Improving Depression Management in Primary Care with Collaboration

Written By : 

Susan Williams, PharmD Candidate 2015

Reviewed By :

Livia Macedo, Pharm.D.

Citations:

1) Finley PR, Rens HR, Pont JT, Gess SL, Louie C, Bull SA, Bero LA. Impact of a collaborative pharmacy practice model on the treatment of depression in primary care. Am J Health Syst Pharm. 2002 Aug 15;59(16):1518-26.

Article Link: http://www.ncbi.nlm.nih.gov/pubmed/12185826
2) Finley PR, Rens HR, Pont JT, Gess SL, Louie C, Bull SA, Lee JY, Bero LA. Impact of a collaborative care model on depression in a primary care setting: a randomized controlled trial. Pharmacotherapy. 2003 Sep;23(9):1175-85.

Article Link: http://www.ncbi.nlm.nih.gov/pubmed/14524649

According to the World Health Organization (WHO), mental illness is purported to cause more disability than any other illnesses in developed countries, with a point prevalence of 25% in US adults and lifetime prevalence of 50%1. Recent sensational news headlines about disturbed individuals who commit violent acts toward others after being overlooked by the mental health care system have brought this public health debate to the forefront. Symptoms of depression in particular are common and may lead to significant morbidity on their own. They may also worsen outcomes of other chronic disease states. The Sertraline Anti-Depressant Heart Attack Randomized Trial (SADHART) found that long-term mortality in ACS patients was influenced by baseline depression severity and failure of sertraline to improve symptoms2. Depressed patients are more likely to present to primary care settings, perhaps due to reduced access and increased costs of specialty care from psychologists or psychiatrists, however, outcomes may be poorer. According to Bower, evidence from systematic reviews may demonstrate increased clinical effectiveness from the implementation of collaborative care models with small to medium effect sizes on health status, patient satisfaction and compliance3. However limited cost effectiveness data may point to increased costs of this model3,4. On the other hand, other studies have shown that collaboration produced better outcomes for patients with moderate to severe depression but may not be necessary or cost effective for large numbers of patients with milder symptoms that may present to primary care practitioners (PCPs)5.

The major innovation of a collaborative care model compared to either enhanced training of the primary care provider (PCP) or utilizing specialist consultation in isolation is the introduction of a care manager. A care manager takes on a significant portion of direct patient care that the PCP would normally do including assessment, patient education and care coordination with the PCP and the specialists. This model is similar to protocol-based chronic disease management systems of non-psychiatric conditions4. Psychological therapy was not associated with improved outcomes in collaborative care, but attitudes and skills of PCPs, case manager supervision by specialists and case manager mental health background did have an impact on outcomes4,6. The most important factor for effectiveness is the degree to which intervention encourages anti-depressant use among patients, which makes sense given the prominent role of medical therapy in the management of depression, particularly by PCPs4. The expertise of pharmacists with patient education and skilled medication management may improve antidepressant appropriateness and adherence6,7. According to Al-Jumah et al, interventions by pharmacists lead to improvement in patients’ adherence and a positive association exists between antidepressant adherence and improvement in depressive symptoms8.

A systematic review by Finley et al found 16 publications where pharmacist interventions for patients with mental illness improved prescribing patterns, most commonly reducing the dosage and absolute number of psychotropic drugs, even relative to psychiatrists7. In Impact of a collaborative pharmacy practice model on the treatment of depression in primary care, they implement a pilot program at Kaiser Permanente Medical Center, San Rafael, CA (KPMCSR) that attempts to improve the management of depression in primary care settings by giving clinical pharmacists a role in the management process. A collaborative care model was created in which clinical pharmacists worked at the interface between primary care and psychiatry. In an intervention group of PCPs at KPMCSR, patients who presented with depressive symptoms were prescribed antidepressant medications then referred to clinical pharmacists. The pharmacists conducted intake interviews, assessed whether patients needed immediate referral to a psychiatrist and if not, provided patient education regarding the illness, treatment with medication and medication adherence. Regular telephone encounters and clinic visits involving disease-state and medication counseling were subsequently performed and documented by the pharmacists. The pharmacists had limited prescribing privileges to modify prescribed doses and add ancillary medications. They were also in contact with the PCP to recommend changes in antidepressants if necessary. Additionally, the pharmacist was in contact and with a psychiatrist liaison at least weekly for consultation regarding patient progress. The remaining PCPs at KPMCSR who prescribed and monitored antidepressants themselves were considered a control or usual care group9.

