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Jurgen Unutzer - One of the best experts on this subject based on the ideXlab platform.
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longitudinal remote coaching for implementation of perinatal Collaborative Care a mixed methods analysis
Psychiatric Services, 2020Co-Authors: Amritha Bhat, Amy M Bauer, Ian M Bennett, Rinad S Beidas, Whitney Eriksen, Frances K Barg, Rachel Gold, Jurgen UnutzerAbstract:The Collaborative Care model (CoCM) is a multicomponent, team-based integrated behavioral health framework. Its effectiveness in the treatment of perinatal depression is established, but implementation has been limited. The authors used longitudinal remote coaching (LRC) as a novel implementation strategy to support systematic case review in a multistate cluster-randomized trial of CoCM for perinatal depression. They describe LRC for perinatal CoCM in three clinics and use of a mixed-methods analysis of data from LRC feedback forms and interviews with participants. LRC is a scalable implementation strategy with potential to support complex models of integrated behavioral health, such as perinatal CoCM.
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text messaging to support a perinatal Collaborative Care model for depression a multi methods inquiry
General Hospital Psychiatry, 2018Co-Authors: Amritha Bhat, Jurgen Unutzer, Johnny Mao, Susan D Reed, Jennifer B UngerAbstract:Abstract Objective Mental health Care integrated into obstetric settings improves access to perinatal depression treatments. Digital interactions such as text messaging between patient and provider can further improve access. We describe the use of text messaging within a perinatal Collaborative Care (CC) program, and explore the association of text messaging content with perinatal depression outcomes. Methods We analyzed data from an open treatment trial of perinatal CC in a rural obstetric clinic. Twenty five women with Patient Health Questionnaire-9 score of ≥10 enrolled in CC, and used text messaging to communicate with their Care Manager(CM). We used surveys and focus groups to assessacceptability of text messaging with surveys and focus groups. We calculated the number of text messages exchanged, and analyzed content to understand usage patterns. We explored association between text messaging content and depression outcomes. Results CMs initiated 85.4% messages, and patients responded to 86.9% messages. CMs used text messaging for appointment reminders, and patients used it to obtain obstetric and parenting information. CMs had concerns about the likelihood of boundary violations. Patients appreciated the asynchronous nature of text messaging. Conclusion Text messaging is feasible and acceptable within a perinatal CC program. We need further research into the effectiveness of text messaging content, and response protocols.
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effective implementation of Collaborative Care for depression what is needed
The American Journal of Managed Care, 2014Co-Authors: Robin R Whitebird, Jurgen Unutzer, Leif I Solberg, Nancy Jaeckels, Pamela B Pietruszewski, Senka Hadzic, Kris A Ohnsorg, Rebecca C Rossom, Arne Beck, Kenneth E JoslynAbstract:There is extensive randomized controlled trial evidence that Collaborative Care for depressed adults in primary Care improves patient outcomes.1-5 Key elements in evidence-based Collaborative Care programs include consistent measurement and monitoring of depression severity, close proactive follow-up by a clinic-based Care manager, and regular psychiatric consultation focused on treatment changes for patients who are not improving with initial treatment. Based on these studies, the U.S. Preventive Services Task Force recommends that routine screening of adults for depression is justified only when systems for Collaborative depression Care are in place.6,7 Not only can Collaborative Care produce better patient outcomes (with rates of remission and response that are approximately twice those of usual Care), but it can also produce net cost-saving over four years.8-10 Despite these findings, however, little is known about which implementation factors are most important for achieving these outcomes. For example, prior studies of Collaborative Care have employed Care managers with wide varieties of education and experience without providing information about comparative benefits on outcomes.1,11 It is also unclear what supports a Care manager needs to function most effectively or whether it is important for the psychiatrist to come on-site to provide consultation and supervision. Similarly, it is unknown whether an effective local primary Care champion or face-to-face communication between the primary Care provider (PCP) and Care manager are important. Between 2008 and 2012, an initiative led by a regional quality improvement Collaborative, the Institute for Clinical Systems Improvement (ICSI), systematically provided standardized training in implementing Collaborative depression Care and consultative support for primary Care clinics throughout Minnesota and western Wisconsin. The initiative, DIAMOND (Depression Improvement Across Minnesota – Offering a New Direction), included payment redesign through a partnership with nearly all commercial health plans in the state.12,13 While maintaining fidelity to the core aspects of the model was required, local tailoring was considered important, so there were significant variations in implementation. The initiative also collected standardized process and outcome data as part of the quality improvement (QI) support system, as well as information about each clinic's approach to the Care model. This quantitative information was supplemented with a round of site visits to all participating groups, providing a unique opportunity to document differences in Care processes and implementation strategies. This information allowed examination of which approaches to implementation might be important for high levels of enrollment and good patient outcomes.
