illnesses, such as diabetes (Katon and Seelig, 2008b). Katon and Selig have reported that “several of the research groups involved in dissemination of collabora- tive care are working with consumer groups, such as the American Associa- tion of Retired Persons (AARP), and the Depression and Bipolar Support Alliance, to lobby insurers to develop payment systems for collaborative care” (Katon and Seelig, 2008b). An innovative approach would be to have insurers help pay for the cost of training and changes in systems of care to help defray initial investment costs, since health insurers are likely to realize cost savings with collaborative care programs. Employers have also recognized the adverse impact of poor quality of care of chronic illnesses like depression on the workforce in terms of decreased productivity, absen- teeism, and disability (Stewart et al., 2003). Recent research suggests that employed patients with depression who have poor adherence to acute and continuation phase antidepressant treatment were 39 and 46 percent more likely, respectively, to file short-term disability claims (Burton et al., 2007). Wang and colleagues have shown that an innovative program combining depression screening with telephone-based collaborative depression care improved both depression outcomes and work productivity compared with usual care when implemented in a large corporation (Wang et al., 2007). Based on research demonstrating the effectiveness of collaborative care, the National Business Group on Health has recently strongly recommended implementation of payment for evidence-based collaborative care programs for depression (Finch and Phillips, 2005). In primary care systems, quality improvement efforts to integrate de- pression collaborative care programs have been hindered by lack of billing codes for the depression care manager in-person and telephone visits and time for caseload supervision by a psychiatrist. Development of Medicare billing codes for these crucial components of collaborative care could en- hance dissemination efforts of this evidence-based model. The six major insurers in Minnesota are collaborating in a quality improvement project (DIAMOND program) for depression in primary care and have developed payment models for the above components of collaborative care; early re-
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276 LIVING WELL WITH CHRONIC ILLNESS ports suggest high levels of patient recovery similar to randomized trials of collaborative care (Korsen and Pietruszewski, 2009). Changes in health insurance that provide higher payments for enhanced outcomes of populations with chronic illnesses such as depression could also enhance dissemination of collaborative care. Most collaborative care trials have enhanced clinical response to depression treatment (percentage of patients with at least 50 percent decrease in depressive symptoms) by 15 to 30 percent (Gilbody et al., 2006). However, lack of financial incentives for clinical improvement as well as difficulty billing for the mental health services utilized in collaborative care has made investment in integrating depression care managers and supervising psychiatrists difficult for systems of care. Another key policy change that could enhance dissemination of col- laborative care is to develop HEDIS performance criteria that research suggests are “tightly linked” to enhanced outcomes (Kerr et al., 2001). The current criteria include documenting the percentage of patients receiv- ing at least 3 visits in the 90 to 120 days after diagnosis and initiation of treatment in primary care as well as the percentage of patients adhering to antidepressant medications at 3 and 6 months (Druss, 2004; NCQA, 2000). These criteria have not been shown by researchers to be linked to enhanced outcomes. Moreover only 20 percent of patients across multiple systems of care actually receive the three visits that HEDIS criteria suggest are impor- tant (Druss, 2004). Many patients who are taking their antidepressant at 6 months are still on the small dosage that was started, which makes few patients better. Most patients need upward titration of medication based on measurement of depressive symptom response, and they often need a second or third medication trial before an optimum type and dosage of antidepressant is found. A performance criterion tightly linked to outcomes could be the percentage of patients with less than a 50 percent decrease in symptoms 12 weeks after initiating antidepressant treatment who re- ceive intensification of depression treatment, such as increased dosage of medication, change to a second medication, or referral for a mental health consultation. Payments to health organizations that report improvement in percentage of patients with at least a 50 percent improvement in their initial level of depressive symptoms at 3 and 6 months could also increase motivation for systems of care to integrate evidence-based models of care. PREVENTION OF DEPRESSION IN PATIENTS WITH CHRONIC MEDICAL ILLNESSES Preventive interventions to decrease incidence of depression in patients with chronic medical illness have been developed in recent years. Rovner and colleagues tested the effect of problem-solving therapy (PST) in patients
