Conference Panel: Depression and Illness: Coordinating Care

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.

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.

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