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are patient characteristics associated with quality of depression Care and outcomes in Collaborative Care programs for depression
General Hospital Psychiatry, 2012Co-Authors: Amy M Bauer, Jurgen Unutzer, Vanessa Azzone, Laurie Alexander, Howard H Goldman, Richard G FrankAbstract:Objective To determine whether demographic or clinical characteristics of primary Care patients are associated with depression treatment quality and outcomes within a Collaborative Care model.
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impact of comorbid panic and posttraumatic stress disorder on outcomes of Collaborative Care for late life depression in primary Care
American Journal of Geriatric Psychiatry, 2005Co-Authors: Mark T Hegel, Jurgen Unutzer, Wayne Katon, John W Williams, Polly H Noel, Lingqi Tang, Patricia A Arean, Elizabeth H B LinAbstract:Objective Comorbid anxiety disorders may result in worse depression treatment outcomes. The authors evaluated the effect of comorbid panic disorder and posttraumatic stress disorder (PTSD) on response to a Collaborative-Care intervention for late-life depression in primary Care. Methods A total of 1,801 older adults with depression were randomized to a Collaborative-Care depression treatment model versus usual Care and assessed at baseline, 3, 6, and 12 months, comparing differences among participants with comorbid panic disorder (N=262) and PTSD (N=191) and those without such comorbid anxiety disorders. Results At baseline, patients with comorbid anxiety reported higher levels of psychiatric and medical illness, greater functional impairment, and lower quality of life. Participants without comorbid anxiety who received Collaborative Care had early and lasting improvements in depression compared with those in usual Care. Participants with comorbid panic disorder showed similar outcomes, whereas those with comorbid PTSD showed a more delayed response, requiring 12 months of intervention to show a significant effect. At 12 months, however, outcomes were comparable. Interactions of intervention status by comorbid PTSD or panic disorder were not statistically significant, suggesting that the Collaborative-Care model performed significantly better than usual Care in depressed older adults both with and without comorbid anxiety. Conclusions Collaborative Care is more effective than usual Care for depressed older adults with and without comorbid panic disorder and PTSD, although a sustained treatment response was slower to emerge for participants with PTSD. Intensive and prolonged follow-up may be needed for depressed older adults with comorbid PTSD.
David Richards - One of the best experts on this subject based on the ideXlab platform.
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impact of telephone delivered case management on the effectiveness of Collaborative Care for depression and anti depressant use a systematic review and meta regression
PLOS ONE, 2019Co-Authors: Joanna L Hudson, Peter Bower, Evangelos Kontopantelis, Simon Gilbody, Janine Archer, David Richards, Penny Bee, Rose Clarke, Andrew S Moriarty, Karina LovellAbstract:Background The health service delivery framework Collaborative Care is an effective intervention for depression. However, uncertainties remain about how to optimise its delivery at scale. Structured case management is a core component of Collaborative Care; its delivery via the telephone may improve access. Aims To examine using meta-regression if telephone delivered case management diminishes the clinical effectiveness of Collaborative Care on depressive symptoms and anti-depressant use relative to face-to-face delivery methods. Methods Randomised controlled trials were eligible if they included Collaborative Care interventions for adults with depression identified using self-report measures or diagnostic interviews and reported depression outcomes. Sociodemographics, intervention characteristics, depressive symptoms, and anti-depressant use were extracted. Random effects univariable and multivariable meta-regression analyses were used to examine the moderating effect of telephone delivered case-management on outcomes. Results Ninety-four trials were identified comprising of 103 comparisons across 24, 132 participants with depression outcomes and 67 comparisons from 15,367 participants with anti-depressant use outcomes. Telephone delivered case management did not diminish the effects of Collaborative Care on depressive symptoms (β = -0.01, 95% CI -0.12 to 0.10; p = 0.86). Telephone delivered case management decreased anti-depressant medication use (relative risk 0.76, 95% CI 0.63 to 0.92; p = 0.005); this effect remained when assessed simultaneously alongside other study-level moderators of Collaborative Care. Conclusion Using remote platforms such as the telephone to deliver case management may be a feasible way to implement Collaborative Care with no loss of effectiveness on depressive symptoms. However, adherence to anti-depressant medication may decrease when telephone case management is used.
