Designing and implementing a primary care intervention trial to improve the quality and outcome of care for major depression

Rost, Kathryn; Nutting, Paul A.; Smith, Jeffrey L.; Werner, James Joseph

doi:10.1016/s0163-8343(00)00059-1

Cited by 92 publications

(81 citation statements)

References 28 publications

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“…The methods used in QuEST 45,[51][52][53][54] and MHAP 53,55 have been described previously and are summarized here. Both projects used a 4-level nested design, recruiting community-based health care programs, primary care practices within program, primary care clinicians within practice, and patients with depression within clinician.…”

Section: Methodsmentioning

confidence: 99%

Improving Detection of Suicidal Ideation Among Depressed Patients in Primary Care

Nutting

Dickinson²,

Rubenstein³

et al. 2005

The Annals of Family Medicine

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PURPOSE Primary care clinicians have diffi culty detecting suicidal patients. This report evaluates the effect of 2 primary care interventions on the detection and subsequent referral or treatment of patients with depression and recent suicidal ideation.METHODS Adult patients in 12 mixed-payer primary care practices and 9 not-forprofi t staff model health maintenance organization (HMO) practices were screened for depression. Matched practices were randomized within plan type to intervention or usual care. The intervention for mixed-payer practices entailed brief training of physicians and offi ce nurses to provide care management. The intervention for HMO practices consisted of guided development of quality improvement teams for depression care. A total of 880 enrolled patients met study criteria for depression, 232 of whom met criteria for recent suicidal ideation. Intervention effects on suicide detection and referral to mental health specialty care were evaluated with mixed-effects multilevel models in intent-to-treat analyses.RESULTS Depressed patients with recent suicidal ideation were detected on 40.7% of index visits in intervention practices, compared with 20.5% in usual care practices (odds ratio = 2.64, 95% confi dence interval, 1.45-5.07), with HMO plan type and male sex associated with detection. The interventions had no effect on referral of patients, starting an antidepressant, or suicidal ideation reported at a 6-month follow-up, although power was limited for all 3 analyses.CONCLUSIONS Primary care interventions to improve depression care can improve detection of recent suicidal ideation. Further work is needed to improve physician response to detection, including referral to specialty care and more aggressive treatment, and to observe the effect on outcomes. INTRODUCTION Suicide represents a major social 1 and economic 2,3 burden on the health of the American people and ranks among the top 10 causes of death for Americans aged 10 years and older. 4 Suicide attempts are even more common, 5-7 increase morbidity and health care costs, 3 and further elevate the risk of individuals for a subsequent completed suicide. 8 Suicide prevention has been identifi ed as a national priority 9,10 and is now the target of a comprehensive national strategy. 4 Primary care physicians have an important role in detecting patients at higher risk for suicide, and for prevention. Many [11][12][13][14] but not all 15 studies report that individuals make primary care visits before completing suicide. Improving primary care for suicidal patients poses several critical challenges. Completed suicide is relatively infrequent in primary care practice. Although suicidal ideation is more frequent than suicidal behavior or completed suicide, 16-21 the relationships among ideation, suicide attempts, and completed suicide are uncertain. 5,6,8,[22][23][24][25][26][27] Patients rarely volunteer suicidal ideation, although many will acknowledge ideation if asked directly 13 Rather than increasing primary care physician vigi...

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Section: Methodsmentioning

confidence: 99%

Improving Detection of Suicidal Ideation Among Depressed Patients in Primary Care

Nutting

Dickinson²,

Rubenstein³

et al. 2005

The Annals of Family Medicine

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show abstract

“…Thus, whereas the results of the trials suggest that providing collaborative care to patients with depression is better than not providing such care, they do not address whether screening would benefit patients with previously unrecognized depression. Underlining this point, among the three largest studies cited by the task force (studies involving > 100 patients), 44% of patients in one trial were given treatment for depression before their enrolment, 21 and 44% of patients in another of the studies were receiving appropriate care for depression, defined as specialized counselling or treatment using antidepressant medication, before their enrolment;…”