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277 APPENDIX A with macular degeneration in one eye and a recent change in vision due to macular disease in the other eye (Rovner et al., 2007). The rationale for this study was data suggesting high rates of depression in patients who developed this irreversible disease. Patients randomized to PST and usual care were found to have significantly lower incidence of depression and were less likely to have decreased function (Rovner et al., 2007). de Jonge and colleagues tested a multifaceted nurse intervention aimed at prevent- ing depression in 100 patients with diabetes or rheumatological disease (de Jonge et al., 2009). At 1-year follow-up, lower rates of incident depres- sion were found in intervention versus usual care patients (36 versus 63 percent) (de Jonge et al., 2009). Pitceathly and colleagues tested a brief psychological intervention versus usual care in a large sample of patients recently diagnosed with cancer (Pitceathly et al., 2009). Although at 12 months there were no intervention versus control differences in incident depression in the overall group (intent-to-treat analysis), among patients with a high risk of depression, a significant intervention effect was found (Pitceathly et al., 2009). Robinson and colleagues tested antidepressants versus PST versus placebo to prevent depression in 176 patients with a recent stroke (Robinson et al., 2008). Over the 12-month period, patients receiving placebo were more likely to develop depression compared with those receiving antidepressants or PST (Robinson et al., 2008). The above studies are promising, but more studies are needed. A key question will be to determine whether it is cost-effective to provide preven- tive interventions to only high-risk groups, such as those with a prior his- tory of anxiety and/or depression. Our research group has found in a 5-year longitudinal study of approximately 3,000 patients with type 2 diabetes that over 80 percent who were depressed at 5-year follow-up either had minor or major depression at baseline (Katon et al., 2009). These data and the results of the above studies suggest preventive treatment of high-risk populations may be most cost-effective. COMMUNITY APPROACHES TO IMPROVING TREATMENT OF DEPRESSION One exciting community-based effort that could be implemented to disseminate collaborative care would be for the Center for Medicare and Medicaid Innovations to develop a dissemination project to test the cost- effectiveness of collaborative care in a large region of the United States. Given the evidence that depression increases medical costs by 50 to 100 percent and that collaborative care often is associated with total medical cost savings, this would seem like a logical next step to decrease Medicare and Medicaid costs. This project could build on the effective training model used in the DIAMOND project that has improved quality and outcomes
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278 LIVING WELL WITH CHRONIC ILLNESS of depression care among primary care patients in Minnesota (Korsen and Pietruszewski, 2009). A second exciting community-based project would involve testing methods to improve mental health care for patients in federally qualified primary care clinics and the medical care of patients with chronic mental illness enrolled in community mental health systems. Funding from the Substance Abuse and Mental Health Services Administration has helped stimulate new models of care with funding for demonstration projects for these two systems to enhance coordination of mental health and physical health care. This funding has led to unique partnerships in which primary care physicians and advanced registered nurse practitioners from federally funded primary care clinics have established clinics in community mental health centers, and, in turn, mental health practitioners from community mental health centers have established clinics in federally funded primary care clinics. CONCLUSION In summary, depression and chronic medical illnesses are associated with functional decline in aging populations. Depression is two to three times more common in people with chronic conditions (Katon, 2011), but there are major gaps in recognition and quality of care for this affec- tive illness. Interventions have been developed and integrated into both community-based public health platforms and primary care platforms and have been shown in randomized controlled trials to improve depression and functional outcomes. Several of the primary care–based collaborative care intervention programs have also shown a high likelihood of total medical cost savings over a 2-year period. Key changes in reimbursement for these new models of care will need to be completed to enhance dissemination effects. REFERENCES Ali, S., M.A. Stone, J.L. Peters, M.J. Davies, and K. Khunti. 2006. The prevalence of co- morbid depression in adults with Type 2 diabetes: A systematic review and meta-analysis. Diabetic Medicine 23(11):1165–1173. AoA (Administration on Aging). 2001. Older Adults and Mental Health: Issues and Oppor- tunities. Washington, DC: Department of Health and Human Services. Asarnow, J.R., L.H. Jaycox, N. Duan, A.P. LaBorde, M.M. Rea, P. Murray, M. Anderson, C. Landon, L. Tang, and K.B. Wells. 2005. Effectiveness of a quality improvement inter- vention for adolescent depression in primary care clinics: A randomized controlled trial. Journal of American Medical Association 293(3):311–319. Banerjee, S., K. Shamash, A.J. Macdonald, and A.H. Mann. 1996. Randomised controlled trial of effect of intervention by psychogeriatric team on depression in frail elderly people at home. British Medical Journal 313(7064):1058–1061.
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