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characteristics of effective Collaborative Care for treatment of depression a systematic review and meta regression of 74 randomised controlled trials
PLOS ONE, 2014Co-Authors: Peter A. Coventry, Evangelos Kontopantelis, Karina Lovell, Simon Gilbody, Chris Dickens, Janine Archer, David Richards, Linda Gask, Joanna L Hudson, Waquas WaheedAbstract:Background Collaborative Care is a complex intervention based on chronic disease management models and is effective in the management of depression. However, there is still uncertainty about which components of Collaborative Care are effective. We used meta-regression to identify factors in Collaborative Care associated with improvement in patient outcomes (depressive symptoms) and the process of Care (use of anti-depressant medication). Methods and Findings Systematic review with meta-regression. The Cochrane Collaboration Depression, Anxiety and Neurosis Group trials registers were searched from inception to 9th February 2012. An update was run in the CENTRAL trials database on 29th December 2013. Inclusion criteria were: randomised controlled trials of Collaborative Care for adults ≥18 years with a primary diagnosis of depression or mixed anxiety and depressive disorder. Random effects meta-regression was used to estimate regression coefficients with 95% confidence intervals (CIs) between study level covariates and depressive symptoms and relative risk (95% CI) and anti-depressant use. The association between anti-depressant use and improvement in depression was also explored. Seventy four trials were identified (85 comparisons, across 21,345 participants). Collaborative Care that included psychological interventions predicted improvement in depression (β coefficient −0.11, 95% CI −0.20 to −0.01, p = 0.03). Systematic identification of patients (relative risk 1.43, 95% CI 1.12 to 1.81, p = 0.004) and the presence of a chronic physical condition (relative risk 1.32, 95% CI 1.05 to 1.65, p = 0.02) predicted use of anti-depressant medication. Conclusion Trials of Collaborative Care that included psychological treatment, with or without anti-depressant medication, appeared to improve depression more than those without psychological treatment. Trials that used systematic methods to identify patients with depression and also trials that included patients with a chronic physical condition reported improved use of anti-depressant medication. However, these findings are limited by the observational nature of meta-regression, incomplete data reporting, and the use of study aggregates.
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cost effectiveness of Collaborative Care for depression in uk primary Care economic evaluation of a randomised controlled trial cadet
PLOS ONE, 2014Co-Authors: Colin Green, Peter Bower, Karina Lovell, Carolyn Chewgraham, David Richards, Linda Gask, Jacqueline J Hill, John Cape, Stephen Pilling, Ricardo ArayaAbstract:Background Collaborative Care is an effective treatment for the management of depression but evidence on its cost-effectiveness in the UK is lacking. Aims To assess the cost-effectiveness of Collaborative Care in a UK primary Care setting. Methods An economic evaluation alongside a multi-centre cluster randomised controlled trial comparing Collaborative Care with usual primary Care for adults with depression (n = 581). Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICER) were calculated over a 12-month follow-up, from the perspective of the UK National Health Service and Personal Social Services (i.e. Third Party Payer). Sensitivity analyses are reported, and uncertainty is presented using the cost-effectiveness acceptability curve (CEAC) and the cost-effectiveness plane. Results The Collaborative Care intervention had a mean cost of �272.50 per participant. Health and social Care service use, excluding Collaborative Care, indicated a similar profile of resource use between Collaborative Care and usual Care participants. Collaborative Care offered a mean incremental gain of 0.02 (95% CI: ?0.02, 0.06) quality-adjusted life-years over 12 months, at a mean incremental cost of �270.72 (95% CI: ?202.98, 886.04), and resulted in an estimated mean cost per QALY of �14,248. Where costs associated with informal Care are considered in sensitivity analyses Collaborative Care is expected to be less costly and more effective, thereby dominating treatment as usual. Conclusion Collaborative Care offers health gains at a relatively low cost, and is cost-effective compared with usual Care against a decision-maker willingness to pay threshold of �20,000 per QALY gained. Results here support the commissioning of Collaborative Care in a UK primary Care setting.
