Managing depression in primary care.
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Counseling↗
Biomedical subjects
G E Simon
Publications and source records attributed to G E Simon.
Cost-effectiveness of systematic depression treatment for high utilizers of general medical care.
BACKGROUND: Expanding access to high-quality depression treatment will depend on the balance of incremental benefits and costs. We examine the incremental cost-effectiveness of an organized depression management program for high utilizers of medical care. METHODS: Computerized records at 3 health maintenance organizations were used to identify adult patients with outpatient medical visit rates above the 85th percentile for 2 consecutive years. A 2-step screening process identified patients with current depressive disorders, who were not in active treatment. Eligible patients were randomly assigned to continued usual care (n = 189) or to an organized depression management program (n = 218). The program included patient education, antidepressant pharmacotherapy initiated in primary care (when appropriate), systematic telephone monitoring of adherence and outcomes, and psychiatric consultation as needed. Clinical outcomes (assessed using the Hamilton Depression Rating Scale on 4 occasions throughout 12 months) were converted to measures of "depression-free days." Health services utilization and costs were estimated using health plan-standardized claims. RESULTS: The intervention program led to an adjusted increase of 47.7 depression-free days throughout 12 months (95% confidence interval [CI], 28.2-67.8 days). Estimated cost increases were $1008 per year (95% CI, $534-$1383) for outpatient health services, $1974 per year for total health services costs (95% CI, $848-$3171), and $2475 for health services plus time-in-treatment costs (95% CI, $880-$4138). Including total health services and time-in-treatment costs, estimated incremental cost per depression-free day was $51.84 (95% CI, $17.37-$108.47). CONCLUSIONS: Among high utilizers of medical care, systematic identification and treatment of depression produce significant and sustained improvements in clinical outcomes as well as significant increases in health services costs.
Ambulatory Care↗
Treatment process and outcomes for managed care patients receiving new antidepressant prescriptions from psychiatrists and primary care physicians.
BACKGROUND: While many studies describe deficiencies in primary care antidepressant treatment, little research has applied similar standards to psychiatric practice. This study compares baseline characteristics, process of care, and outcomes for managed care patients who received new antidepressant prescriptions from psychiatrists and primary care physicians. METHODS: At a prepaid health plan in Washington State, patients receiving initial antidepressant prescriptions from psychiatrists (n = 165) and primary care physicians (n = 204) completed a baseline assessment, including the Structured Clinical Interview for DSM-IV depression module, a 20-item depression assessment from the Symptom Checklist-90, and the Medical Outcomes Survey 36-Item Short-Form Health Survey functional status questionnaire. All measures were repeated after 2 and 6 months. Computerized data were used to assess antidepressant refills and follow-up visits over 6 months. RESULTS: At baseline, psychiatrists' patients reported slightly higher levels of functional impairment and greater prior use of specialty mental health care. During follow-up, psychiatrists' patients made more frequent follow-up visits, and the proportion making 3 or more visits in 90 days was 57% vs 26% for primary care physicians' patients. The proportion receiving antidepressant medication at an adequate dose for 90 days or more was similar (49% vs 48%). The 2 groups showed similar rates of improvement in all measures of symptom severity and functioning. CONCLUSIONS: In this sample, clinical differences between patients treated by psychiatrists and primary care physicians were modest. Shortcomings in depression treatment frequently noted in primary care (inadequate follow-up care and high rates of inadequate antidepressant treatment) were also common in specialty practice. Possible selection bias limits any conclusions about relative effectiveness or cost-effectiveness.
Adult↗
A cross-national study of the course of persistent pain in primary care.
