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By Melissa Capers
Depression frequently occurs in tandem with chronic medical illnesses, complicating
the treatment of both. A review of patients in a managed care program based in Colorado
found that more than half of all patients with congestive heart failure (54 percent),
nearly half of all patients with diabetes (46 percent), and 40 percent of patients
with asthma were also diagnosed with depression.
One-third of primary care patients with depression have a co-occurring medical condition,
and another third have two, according to Daniel E. Ford, M.D., M.P.H., of The Johns
Hopkins University.
For persons with depression, taking control of their medical illness is difficult.
According to Jurgen Unutzer, M.D., M.P.H., of the University of Washington Medical
School, disability, morbidity, mortality, and costs all rise when chronic medical diseases
co-occur with depression. Making a difficult situation even worse, depression also
decreases patient self-care and adherence to treatment, Dr. Unutzer added.
Jurgen Unutzer, M.D., M.P.H. (top right), of the University
of Washington Medical School |
For patients with co-occurring depression and medical illness, a systems-based response
appears to result in positive clinical outcomes. Care coordination—staffing to
assure that medical and behavioral health providers and treatments work together—has
shown promising results in reducing symptoms of depression and some medical illnesses.
Three different models of care coordination for primary care patients with co-occurring
depression and medical illness were described at the Complexities of Co-Occurring Disorders
Conference. Two have already shown promising results.
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Care Coordination Models
Improving Mood—Promoting Access to Collaborative Treatment for Late-Life Depression (IMPACT)
Presenter: Jurgen Unutzer, M.D., M.P.H., University of Washington
Medical School.
Model: A depression care manager (a psychologist or psychology-trained
registered nurse or social worker based in a primary care practice) provides patient
education, follow-up, treatment support, and brief psychotherapy.
Results: A randomized control trial of 400 providers and 1,801 patients
found that those receiving the IMPACT intervention showed a greater reduction in depression
and reported more depression-free days than did those receiving usual care. In addition,
a subset study of 1,001 patients with depression and arthritis showed a significant
decline in reported arthritis pain among patients receiving the IMPACT intervention.
Re-engineering Systems for Primary Care Treatment of Depression (RESPECT)
Presenter: Marshall Thomas, M.D., Colorado Access.
Model: Colorado Access, the State Medicaid Managed Care Organization,
is implementing a care coordination model in which care managers who are registered
nurses, based in the managed care organization, work with medical and behavioral health
providers to coordinate care and develop a care plan. Care managers also provide outreach
and treatment support calls to patients.
Results: In a recently completed, randomized, controlled trial supported
through the MacArthur Initiative on Depression and Primary Care, patients receiving
RESPECT coordination showed significant improvements in depression symptoms compared
with those receiving usual care. Additional dissemination trials of this model are
under way through the Robert Wood Johnson Foundation’s Depression in Primary
Care: Linking Clinical and System Strategies Initiative.
Guided Care
Presenter: Charles Boult, M.D., M.P.H., M.B.A., The Johns Hopkins
University.
Model: A registered nurse based in a primary care practice receives
9-week, 25-module training in the Guided Care intervention, and in use of Guided Care
data collection and decision support software. The guided care nurse assists one to
three physicians in caring for high-risk patients with chronic conditions. The guided
care nurse completes an in-home assessment of the patient’s clinical needs and
preferences, works with the physician to develop an evidence-based plan of care, monitors
the patient by telephone, coordinates providers and care facilities, and provides education
and support to unpaid caregivers (e.g., family members, friends).
Results: Randomized control trials will begin this fall.
« See Also—Previous Article
« See Part 1: Complexities
of Co-Occurring Conditions Conference: Experts Identify Problems, Examine Solutions
« See Part 2: Complexities
of Co-Occurring Conditions Conference: Experts Identify Problems, Examine Solutions
« See Part 3: Complexities
of Co-Occurring Conditions Conference: Experts Identify Problems, Examine Solutions
See Also—Conference Panels:
« See Conference Panel:
Improving Outcomes
« See Conference Panel:
Housing and Treatment
« See Conference Panel:
Depression and Illness: Coordinating Care
See Also—Complexities of Co-Occurring Conditions Conference:
4 Million Have Co-Occurring Serious Mental
Illness, Substance Abuse »
Center for Excellence »
Resources »
See Also—Next
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