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clinical effectiveness of Collaborative Care for depression in uk primary Care cadet cluster randomised controlled trial
BMJ, 2013Co-Authors: David Richards, Peter Bower, Karina Lovell, Carolyn Chewgraham, Linda Gask, Jacqueline J Hill, John Cape, Stephen Pilling, Ricardo Araya, David KesslerAbstract:Objective To compare the clinical effectiveness of Collaborative Care with usual Care in the management of patients with moderate to severe depression. Design Cluster randomised controlled trial. Setting 51 primary Care practices in three primary Care districts in the United Kingdom. Participants 581 adults aged 18 years and older who met ICD-10 (international classification of diseases, 10th revision) criteria for a depressive episode on the revised Clinical Interview Schedule. We excluded acutely suicidal patients and those with psychosis, or with type I or type II bipolar disorder; patients whose low mood was associated with bereavement or whose primary presenting problem was alcohol or drug abuse; and patients receiving psychological treatment for their depression by specialist mental health services. We identified potentially eligible participants by searching computerised case records in general practices for patients with depression. Interventions Collaborative Care, including depression education, drug management, behavioural activation, relapse prevention, and primary Care liaison, was delivered by Care managers. Collaborative Care involved six to 12 contacts with participants over 14 weeks, supervised by mental health specialists. Usual Care was family doctors’ standard clinical practice. Main outcome measures Depression symptoms (patient health questionnaire 9; PHQ-9), anxiety (generalised anxiety disorder 7; GAD-7), and quality of life (short form 36 questionnaire; SF-36) at four and 12 months; satisfaction with service quality (client satisfaction questionnaire; CSQ-8) at four months. Results 276 participants were allocated to Collaborative Care and 305 allocated to usual Care. At four months, mean depression score was 11.1 (standard deviation 7.3) for the Collaborative Care group and 12.7 (6.8) for the usual Care group. After adjustment for baseline depression, mean depression score was 1.33 PHQ-9 points lower (95% confidence interval 0.35 to 2.31, P=0.009) in participants receiving Collaborative Care than in those receiving usual Care at four months, and 1.36 points lower (0.07 to 2.64, P=0.04) at 12 months. Quality of mental health but not physical health was significantly better for Collaborative Care than for usual Care at four months, but not 12 months. Anxiety did not differ between groups. Participants receiving Collaborative Care were significantly more satisfied with treatment than those receiving usual Care. The number needed to treat for one patient to drop below the accepted diagnostic threshold for depression on the PHQ-9 was 8.4 immediately after treatment, and 6.5 at 12 months. Conclusions Collaborative Care has persistent positive effects up to 12 months after initiation of the intervention and is preferred by patients over usual Care. Trial registration number ISRCTN32829227.
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what work has to be done to implement Collaborative Care for depression process evaluation of a trial utilizing the normalization process model
Implementation Science, 2010Co-Authors: Linda Gask, Peter Bower, Karina Lovell, Simon Gilbody, Janine Archer, Annette Jean Lankshear, Diane Escott, Angela E Simpson, David RichardsAbstract:There is a considerable evidence base for 'Collaborative Care' as a method to improve quality of Care for depression, but an acknowledged gap between efficacy and implementation. This study utilises the Normalisation Process Model (NPM) to inform the process of implementation of Collaborative Care in both a future full-scale trial, and the wider health economy. Application of the NPM to qualitative data collected in both focus groups and one-to-one interviews before and after an exploratory randomised controlled trial of a Collaborative model of Care for depression. Findings are presented as they relate to the four factors of the NPM (interactional workability, relational integration, skill-set workability, and contextual integration) and a number of necessary tasks are identified. Using the model, it was possible to observe that predictions about necessary work to implement Collaborative Care that could be made from analysis of the pre-trial data relating to the four different factors of the NPM were indeed borne out in the post-trial data. However, additional insights were gained from the post-trial interview participants who, unlike those interviewed before the trial, had direct experience of a novel intervention. The professional freedom enjoyed by more senior mental health workers may work both for and against normalisation of Collaborative Care as those who wish to adopt new ways of working have the freedom to change their practice but are not obliged to do so. The NPM provides a useful structure for both guiding and analysing the process by which an intervention is optimized for testing in a larger scale trial or for subsequent full-scale implementation.
Wayne Katon - One of the best experts on this subject based on the ideXlab platform.
