Bring It Up: An Adapted Collaborative Care Model for Depression in a Safety-net Primary Care Clinic

Abstract

Background While over 90 clinical trials demonstrate the efficacy of the collaborative care model (CCM) to treat depression in primary care, there is significant variability in real-world CCM implementation and scalability. Our objective was to determine the feasibility and effectiveness of an adapted CCM in a safety-net primary care setting. Methods Bring It Up! (BIU) is a pilot trial comparing an adapted CCM (intervention group) to usual care (historical controls) for patients with depression in a primary care safety-net clinic. Inclusion criteria: 1) age ≥ 18; 2) PHQ-9 score ≥ 10; and 3) major depressive disorder diagnosis. We included patients who completed ≥ 6 months of treatment upon rolling enrollment (4/1/18 − 10/31/19). Historical controls completed ≥ 6 months of usual care in 2017. BIU included all aspects of CCM except accountable care and leveraged existing staff rather than a dedicated care manager. Referring PCPs received evidence-based depression care training, and the team enrolled patients and delivered depression care. Usual care consisted of appointments with PCP and behavioral health staff if referred by PCP. The primary outcome was depression remission (PHQ-9 < 5) within six months. Other depression care secondary outcomes included depression response and adherence to treatment guidelines. We also collected care coordination process outcomes. Data were extracted from the electronic health record. Results Thirty-six patients received the BIU intervention; 41 controls received usual care. Depression remission was achieved in 35.3% of intervention patients and 0% of controls (p = 0.001); and 47.1% of intervention patients achieved ≥ 50% reduction in PHQ-9 compared to 9.1% of controls (p = 0.003). Further, 72.7% of intervention patients had guideline-recommended antidepressant medication titration compared to 35.5% of controls (p = 0.003); 94.4% of intervention patients had PHQ-9 repeated compared to 53.7% of controls (p < 0.001). Conclusions An adapted CCM was feasible and improved depression care in a safety-net clinic. Trial registration Retrospectively registered with UCSF IRB on 12/22/2020. UCSF IRB number: 20-31424