Collaborative Care Management of Late-Life Depression in the Primary Care Setting

Unützer, Jürgen; Katon, Wayne; Callahan, Christopher M.; Williams, John W; Hunkeler, Enid M.; Harpole, Linda H.; Hoffing, Marc; Penna, Richard Della; Noël, Polly Hitchcock; Lin, Elizabeth; Areán, Patricia A.; Hegel, Mark T.; Tang, Lingqi; Belin, Thomas R.; Oishi, Sabine; Langston, Christopher A.

doi:10.1001/jama.288.22.2836

Cited by 2,161 publications

(1,800 citation statements)

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“…This rate closely approximates retention in collaborative care research trials. (1, 3, 4, 27) Moreover, our survival models accounted for attrition in constructing estimates of outcomes over time.…”

Section: Discussionmentioning

confidence: 99%

“…(1–6) The IMPACT trial, one exemplar of collaborative care, demonstrated significant improvement in depression outcomes among elderly patients with cost savings in the long-term. (3) These promising results have engendered considerable national interest in the dissemination of integrated models, and the corresponding need to understand how to implement such models in real-world settings. (7, 8) Presently, little is known about the care provided or the outcomes achieved when such models are adopted by community-based practices, particularly those in resource-poor settings.…”

Section: Introductionmentioning

confidence: 99%

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Implementation of Collaborative Depression Management at Community-Based Primary Care Clinics: An Evaluation

Bauer¹,

Azzone²,

Goldman³

et al. 2011

Psychiatric Services

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Objective This study evaluates a large demonstration project of collaborative care in community health centers by examining the role of clinic site on measures of the implementation process and on clinical outcomes that are not accounted for by characteristics of the patients served. Methods This quasi-experimental study examines data on the treatment of 2821 patients over three years at six organizations that implemented collaborative depression care. Outcome data included two quality indicators (receipt of early follow-up or appropriate pharmacotherapy) and depression improvement (50% reduction in PHQ-9 score or PHQ-9 score ≤ 5). Results Multivariate logistic regression models revealed significant differences across clinics in the probability of receiving early follow-up (.34 to .88) or appropriate pharmacotherapy (.27 to .69); or experiencing improvement (.36 to .84) after adjustment for patient characteristics. Similarly, Cox proportional hazards models revealed that time to improvement differed significantly across clinics (p ≤ 0.0001) after adjusting for patient characteristics. Conclusions Across all sites, a plurality of patients achieved meaningful improvement in depression and in many sites improvement occurred rapidly. Despite receiving similar training and resources, organizations exhibited substantial variability in their ability to enact change in clinical care systems, as evidenced by both quality indicators and outcomes. Although we cannot conclude that performance on quality indicators caused improved outcomes, those sites that performed better had better outcomes, differences that were not attributable to patient characteristics.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Implementation of Collaborative Depression Management at Community-Based Primary Care Clinics: An Evaluation

Bauer¹,

Azzone²,

Goldman³

et al. 2011

Psychiatric Services

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“…For example, only 40-50% of older adults respond to the first prescribed antidepressant medication. 24-25 In those that do respond, response is often slow, sometimes taking up to 4 months 26 and once response is achieved, relapse and recurrence are common. Approximately 60% of community-dwelling older adults with MDD who initially responded to antidepressant treatment became depressed again within 2 years unless they were maintained on antidepressant pharmacotherapy.…”