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Collaborative Care for perinatal depression in socioeconomically disadvantaged women a randomized trial
Depression and Anxiety, 2015Co-Authors: Nancy K Grote, Joan Russo, Wayne Katon, Mary Jane Lohr, Mary Curran, Erin Galvin, Kathy CarsonAbstract:Background Both antenatal and postpartum depression have adverse, lasting effects on maternal and child well-being. Socioeconomically disadvantaged women are at increased risk for perinatal depression and have experienced difficulty accessing evidence-based depression Care. The authors evaluated whether “MOMCare,”a culturally relevant, Collaborative Care intervention, providing a choice of brief interpersonal psychotherapy and/or antidepressants, is associated with improved quality of Care and depressive outcomes compared to intensive public health Maternity Support Services (MSS-Plus). Methods A randomized multisite controlled trial with blinded outcome assessment was conducted in the Seattle-King County Public Health System. From January 2010 to July 2012, pregnant women were recruited who met criteria for probable major depression and/or dysthymia, English-speaking, had telephone access, and ≥18 years old. The primary outcome was depression severity at 3-, 6-, 12-, 18-month postbaseline assessments; secondary outcomes included functional improvement, PTSD severity, depression response and remission, and quality of depression Care. Results All participants were on Medicaid and 27 years old on average; 58% were non-White; 71% were unmarried; and 65% had probable PTSD. From before birth to 18 months postbaseline, MOMCare (n = 83) compared to MSS-Plus participants (n = 85) attained significantly lower levels of depression severity (Wald's χ2 = 6.09, df = 1, P = .01) and PTSD severity (Wald's χ2 = 4.61, df = 1, P = .04), higher rates of depression remission (Wald's χ2 = 3.67, df = 1, P = .05), and had a greater likelihood of receiving ≥4 mental health visits (Wald's χ2 = 58.23, df = 1, P < .0001) and of adhering to antidepressants in the prior month (Wald's χ2 = 10.00, df = 1, P < .01). Conclusion Compared to MSS-Plus, MOMCare showed significant improvement in quality of Care, depression severity, and remission rates from before birth to 18 months postbaseline for socioeconomically disadvantaged women. Findings suggest that evidence-based perinatal depression Care can be integrated into the services of a county public health system in the United States. Clinical Trial Registration: ClinicalTrials.govNCT01045655.
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Collaborative Care for adolescents with depression in primary Care a randomized clinical trial
JAMA, 2014Co-Authors: Laura P Richardson, Evette J Ludman, Elizabeth Mccauley, Jeff Lindenbaum, Cindy Larison, Chuan Zhou, Greg Clarke, David A Brent, Wayne KatonAbstract:Importance Up to 20% of adolescents experience an episode of major depression by age 18 years yet few receive evidence-based treatments for their depression. Objective To determine whether a Collaborative Care intervention for adolescents with depression improves depressive outcomes compared with usual Care. Design Randomized trial with blinded outcome assessment conducted between April 2010 and April 2013. Setting Nine primary Care clinics in the Group Health system in Washington State. Participants Adolescents (aged 13-17 years) who screened positive for depression (Patient Health Questionnaire 9-item [PHQ-9] score ≥10) on 2 occasions or who screened positive and met criteria for major depression, spoke English, and had telephone access were recruited. Exclusions included alcohol/drug misuse, suicidal plan or recent attempt, bipolar disorder, developmental delay, and seeing a psychiatrist. Interventions Twelve-month Collaborative Care intervention including an initial in-person engagement session and regular follow-up by master’s-level clinicians. Usual Care control youth received depression screening results and could access mental health services through Group Health. Main Outcomes and Measures The primary outcome was change in depressive symptoms on a modified version of the Child Depression Rating Scale–Revised (CDRS-R; score range, 14-94) from baseline to 12 months. Secondary outcomes included change in Columbia Impairment Scale score (CIS), depression response (≥50% decrease on the CDRS-R), and remission (PHQ-9 score Results Intervention youth (n = 50), compared with those randomized to receive usual Care (n = 51), had greater decreases in CDRS-R scores such that by 12 months intervention youth had a mean score of 27.5 (95% CI, 23.8-31.1) compared with 34.6 (95% CI, 30.6-38.6) in control youth (overall intervention effect: F 2,747.3 = 7.24, P P = .009) and remission (50.4% vs 20.7%, OR = 3.9, 95% CI, 1.5-10.6; P = .007). Conclusions and Relevance Among adolescents with depression seen in primary Care, a Collaborative Care intervention resulted in greater improvement in depressive symptoms at 12 months than usual Care. These findings suggest that mental health services for adolescents with depression can be integrated into primary Care. Trial Registration clinicaltrials.gov Identifier:NCT01140464
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essential articles on Collaborative Care models for the treatment of psychiatric disorders in medical settings a publication by the academy of psychosomatic medicine research and evidence based practice committee
Psychosomatics, 2014Co-Authors: Jeff C Huffman, Michael Sharpe, Shehzad K Niazi, James R Rundell, Wayne KatonAbstract:Background Collaborative Care interventions for psychiatric disorders combine several components integrated into the medical setting: (1) systematic psychiatric assessment, (2) use of a nonphysician Care manager to perform longitudinal symptom monitoring, treatment interventions, and Care coordination, and (3) specialist-provided stepped-Care recommendations. Collaborative Care interventions have now been evaluated in a wide spectrum of Care settings and offer great promise as a way of increasing quality of patient Care, improving health of populations, and reducing health Care costs. Methods A systematic search of PubMed/MEDLINE databases was performed for publications between January 1970 and May 2013 to identify articles describing Collaborative Care and related interventions. Identified articles were then evaluated independently by multiple reviewers for quality and importance; additional articles were identified by searching reference lists and through recommendations of senior content-matter experts. The articles considered to be both of high quality and most important were then placed into categories and annotated reviews performed. Results Over 600 articles were identified of which 67 were selected for annotated review. The results reported in these articles indicate that Collaborative Care interventions for psychiatric disorders have been consistently successful in improving key outcomes in both research and clinical intervention studies; cost analyses also suggest that this model is cost effective. Conclusions Collaborative Care models for psychiatric disorders are likely to serve an increasingly large role in health Care given their effect on patient and population outcomes and their focus on integration of Care.