67% of intervention patients completed the entire 6 months of the study in the collaborative model, with losses primarily due to psychiatry referral, lack of efficacy, or refusal of antidepressants. The average intervention patient began with mild to moderate depression severity and a moderate impairment in work and social functioning, which significantly improved at 6 week and 6 month timepoints when they were evaluated at clinic visits. Intervention patients had a significantly higher rate of medication adherence (15.2% more than control) and were more likely to continue antidepressant therapy beyond three months (25% more likely). They were more satisfied with their care according to their responses to post-study surveys and had a greater decrease in their resource utilization (in terms of PCP contacts in the 12 months after initiating antidepressants, a 27% difference) compared to the control patients. Although maintenance doses were similar between groups, intervention patients were more likely (18.8% more likely) to switch antidepressant medications during follow-up9.

A notable strength of this pilot study was that patients who had received counseling or antidepressants within the previous 6 months were excluded.  This study was also advantageous in that there were no significant differences in demographics or medical comorbidities between the study groups. However, the intervention group was more likely to have received antidepressants or counseling prior to this study compared to the control group, which may reflect selection bias and play a role in their adherence and the efficacy of treatment. PCPs were assigned to the intervention or control arms in a nonrandomized fashion due based on willingness to participate and clinic capacity so it cannot be assumed that the overall medical care was comparable among providers. There may have been baseline prescribing differences between intervention and control PCPs due to indirect pharmacist influence or more favorable attitudes towards the pharmacists before and during the study.  Also, depression severity and functional impairment was not assessed in the control group, therefore their improvements could only be inferred based on improvements in medication adherence9.

Immediately after completing the above pilot study, the authors followed it with a randomized controlled trial with mostly the same study population, setting and methods. This work was described in a subsequent publication Impact of a Collaborative Care Model on Depression in a Primary Care Setting: A Randomized Controlled Trial. This study corroborated the first in that there was an increase in medication adherence and reduction in PCP visits for the intervention group vs. the control group, and some statistically significant differences in satisfaction survey. Although they improved the study design by introducing randomization of PCPs to the intervention and control arms, flaws remained in the study protocol such as a lack of double-blinding. This study had less power than the previous one, leading to a decreased ability to detect statistically significant differences between the intervention and control groups10. There were questions raised about the applicability of the findings from this setting and patient demographic (large staff-model HMO with older, white, primarily female and more affluent patients with mild depression) to other settings and populations. Both studies were also too limited to adequately examine overall cost-effectiveness (such as the difference in total costs/resource utilization between the two groups, especially considering the costs of employing pharmacists and mental health specialists)9,10. Collaborative care models with expert personnel may be more costly, therefore cost-effectiveness tradeoffs may become a consideration when designing these interventions6. Determinations of cost-effectiveness have inferred both cost savings and increased costs3,4,5,7.

The authors admitted to various biases that may have been present in the trial that appear to weaken its validity but highlight positive aspects of primary care-pharmacy collaboration. Recruitment rates for study randomization diminished over time as PCPs insisted that patients receive collaborative care, likely producing selection bias. Also, the adherence rate of the control group was increased to higher than national benchmark levels in the randomized trial compared to the pilot project, which the authors attribute to possible intervention bias, as prescribing habits may have improved after clinical pharmacist services were established at KPMCSR. The Hawthorne effect was also posited10. Further studies, particularly in other settings, are needed to provide definitive evidence of the value of collaborative mental health care services provided by pharmacists in primary care but it already appears that patients and providers in this setting had recognized a benefit. The addition of pharmacists to a patient-management team may have the potential to improve patient outcomes directly and indirectly, increase patient satisfaction with their care, and improve efficiency of the use of health care resources.

References 

  1. Reeves W, Strine T, Pratt L, Thompson W, Ahluwalia I, Dhingra S, McKnight-Eily L, Harrison L. Mental Illness Surveillance Among Adults in the Unites States. CDC WWMR 2011, 60; 1-32.
  2. Tsu L. Depression in Cardiac Patients: Underrecognized and Undertreated. US Pharmacist. 2012; 37(11): HS-12-HS-15.
  3. Bower P, Gilbody S. Managing common mental health disorders in primary care: conceptual models and evidence base. BMJ. Apr 9, 2005; 330(7495): 839–842.
  4. Bower P. Collaborative Models Between Primary Care and Specialist Services in the Management of Common Mental Health Problems. Clinical Neuropsychiatry. 2011; 4:243-251.
  5. Katon W, von Korff M, Lin E et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA. 1995; 273:1026-31.
  6. Bower P, Gilbody S, Richards D, Fletcher J, Sutton A. Collaborative care for depression in primary care. Making sense of a complex intervention: systematic review and meta-regression. The British Journal of Psychiatry (2006)189: 484-493.
  7. Finley PR, Crismon ML, Rush AJ. Evaluating the impact of pharmacists in mental health: a systematic review. Pharmacotherapy. 2003 Dec 23(12):1634-44.
  8. Al-Jumah KA, Qureshi NA. Impact of pharmacist interventions on patients’ adherence to antidepressants and patient-reported outcomes: a systematic review. Patient Prefer Adherence. 2012;6:87-100.
  9. Finley PR, Rens HR, Pont JT, Gess SL, Louie C, Bull SA, Bero LA. Impact of a collaborative pharmacy practice model on the treatment of depression in primary care. Am J Health Syst Pharm. 2002 Aug 15;59(16):1518-26.
  10. Finley PR, Rens HR, Pont JT, Gess SL, Louie C, Bull SA, Lee JY, Bero LA. Impact of a collaborative care model on depression in a primary care setting: a randomized controlled trial. Pharmacotherapy. 2003 Sep;23(9):1175-85.
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Effects of Multidisciplinary Care on Residential Care Facilities: Does it Make a Difference?