Data from the World Health Organization's study of psychological problems in general health care were used to examine the course of persistent pain syndromes among primary care patients. Across 15 sites in 14 countries, 3197 randomly selected primary care patients completed baseline and 12-month follow-up assessments of pain, other somatic symptoms, and anxiety and depressive disorders (the Composite International Diagnostic Interview), and an assessment of occupational role disability (the Social Disability Schedule). Of patients with a persistent pain condition at baseline, 49% had not recovered 12 months later. The probability of non-recovery varied significantly across study centers and was significantly associated with the number of pain sites at baseline. After adjustment for age, sex, and study center, baseline anxiety or depressive disorder did not predict non-recovery of persistent pain. Among those without a persistent pain disorder at baseline, the rate of onset was 8.8% with a significant variability in risk across centers. The baseline characteristics predicting the onset of persistent pain disorder were psychological disorder, poor self-rated health, and occupational role disability. A persistent pain disorder at baseline predicted the onset of a psychological disorder to the same degree that a baseline psychological disorder predicted the subsequent onset of persistent pain. Persistent pain conditions are common among primary care patients, and the probability of resolution over 12 months is approximately 50%. We found a strong and symmetrical relationship between persistent pain and psychological disorder. Impairment of daily activities appears to be a central component of that relationship.
Adult↗
Does physician education on depression management improve treatment in primary care?
OBJECTIVE: To assess the effect of physician training on management of depression. DESIGN: Primary care physicians were randomly assigned to a depression management intervention that included an educational program. A before-and-after design evaluated physician practices for patients not enrolled in the intervention trial. SETTING: One hundred nine primary care physicians in 2 health maintenance organizations located in the Midwest and Northwest regions of the United States. PATIENTS/PARTICIPANTS: Computerized pharmacy and visit data from a group of 124,893 patients who received visits or prescriptions from intervention and usual care physicians. INTERVENTIONS: Primary care physicians received education on diagnosis and optimal management of depression over a 3-month training period. Methods of education included small group interactive discussions, expert demonstrations, role-play, and academic detailing of pharmacotherapy, criteria for urgent psychiatric referrals, and case reviews with psychiatric consultants. MEASUREMENTS AND MAIN RESULTS: Pharmacy and visit data provided indicators of physician management of depression: rate of newly diagnosed depression, new prescription of antidepressant medication, and duration of pharmacotherapy. One year after the training period, intervention and usual care physicians did not differ significantly in the rate of new depression diagnosis (P =.95) or new prescription of antidepressant medicines (P =.10). Meanwhile, patients of intervention physicians did not differ from patients of usual care physicians in adequacy of pharmacotherapy (P =.53) as measured by 12 weeks of continuous antidepressant treatment. CONCLUSIONS: After education on optimal management of depression, intervention physicians did not differ from their usual care colleagues in depression diagnosis or pharmacotherapy.
Adult↗
Depression and work productivity: the comparative costs of treatment versus nontreatment.
This article discusses the impact of depression on work productivity and the potential for improved work performance associated with effective treatment. We undertook a review of the literature by means of a computer search using the following key terms: cost of illness, work loss, sickness absence, productivity, performance, and disability. Published works were considered in four categories: (1) naturalistic cross-sectional studies that found greater self-reported work impairment among depressed workers; (2) naturalistic longitudinal studies that found a synchrony of change between depression and work impairment; (3) uncontrolled treatment studies that found reduced work impairment with successful treatment; and (4) controlled trials that usually, but not always, found greater reduction in work impairment among treated patients. Observational data suggest that productivity gains following effective depression treatment could far exceed direct treatment costs. Randomized effectiveness trials are needed before we can conclude definitively that depression treatment results in productivity improvements sufficient to offset direct treatment costs.
Absenteeism↗
Treating depression in patients with chronic disease: recognition and treatment are crucial; depression worsens the course of a chronic illness.
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Chronic Disease↗
Cost-effectiveness of a collaborative care program for primary care patients with persistent depression.
OBJECTIVE: The authors evaluated the incremental cost-effectiveness of stepped collaborative care for patients with persistent depressive symptoms after usual primary care management. METHOD: Primary care patients initiating antidepressant treatment completed a standardized telephone assessment 6-8 weeks after the initial prescription. Those with persistent major depression or significant subthreshold depressive symptoms were randomly assigned to continued usual care or collaborative care. The collaborative care included systematic patient education, an initial visit with a consulting psychiatrist, 2-4 months of shared care by the psychiatrist and primary care physician, and monitoring of follow-up visits and adherence to medication regimen. Clinical outcomes were assessed through blinded telephone assessments at 1, 3, and 6 months. Health services utilization and costs were assessed through health plan claims and accounting data. RESULTS: Patients receiving collaborative care experienced a mean of 16.7 additional depression-free days over 6 months. The mean incremental cost of depression treatment in this program was $357. The additional cost was attributable to greater expenditures for antidepressant prescriptions and outpatient visits. No offsetting decrease in use of other health services was observed. The incremental cost-effectiveness was $21.44 per depression-free day. CONCLUSIONS: A stepped collaborative care program for depressed primary care patients led to substantial increases in treatment effectiveness and moderate increases in costs. These findings are consistent with those of other randomized trials. Improving outcomes of depression treatment in primary care requires investment of additional resources, but the return on this investment is comparable to that of many other widely accepted medical interventions.