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the association of patient relationship style and outcomes in Collaborative Care treatment for depression in patients with diabetes
Medical Care, 2006Co-Authors: Paul Ciechanowski, Gregory E Simon, Joan Russo, Wayne Katon, Evette J Ludman, Michael Von Korff, Bessie A YoungAbstract:PURPOSE: We sought to determine whether relationship style in patients with diabetes receiving depression treatment is associated with differential quality of Care and depression outcomes. METHODS: From 9 health maintenance organization clinics, 324 primary Care patients with diabetes and comorbid major depression and/or dysthymia participated in the Pathways randomized controlled trial of Collaborative Care for depression (n = 160) versus usual Care (n = 164). The intervention provided outreach, enhanced support of antidepressant medication use, and problem-solving treatment delivered by nurse case managers. Using attachment theory principles, we categorized patients as having an independent (n = 190) or interactive (n = 134) relationship style. We assessed whether patient relationship style moderated treatment group differences in quality of Care and depression outcomes. RESULTS: Among independent relationship style patients, the intervention resulted in significantly greater satisfaction with depression Care in the first 6 months and 47 more depression-free days (P < 0.0003) based on the Hopkins Symptom Checklist at 12 months, compared with usual Care. There were no significant treatment group differences in satisfaction with Care or depression outcomes among patients with interactive relationship style. Among patients receiving the intervention, those with an independent relationship style received significantly more problem-solving treatment sessions as compared with patients with an interactive relationship style. CONCLUSION: Among depressed patients with diabetes, the Pathways Collaborative Care intervention improved quality of Care for depression compared with usual Care in both relationship style groups but was associated with significantly better depressive outcomes and greater satisfaction with Care compared with usual Care in patients with independent but not interactive relationship style.
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impact of comorbid panic and posttraumatic stress disorder on outcomes of Collaborative Care for late life depression in primary Care
American Journal of Geriatric Psychiatry, 2005Co-Authors: Mark T Hegel, Jurgen Unutzer, Wayne Katon, John W Williams, Polly H Noel, Lingqi Tang, Patricia A Arean, Elizabeth H B LinAbstract:Objective Comorbid anxiety disorders may result in worse depression treatment outcomes. The authors evaluated the effect of comorbid panic disorder and posttraumatic stress disorder (PTSD) on response to a Collaborative-Care intervention for late-life depression in primary Care. Methods A total of 1,801 older adults with depression were randomized to a Collaborative-Care depression treatment model versus usual Care and assessed at baseline, 3, 6, and 12 months, comparing differences among participants with comorbid panic disorder (N=262) and PTSD (N=191) and those without such comorbid anxiety disorders. Results At baseline, patients with comorbid anxiety reported higher levels of psychiatric and medical illness, greater functional impairment, and lower quality of life. Participants without comorbid anxiety who received Collaborative Care had early and lasting improvements in depression compared with those in usual Care. Participants with comorbid panic disorder showed similar outcomes, whereas those with comorbid PTSD showed a more delayed response, requiring 12 months of intervention to show a significant effect. At 12 months, however, outcomes were comparable. Interactions of intervention status by comorbid PTSD or panic disorder were not statistically significant, suggesting that the Collaborative-Care model performed significantly better than usual Care in depressed older adults both with and without comorbid anxiety. Conclusions Collaborative Care is more effective than usual Care for depressed older adults with and without comorbid panic disorder and PTSD, although a sustained treatment response was slower to emerge for participants with PTSD. Intensive and prolonged follow-up may be needed for depressed older adults with comorbid PTSD.