Section: Recommendation Of the Us Preventive Services Task Forcementioning

confidence: 99%

Rethinking recommendations for screening for depression in primary care

Thombs¹,

Coyne²,

Cuijpers³

et al. 2011

CMAJ

193

198

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“…In terms of substantive findings, clients had a high prevalence of depression, 33 % overall and 35 % in primary care/public health settings with even higher prevalence in other screening locations; by comparison, depression rates in primary care are typically 6-20 %. 7,40,[48][49][50] Thus, clients in safety net populations within under-resourced communities have a high burden of depression meriting evaluation. The clients were primarily African American or Latino and most were uninsured, met federal poverty criteria, or were not employed.…”

Section: Discussionmentioning

confidence: 99%

“…Many studies of quality improvement in specific sites or applying CBPR to health rely on convenience samples, 7,38,[55][56][57][58][59][60][61] and use integrated systems or households or settings in government districts. 39,49,[62][63][64][65][66] The study findings are based on client self-report and may not accurately reflect actual service use due to problems such as client recall. In addition, our findings are limited to financially stable, community-based safety-net programs in Los Angeles.…”

Section: Discussionmentioning

confidence: 99%

Community-Partnered Evaluation of Depression Services for Clients of Community-Based Agencies in Under-Resourced Communities in Los Angeles

et al. 2013

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BACKGROUND:As medical homes are developing under health reform, little is known regarding depression services need and use by diverse safety-net populations in under-resourced communities. For chronic conditions like depression, primary care services may face new opportunities to partner with diverse community service providers, such as those in social service and substance abuse centers, to support a collaborative care model of treating depression. OBJECTIVE: To understand the distribution of need and current burden of services for depression in underresourced, diverse communities in Los Angeles. DESIGN: Baseline phase of a participatory trial to improve depression services with data from client screening and follow-up surveys. PARTICIPANTS: Of 4,440 clients screened from 93 programs (primary care, mental health, substance abuse, homeless, social and other community services) in 50 agencies, 1,322 were depressed according to an eight-item Patient Health Questionnaire (PHQ-8) and gave contact information; 1,246 enrolled and 981 completed surveys. Ninety-three programs, including 17 primary care/public health, 18 mental health, 20 substance abuse, ten homeless services, and 28 social/other community services, participated. MAIN MEASURES:Comparisons by setting in 6-month retrospective recall of depression services use. KEY RESULTS: Depression prevalence ranged from 51.9 % in mental health to 17.2 % in social-community programs. Depressed clients used two settings on average to receive depression services; 82 % used any setting. More clients preferred counseling over medication for depression treatment. CONCLUSIONS: Need for depression care was high, and a broad range of agencies provide depression care. Although most participants had contact with primary care, most depression services occurred outside of primary care settings, emphasizing the need to coordinate and support the quality of community-based services across diverse community settings.KEY WORDS: depression services; community-partnered; participatory research; CPPR; CBPR; community-based; under-resourced. J Gen Intern Med 28(10):1279-87 DOI: 10.1007/s11606-013-2480-7 © Society of General Internal Medicine 2013 BACKGROUND Current healthcare reforms call for expansions of primary care and integrated medical homes for safety-net populations. 1,2 Primary care is a "de facto" mental health setting, 3 where rates of recognition and treatment for depression are lower than in specialty mental health settings. 4 While collaborative care is effective for primary care depressed patients, [5][6][7] little is known about how to conceptualize depression management in neighborhoods with high rates of poverty and ethnic minority representation. 8 Neighborhood poverty is predictive of depression onset, 9 and while prevalence of depressive disorders is similar for Latinos and African Americans relative to non-Hispanic whites, 10,11 African Americans may have greater severity when depressed. 12 Ethnic and socioeconomic disparities in access to and quality of mental health...

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Designing and implementing a primary care intervention trial to improve the quality and outcome of care for major depression

Cited by 92 publications

References 28 publications

Improving Detection of Suicidal Ideation Among Depressed Patients in Primary Care

Improving Detection of Suicidal Ideation Among Depressed Patients in Primary Care

Rethinking recommendations for screening for depression in primary care

Community-Partnered Evaluation of Depression Services for Clients of Community-Based Agencies in Under-Resourced Communities in Los Angeles

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