Section: Late-life Depression: Definition Extent Burden and Hopementioning

confidence: 99%

The Age-by-Disease Interaction Hypothesis of Late-Life Depression

McKinney

Sibille

2013

The American Journal of Geriatric Psychiatry

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The phenomenological diagnosis of depression is successful in increasing diagnostic reliability, but it is a classification scheme without biological bases. One subtype of depression for which evidence suggests a unique biological basis is late-life depression (LLD), with first onset of symptoms after the age of 65. LLD is common and poses a significant burden on affected individuals, caretakers, and society. The pathophysiology of LLD includes disruptions of the neural network underlying mood, which can be conceptualized as the result of dysfunction in multiple underlying biological processes. Here, we briefly review current LLD hypotheses and then describe the characteristics of molecular brain aging and their overlap with disease processes. Further, we propose a new hypothesis for LLD, the Age-by-Disease Interaction hypothesis, which posits that the clinical presentation of LLD is the integrated output of specific biological processes that are pushed in LLD-promoting directions by changes in gene expression naturally occurring during brain aging, hence leading the brain to a physiological state that is more susceptible to LLD, since additional pushes by genetic, environmental and biochemical factors may now be sufficient to generate dysfunctional states that produce depressive symptoms. We put our propositions together into a decanalization model to aid in illustrating how age-related biological changes of the brain can shift the repertoire of available functional states in a pro-depression direction, and how additional factors can readily lead the system into distinct and stable maladaptive phenotypes, including LLD. This model brings together basic research on neuropsychiatric and neurodegenerative diseases more closely with the investigation of normal aging. Specifically, identifying biological processes affected during normal aging may inform the development of new interventions for the prevention and treatment of LLD.

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“…82 Organized follow-up programs that include patient education, telephone or in-person contact every 2 to 4 weeks, monitoring of medication adherence, and psychiatric consultation as necessary improve outcomes for depressed cardiac patients. [83][84][85][86] "Measurement-based care," which uses frequent ratings of symptoms and adverse effects to guide dose adjustments and changes in treatment, can also be of benefit. 87 If antidepressant medication does not improve symptoms by 4 weeks and adverse effects are tolerable, the initial medication dose should be doubled.…”

Section: How Should Cardiac Patients Be Followed Up After Initiatingmentioning

confidence: 99%

Depression and Cardiovascular Disease

Whooley¹

2006

JAMA

218

163

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Major depressive disorder is a risk factor for the development of incident coronary heart disease events in healthy patients and for adverse cardiovascular outcomes in patients with established heart disease. Depression is present in 1 of 5 outpatients with coronary heart disease and in 1 of 3 outpatients with congestive heart failure, yet the majority of cases are not recognized or appropriately treated. It is not known whether treating depression improves cardiovascular outcomes, but antidepressant treatment with selective serotonin reuptake inhibitors is generally safe, alleviates depression, and improves quality of life. This article evaluates the importance of major depression in patients with cardiovascular disease, and provides practical guidance for identifying and treating this disorder. CASE PRESENTATIONA 58-year-old man with a history of coronary heart disease (CHD), type 2 diabetes mellitus, hypertension, smoking, and alcohol dependence presented for routine medical care. He had initially sought medical attention for exertional angina 5 years previously, at which time he underwent exercise treadmill testing with thallium that was positive for reversible perfusion defects in the anterior, septal, and inferior walls. Subsequent coronary angiography revealed diffuse heavy calcifications in the left anterior descending artery with a moderate lesion prior to the first diagonal. Several major septal perforators had significant lesions at their origins. In the dominant right coronary artery, there were diffuse calcifications but no significant lesions. The left circumflex and large ramus intermedius were free of discrete lesions. Left ventricular function was normal.The patient underwent single-vessel (left internal mammary artery to left anterior descending artery) coronary artery bypass grafting (CABG) surgery. He was prescribed atenolol 100 mg/ d, lisinopril 40 mg/d, lovastatin 80 mg/d, aspirin 325 mg/d, metformin 850 mg 3 times a day, and glipizide 10 mg 2 times a day. Despite being nonadherent to his prescribed medications, he remained stable for 5 years, but then one day, while doing household chores, he suddenly developed chest pressure, shortness of breath, and diaphoresis that lasted 12 hours. On admission to the hospital his troponin I was elevated and peaked at 0.7 ng/mL (normal, <0.05 ng/mL), consistent with a myocardial infarction (MI). His electrocardiogram had not changed.

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Collaborative Care Management of Late-Life Depression in the Primary Care Setting

Abstract: The IMPACT collaborative care model appears to be feasible and significantly more effective than usual care for depression in a wide range of primary care practices.

Cited by 2,161 publications

References 75 publications

Implementation of Collaborative Depression Management at Community-Based Primary Care Clinics: An Evaluation

Implementation of Collaborative Depression Management at Community-Based Primary Care Clinics: An Evaluation

The Age-by-Disease Interaction Hypothesis of Late-Life Depression

Depression and Cardiovascular Disease

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