Karina Lovell - One of the best experts on this subject based on the ideXlab platform.
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impact of telephone delivered case management on the effectiveness of Collaborative Care for depression and anti depressant use a systematic review and meta regression
PLOS ONE, 2019Co-Authors: Joanna L Hudson, Peter Bower, Evangelos Kontopantelis, Simon Gilbody, Janine Archer, David Richards, Penny Bee, Rose Clarke, Andrew S Moriarty, Karina LovellAbstract:Background The health service delivery framework Collaborative Care is an effective intervention for depression. However, uncertainties remain about how to optimise its delivery at scale. Structured case management is a core component of Collaborative Care; its delivery via the telephone may improve access. Aims To examine using meta-regression if telephone delivered case management diminishes the clinical effectiveness of Collaborative Care on depressive symptoms and anti-depressant use relative to face-to-face delivery methods. Methods Randomised controlled trials were eligible if they included Collaborative Care interventions for adults with depression identified using self-report measures or diagnostic interviews and reported depression outcomes. Sociodemographics, intervention characteristics, depressive symptoms, and anti-depressant use were extracted. Random effects univariable and multivariable meta-regression analyses were used to examine the moderating effect of telephone delivered case-management on outcomes. Results Ninety-four trials were identified comprising of 103 comparisons across 24, 132 participants with depression outcomes and 67 comparisons from 15,367 participants with anti-depressant use outcomes. Telephone delivered case management did not diminish the effects of Collaborative Care on depressive symptoms (β = -0.01, 95% CI -0.12 to 0.10; p = 0.86). Telephone delivered case management decreased anti-depressant medication use (relative risk 0.76, 95% CI 0.63 to 0.92; p = 0.005); this effect remained when assessed simultaneously alongside other study-level moderators of Collaborative Care. Conclusion Using remote platforms such as the telephone to deliver case management may be a feasible way to implement Collaborative Care with no loss of effectiveness on depressive symptoms. However, adherence to anti-depressant medication may decrease when telephone case management is used.
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association between chronic physical conditions and the effectiveness of Collaborative Care for depression an individual participant data meta analysis
JAMA Psychiatry, 2016Co-Authors: Maria Panagioti, Peter Bower, Evangelos Kontopantelis, Karina Lovell, Simon Gilbody, Waquas Waheed, Chris Dickens, Janine Archer, Gregory E Simon, Kathleen EllAbstract:IMPORTANCE: Collaborative Care is an intensive Care model involving several health Care professionals working together, typically a physician, a case manager, and a mental health professional. Meta-analyses of aggregate data have shown that Collaborative Care is particularly effective in people with depression and comorbid chronic physical conditions. However, only participant-level analyses can rigorously test whether the treatment effect is influenced by participant characteristics, such as chronic physical conditions. OBJECTIVE: To assess whether the effectiveness of Collaborative Care for depression is moderated by the presence, type, and number of chronic physical conditions. DATA SOURCES: Data were obtained from MEDLINE, EMBASE, PubMed, PsycINFO, CINAHL Complete, and Cochrane Central Register of Controlled Trials, and references from relevant systematic reviews. The search and collection of eligible studies was ongoing until May 22, 2015. STUDY SELECTION: This was an update to a previous meta-analysis. Two independent reviewers were involved in the study selection process. Randomized clinical trials that compared the effectiveness of Collaborative Care with usual Care in adults with depression and reported measured changes in depression severity symptoms at 4 to 6 months after randomization were included in the analysis. Key search terms included depression, dysthymia, anxiety, panic, phobia, obsession, compulsion, posttraumatic, Care management, case management, Collaborative Care, enhanced Care, and managed Care. DATA EXTRACTION AND SYNTHESIS: Individual participant data on baseline demographics and chronic physical conditions as well as baseline and follow-up depression severity symptoms were requested from authors of the eligible studies. One-step meta-analysis of individual participant data using appropriate mixed-effects models was performed. MAIN OUTCOMES AND MEASURES: Continuous outcomes of depression severity symptoms measured using self-reported or observer-rated measures. RESULTS: Data sets from 31 randomized clinical trials including 36 independent comparisons (N = 10 962 participants) were analyzed. Individual participant data analyses found no significant interaction effects, indicating that the presence (interaction coefficient, 0.02 [95% CI, -0.10 to 0.13]), numbers (interaction coefficient, 0.01 [95% CI, -0.01 to 0.02]), and types of chronic physical conditions do not influence the treatment effect. CONCLUSIONS AND RELEVANCE: There is evidence that Collaborative Care is effective for people with depression alone and also for people with depression and chronic physical conditions. Existing guidance that recommends limiting Collaborative Care to people with depression and physical comorbidities is not supported by this individual participant data meta-analysis.
