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Practice-Based Interventions Addressing Concomitant Depression and Chronic Medical Conditions in the Primary Care Setting
Comparative Effectiveness Reviews, No. 75
Investigators: Lea Watson, MD, MPH, Halle R Amick, MSPH, Bradley N Gaynes, MD, MPH, Kimberly A Brownley, PhD, Samruddhi Thaker, MBBS, MHA, PhD, Meera Viswanathan, PhD, and Daniel E Jonas, MD, MPH.
Author Information and AffiliationsStructured Abstract
Objectives:
For adults with concomitant depression and chronic medical conditions seen in the primary care setting, to assess the effectiveness of practice-based interventions for improving mental health or medical outcomes.
Data Sources:
We searched MEDLINE®, Embase, the Cochrane Library, CINAHL®, and PsycINFO® from inception to December 2011. We identified additional studies from reference lists and technical experts.
Review Methods:
Two people independently selected, extracted data from, and rated the quality of relevant trials and systematic reviews. We conducted quantitative analyses for outcomes when feasible and reported all results by medical condition when possible. Two reviewers graded the strength of evidence (SOE) using established criteria.
Results:
We included 24 published articles reporting data from 12 studies (9 randomized controlled trials and 3 preplanned subgroup analyses from a tenth trial). Sample sizes ranged from 55 to 1,001, and study duration ranged from 6 to 60 months. Eleven studies were conducted in the United States (1 in Puerto Rico) and 1 in Scotland. All studies characterized their respective intervention as a form of collaborative care compared with usual or enhanced usual care, and generally involved a care manager with physician supervision; we found no studies describing other types of practice-based interventions. Settings of care for included studies, although rarely characterized, included both open and closed systems. All studies specified depression as the targeted mental health condition. Medical conditions included arthritis, cancer, diabetes, heart disease, HIV, and one or more conditions. Our meta-analyses found that intervention recipients achieved greater improvement than controls in depression symptoms, response, remission, and depression-free days (moderate SOE); satisfaction with care (moderate SOE); and mental and physical quality of life (moderate SOE). Few data were available on outcomes for chronic medical conditions, except for diabetes; only one trial used a medical outcome as the primary outcome. Diabetic patients receiving collaborative care exhibited no difference in diabetes control as compared with control groups (change in HbA1c: weighted mean difference 0.13, 95% CI, −0.22 to 0.48 at 6 months; 0.24, 95% CI, −0.14 to 0.62 at 12 months; low SOE).
Conclusions:
Collaborative care interventions improved outcomes for depression and quality of life in primary care patients with multiple different medical conditions. Few data were available on medical outcomes, except for HbA1c in diabetes, which showed no difference between treatment and usual care. Future studies should be designed to target a broader range of medical conditions, or clusters of conditions, and should compare variations of practice-based interventions in head-to-head trials.
Contents
- Preface
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Results
- Introduction
- Results of Literature Searches
- Description of Included Studies
- Key Question 1a Among adults with chronic medical conditions and concomitant depression (such as patients with diabetes and depression) treated in the primary care setting, what is the comparative effectiveness of practice-based interventions aimed at improving depression or both depression and chronic medical conditions (when compared with similar interventions or usual care) on intermediate depression outcomes (e.g., symptom improvement)?
- Key Question 1b Among adults with chronic medical conditions and concomitant depression (such as patients with diabetes and depression) treated in the primary care setting, what is the comparative effectiveness of practice-based interventions aimed at improving depression or both depression and chronic medical conditions (when compared with similar interventions or usual care) on other mental health outcomes (e.g., depression-related quality of life) and use of mental health-related services?
- Key Question 2a Among adults with chronic medical conditions and concomitant depression (such as patients with diabetes and depression) treated in the primary care setting, what is the comparative effectiveness of practice-based interventions aimed at improving depression or both depression and chronic medical conditions (when compared with similar interventions or usual care) on intermediate chronic medical outcomes (e.g., hemoglobin [Hb]A1c for patients with diabetes)?
- Key Question 2b Among adults with chronic medical conditions and concomitant depression (such as patients with diabetes and depression) treated in the primary care setting, what is the comparative effectiveness of practice-based interventions aimed at improving depression or both depression and chronic medical conditions (when compared with similar interventions or usual care) on general and other health outcomes (e.g., diabetes-related morbidity, use of general health-related services, costs)?
- Key Question 3 What harms are associated with practice-based interventions for primary care patients with chronic medical conditions and concomitant depression?
- Key Question 4 What are the characteristics of the practice-based interventions addressing concomitant depression and chronic medical conditions used in the primary care setting with regard to specific components and/or intensity (e.g., visit frequency, total number of contacts, provider discipline, use of self-management)?
- Key Question 5 What are the specific characteristics of the practice setting where the interventions were delivered with regard to such variables as organizational characteristics (e.g., decision support, level of integration, information technology, electronic medical records, presence of mental health services on site, payer and service mix, practice size, and practice location/setting) or the relationship between elements of the system in which the practice operates (e.g., coordination, financing of care, payment arrangements)?
- Discussion
- References
- Appendix A Search Strategy
- Appendix B Excluded Studies
- Appendix C Evidence Tables
- Appendix D Quality Assessment
- Appendix E Meta-Analyses
- Appendix F Strength of Evidence
Prepared for: Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services1, Contract No. 290-2007-10056-I, Prepared by: RTI International–University of North Carolina Evidence-based Practice Center, Research Triangle Park, NC
Suggested citation:
Watson L, Amick HR, Gaynes BN, Brownley KA, Thaker S, Viswanathan M, Jonas DE. Practice-Based Interventions Addressing Concomitant Depression and Chronic Medical Conditions in the Primary Care Setting. Comparative Effectiveness Review No. 75. (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I.) AHRQ Publication No. 12-EHC106-EF. Rockville, MD: Agency for Healthcare Research and Quality. August 2012. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the RTI International–University of North Carolina Evidence-based Practice Center under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2007-10056-I). The findings and conclusions in this document are those of the author(s), who are responsible for its content; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others—make well-informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report may be used, in whole or in part, as the basis for the development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products or actions may not be stated or implied.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
- 1
540 Gaither Road, Rockville, MD 20850; www
.ahrq.gov
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