Adult↗
Managing depression in medical outpatients.
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Algorithms↗
Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care.
OBJECTIVE: To test the effectiveness of two programmes to improve the treatment of acute depression in primary care. DESIGN: Randomised trial. SETTING: Primary care clinics in Seattle. PATIENTS: 613 patients starting antidepressant treatment. INTERVENTION: Patients were randomly assigned to continued usual care or one of two interventions: feedback only and feedback plus care management. Feedback only comprised feedback and algorithm based recommendations to doctors on the basis of data from computerised records of pharmacy and visits. Feedback plus care management included systematic follow up by telephone, sophisticated treatment recommendations, and practice support by a care manager. MAIN OUTCOME MEASURES: Blinded interviews by telephone 3 and 6 months after the initial prescription included a 20 item depression scale from the Hopkins symptom checklist and the structured clinical interview for the current DSM-IV depression module. Visits, antidepressant prescriptions, and overall use of health care were assessed from computerised records. RESULTS: Compared with usual care, feedback only had no significant effect on treatment received or patient outcomes. Patients receiving feedback plus care management had a higher probability of both receiving at least moderate doses of antidepressants (odds ratio 1.99, 95% confidence interval 1.23 to 3.22) and a 50% improvement in depression scores on the symptom checklist (2.22, 1.31 to 3.75), lower mean depression scores on the symptom checklist at follow up, and a lower probability of major depression at follow up (0.46, 0.24 to 0.86). The incremental cost of feedback plus care management was about $80 ( pound50) per patient. CONCLUSIONS: Monitoring and feedback to doctors yielded no significant benefits for patients in primary care starting antidepressant treatment. A programme of systematic follow up and care management by telephone, however, significantly improved outcomes at modest cost.
Acute Disease↗
Randomized trial of a depression management program in high utilizers of medical care.
BACKGROUND: High utilizers of nonpsychiatric health care services have disproportionally high rates of undiagnosed or undertreated depression. OBJECTIVE: To determine the impact of offering a systematic primary care-based depression treatment program to depressed "high utilizers" not in active treatment. DESIGN: Randomized clinical trial. SETTING: One hundred sixty-three primary care practices in 3 health maintenance organizations located in different geographic regions of the United States. PATIENTS: A group of 1465 health maintenance organization members were identified as depressed high utilizers using a 2-stage telephone screening process. Eligibility criteria were met by 410 patients and 407 agreed to enroll: 218 in the depression management program (DMP) practices and 189 in the usual care (UC) group. INTERVENTION: The DMP included patient education materials, physician education programs, telephone-based treatment coordination, and antidepressant pharmacotherapy initiated and managed by patients' primary care physicians. MAIN OUTCOME MEASURES: Depression severity was measured using the Hamilton Depression Rating Scale (Ham-D) and functional status using the Medical Outcomes Study 20-item short form (SF-20) subscales. Outpatient visit and hospitalization rates were measured using the health plan's encounter data. RESULTS: Based on an intent-to-treat analysis, at least 3 antidepressant prescriptions were filled in the first 6 months by 151 (69.3%) of 218 of DMP patients vs 35 (18.5%) of 189 in UC (P < .001). Improvements in Ham-D scores were significantly greater in the intervention group at 6 weeks (P = .04), 3 months (P = .02), 6 months (P < .001), and 12 months (P < .001). At 12 months, DMP intervention patients were more improved than UC patients on the mental health, social functioning, and general health perceptions scales of the SF-20 (P < .05 for all). CONCLUSION: In depressed high utilizers not already in active treatment, a systematic primary care-based treatment program can substantially increase adequate antidepressant treatment, decrease depression severity, and improve general health status compared with usual care.