Written By :

Janice Lee, PharmD Candidate 2015

Reviewed By :

Livia Macedo, Pharm.D.

Citation:

Boorsma M, Frijters DH, Knol DL, Ribbe ME, Nijpels G, van Hout HP. Effects of multidisciplinary integrated care on quality of care in residential care facilities for elderly people: a cluster randomized trial. CMAJ. 2011 Aug 9;183(11):E724-32.

Article Link

In 2011 the Canadian Medical Association Journal published the: Effects of Multidisciplinary integrated care on quality of care in residential care facilities for elderly people: a cluster randomized trial1. This study was able to cite the correlation between multidisciplinary team care and the improvement of standard care for elderly individuals in residential care facilities. A randomized controlled trial involving ten residential care facilities in the Netherlands were utilized. Five of the facilities provided multidisciplinary integrated care, and five provided usual care. The intervention consisted of geriatric assessment of functional every three months. The assessment was used by trained nurse-assistants to design the guide of individual care plan; discussion of the outcomes and care priorities with the family physician, resident and the patient’s family. There were multidisciplinary meetings with the nurse-assistant, family physician, psychologist and geriatrician to discuss residents with complex needs.1

Although this study showed improved quality of care with a multidisciplinary team, this data has several limitations.  First, the patient population of the elderly is difficult to evaluate because individuals often have functional and cognitive impairments that increase over time1. Additionally, since most individuals in long-term care have various health ailments, the duration of the trial was only six months due to the high risk of drop out.

Second, the study was conducted in the Netherlands where the generalizability of results to be applicable to the United States does not necessarily apply. Long term care in the Netherlands is funded by mandatory state controlled insurance2. In contrast, long-term care in the U.S. such as residential facilities for the elderly is mostly self-financed by individuals. Thus, long-term health care in the U.S. is variable and contingent on financial cost3.

The applicability of conducting an ideal multidisciplinary team in the US health care system also remains questionable due to financial restrictions. Staffing a competent team to work together where the education level, experience and interprofessional skills of cooperation and good communication take time and depend on the individual’s themselves4. The cohesiveness of the health care team to make effective decisions depends on the infrastructure and the individual members of the team itself. Trust in professional competency and positive rapport takes time to develop in an interdisciplinary setting.

Additionally, the facility itself and the criteria of staff education and standards can differ from facility to facility. Various facilities have different policies in regards to their mix of staffing and their admittance policy for elderly individuals in need of care, as well as their discharge policies in relinquishment of care. Thus, the process of care in a multidisciplinary care team depends on cultivating a professional team in a cost-effective infrastructure.

Although this randomized control trial was major in respect to showing how multidisciplinary care can have improved outcomes, it remains to be seen whether this can be carried out on a financial and organizational level in the United States. Since many patients base their health care decisions on their financial limitations, managed care settings can be one way to resolve the heterogeneity of team members and account for the financial demands in implementing primary care4.  Conducting future clinical trials in these managed care settings in the U.S. can be one way to develop evidence for the effectiveness of multidisciplinary team based care in primary settings.

 

References

1. Boorsma M, Frijters DH, Knol DL, Ribbe ME, Nijpels G, van Hout HP.  Effects of multidisciplinary integrated care on quality of care in residential care facilities for elderly people: a cluster randomized trial. CMAJ. 2011 Aug 9;183(11):E724-32.

2. Schoen C, Osborn R, Doty M, Bishop M, Peugh J, Murukutia N.  Toward higher-performance heath systems: adults’ health care experiences in seven countries, 2007. Health Aff (Millwood). 2007 Nov-Dec;26(6):w717-34.

3.  Feder J, Komisar HL, Niefeld M. Long-term care in united states: an overview. Health Aff (Millwood). 2000 May-Jun;19(3):40-56.

4.  Boul C, Reider L, Leff B, Frick K, Boyd C, Wolff J, Frey K, Karm L, Wegener S, Mroz T, Scharfstein D. The effect of guided care teams on the use of health services, results from a cluster-randomized controlled trial. Arch Intern Med. 2011 Mar 14;171(5):460-6.