Antidepressive Agents↗
Large medical databases, population-based research, and patient confidentiality.
OBJECTIVE: This article is a discussion of the use of large clinical databases in population-based research on psychiatric disorders. METHOD: The authors review uses of large clinical databases in research on the etiology, impact, and treatment of psychiatric disorders. They also describe existing privacy safeguards applicable to use of medical records data in research. RESULTS: The growth of large medical databases has prompted increasing concern about the confidentiality of patient records. Efforts to restrict access to computerized medical data, however, may preclude use of such data in important and legitimate research. Prior research using large medical databases has made important contributions across a broad range of topics, including epidemiology, genetics, treatment effectiveness, and health policy. Continued population-based research will be essential in order to preserve the accessibility and quality of treatment for people with psychiatric disorders. CONCLUSIONS: Public domain research should be distinguished from proprietary or commercial uses of health information, and existing privacy safeguards should be vigorously applied. In our efforts to protect patient privacy, however, we should take care not to endorse or reinforce prejudices against psychiatric treatment and people who suffer from psychiatric disorders. Neither should we ignore important opportunities to improve quality of care and influence public policy through population-based research.
Confidentiality↗
Long-term prognosis of depression in primary care.
This article uses longitudinal data from a primary care sample to examine long-term prognosis of depression. A sample of 225 patients initiating antidepressant treatment in primary care completed assessments of clinical outcome (Hamilton Depression Rating Scale and the mood module of the Structured Clinical Interview for DSM-IIIR) 1, 3, 6, 9, 12, 18 and 24 months after initiating treatment. The proportion of patients continuing to meet criteria for major depression fell rapidly to approximately 10% and remained at approximately that level throughout follow-up. The proportion meeting criteria for remission (Hamilton Depression score of 7 or less) rose gradually to approximately 45%. Long-term prognosis (i.e. probability of remission at 6 months and beyond) was strongly related to remission status at 3 months (odds ratio 3.65; 95% confidence interval, 2.81-4.76) and only modestly related to various clinical characteristics assessed at baseline (e.g. prior history of recurrent depression, medical comorbidity, comorbid anxiety symptoms). The findings indicate that potentially modifiable risk factors influence the long-term prognosis of depression. This suggests that more systematic and effective depression treatment programmes might have an important effect on long-term course and reduce the overall burden of chronic and recurrent depression.
Adolescent↗
An international study of the relation between somatic symptoms and depression.
BACKGROUND AND METHODS: Patients with depression, particularly those seen by primary care physicians, may report somatic symptoms, such as headache, constipation, weakness, or back pain. Some previous studies have suggested that patients in non-Western countries are more likely to report somatic symptoms than are patients in Western countries. We used data from the World Health Organization's study of psychological problems in general health care to examine the relation between somatic symptoms and depression. The study, conducted in 1991 and 1992, screened 25,916 patients at 15 primary care centers in 14 countries on 5 continents. Of the patients in the original sample, 5447 underwent a structured assessment of depressive and somatoform disorders. RESULTS: A total of 1146 patients (weighted prevalence, 10.1 percent) met the criteria for major depression. The range of patients with depression who reported only somatic symptoms was 45 to 95 percent (overall prevalence, 69 percent; P=0.002 for the comparison among centers). A somatic presentation was more common at centers where patients lacked an ongoing relationship with a primary care physician than at centers where most patients had a personal physician (odds ratio, 1.8; 95 percent confidence interval, 1.2 to 2.7). Half the depressed patients reported multiple unexplained somatic symptoms, and 11 percent denied psychological symptoms of depression on direct questioning. Neither of these proportions varied significantly among the centers. Although the overall prevalence of depressive symptoms varied markedly among the centers, the frequencies of psychological and physical symptoms were similar. CONCLUSIONS: Somatic symptoms of depression are common in many countries, but their frequency varies depending on how somatization is defined. There is substantial variation in how frequently patients with depression present with strictly somatic symptoms. In part, this variation may reflect characteristics of physicians and health care systems, as well as cultural differences among patients.
Adult↗
Stability of somatization disorder and somatization symptoms among primary care patients.
BACKGROUND: Diagnostic criteria for somatization disorder emphasize its early onset and long-term stability. Research assessments of somatization disorder depend on lifetime recall of medically unexplained somatic symptoms. METHODS: Longitudinal data from the World Health Organization Psychological Problems in General Health Care study were used to examine stability of somatization disorder and somatization symptoms over 12 months. At 15 study sites in 14 countries, consecutive primary care patients (N = 25916) were screened using the 12-item General Health Questionnaire. A stratified random sample (n = 5447) was selected for a baseline diagnostic assessment using the Composite International Diagnostic Interview. All cases and a random sample of noncases were asked to complete a follow-up diagnostic assessment 12 months later (n = 3196). RESULTS: While the baseline and 12-month interviews identified a similar number of patients with DSM-IV somatization disorder (74 and 70), only 21 cases were consistently identified at both assessments. Examination of individual symptoms found that 61% of lifetime medically unexplained somatic symptoms detected at baseline were not detected during the lifetime interview 12 months later. When analyses were broadened to all lifetime symptoms reported at baseline (including those found to be "medically explained" or "not clinically significant"), 43% of lifetime symptoms reported at baseline were "lost" 12 months later. CONCLUSIONS: Given that the baseline and follow-up assessments both asked about lifetime symptoms, the loss of somatization disorder or individual somatic symptoms can only represent inconsistent recall. The instability of recall observed here has significant implications for the diagnosis of somatization disorder by structured interview and may also have implications for current diagnostic criteria.
Adolescent↗
The natural history of somatization in primary care.
BACKGROUND: Somatization is often regarded as a chronic disorder. However, empirical studies to support this view and to determine its natural history in primary care are lacking. This paper provides data on the incidence and persistence of current somatization syndrome in a large cross-national sample drawn from 15 sites in 14 countries. METHODS: After screening with the General Health Questionnaire, a stratified sample of 5438 primary care patients was interviewed with the Composite International Diagnostic Interview and evaluated for physical health status, self-rated overall health and for occupational disability. Twelve months later, 3204 of the patients completed follow-up interviews. RESULTS: Over a 12-month period, an abridged form of somatization defined as four current symptoms in males and six in females was persistent in 45.9% of the patients. Persistence of syndrome was related to age and to subjective indices of psychological distress at baseline. Persistence was unrelated to depression. The 12-month incidence of the abridged somatization syndrome was 7.1% (95% CI, 6.1-8.3%). Individuals with depression at baseline and those with poor view of their health were more likely to develop new episodes of somatization 12-months later. CONCLUSION: Somatization syndrome showed considerable change over time. Persistence and onset of somatization were related to both level of psychopathology and health beliefs.
Adolescent↗
Depression among high utilizers of medical care.
OBJECTIVE: To determine the prevalence of unrecognized or unsuccessfully treated depression among high utilizers of medical care, and to describe the relation between depression, medical comorbidities, and resource utilization. DESIGN: Survey. SETTING: Three HMOs located in different geographic regions of the United States. PATIENTS: A total of 12,773 HMO members were identified as high utilizers. Eligibility criteria for depression screening were met by 10,461 patients. MEASUREMENTS AND MAIN RESULTS: Depression status was assessed with the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders. Fourth Edition. Depression screening was completed in 7,203 patients who were high utilizers of medical care, of whom 1,465 (20.3%) screened positive for current major depression or major depression in partial remission. Among depressed patients, 621 (42.4%) had had a visit with a mental health specialist or a diagnosis of depression or both within the previous 2 years. The prevalence of well-defined medical conditions was the same in patients with and patients without evidence of depression (41.5% vs 41.5%, p = .87). However, high-utilizing patients who had not made a visit for a nonspecific complaint during the previous 2 years were at significantly lower risk of depression (13.1% vs 22.4%, p < .001). Patients with current depression or depression in partial remission had significantly higher numbers of annual office visits and hospital days per 1,000 than patients without depression. CONCLUSIONS: Although there was evidence that mental health problems had previously been recognized in many of the patients, a large percentage of high utilizers still suffered from active depression that either went unrecognized or was not being treated successfully. Patients who had not made visits for nonspecific complaints were at significantly lower risk of depression. Depression among high utilizers was associated with higher resource utilization.
Comorbidity↗