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Clinical effectiveness and cost-effectiveness of Collaborative Care for depression in UK primary Care (CADET): a cluster randomised controlled trial
NIHR Journals Library, 2016Co-Authors: David A Richards, Peter Bower, Karina Lovell, Linda Gask, John Cape, Stephen Pilling, Ricardo Araya, David Kessler, Carolyn Chew-graham, Michael BarkhamAbstract:Background: Collaborative Care is effective for depression management in the USA. There is little UK evidence on its clinical effectiveness and cost-effectiveness. Objective: To determine the clinical effectiveness and cost-effectiveness of Collaborative Care compared with usual Care in the management of patients with moderate to severe depression. Design: Cluster randomised controlled trial. Setting: UK primary Care practices (n = 51) in three UK primary Care districts. Participants: A total of 581 adults aged ≥ 18 years in general practice with a current International Classification of Diseases, Tenth Edition depressive episode, excluding acutely suicidal people, those with psychosis, bipolar disorder or low mood associated with bereavement, those whose primary presentation was substance abuse and those receiving psychological treatment. Interventions: Collaborative Care: 14 weeks of 6–12 telephone contacts by Care managers; mental health specialist supervision, including depression education, medication management, behavioural activation, relapse prevention and primary Care liaison. Usual Care was general practitioner standard practice. Main outcome measures: Blinded researchers collected depression [Patient Health Questionnaire-9 (PHQ-9)], anxiety (General Anxiety Disorder-7) and quality of life (European Quality of Life-5 Dimensions three-level version), Short Form questionnaire-36 items) outcomes at 4, 12 and 36 months, satisfaction (Client Satisfaction Questionnaire-8) outcomes at 4 months and treatment and service use costs at 12 months. Results: In total, 276 and 305 participants were randomised to Collaborative Care and usual Care respectively. Collaborative Care participants had a mean depression score that was 1.33 PHQ-9 points lower [n = 230; 95% confidence interval (CI) 0.35 to 2.31; p = 0.009] than that of participants in usual Care at 4 months and 1.36 PHQ-9 points lower (n = 275; 95% CI 0.07 to 2.64; p = 0.04) at 12 months after adjustment for baseline depression (effect size 0.28, 95% CI 0.01 to 0.52; odds ratio for recovery 1.88, 95% CI 1.28 to 2.75; number needed to treat 6.5). Quality of mental health but not physical health was significantly better for Collaborative Care at 4 months but not at 12 months. There was no difference for anxiety. Participants receiving Collaborative Care were significantly more satisfied with treatment. Differences between groups had disappeared at 36 months. Collaborative Care had a mean cost of £272.50 per participant with similar health and social Care service use between Collaborative Care and usual Care. Collaborative Care offered a mean incremental gain of 0.02 (95% CI –0.02 to 0.06) quality-adjusted life-years (QALYs) over 12 months at a mean incremental cost of £270.72 (95% CI –£202.98 to £886.04) and had an estimated mean cost per QALY of £14,248, which is below current UK willingness-to-pay thresholds. Sensitivity analyses including informal Care costs indicated that Collaborative Care is expected to be less costly and more effective. The amount of participant behavioural activation was the only effect mediator. Conclusions: Collaborative Care improves depression up to 12 months after initiation of the intervention, is preferred by patients over usual Care, offers health gains at a relatively low cost, is cost-effective compared with usual Care and is mediated by patient activation. Supervision was by expert clinicians and of short duration and more intensive therapy may have improved outcomes. In addition, one participant requiring inpatient treatment incurred very significant costs and substantially inflated our cost per QALY estimate. Future work should test enhanced intervention content not Collaborative Care per se. Trial registration: Current Controlled Trials ISRCTN32829227. Funding: This project was funded by the Medical Research Council (MRC) (G0701013) and managed by the National Institute for Health Research (NIHR) on behalf of the MRC–NIHR partnership
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integrated primary Care for patients with mental and physical multimorbidity cluster randomised controlled trial of Collaborative Care for patients with depression comorbid with diabetes or cardiovascular disease
BMJ, 2015Co-Authors: Peter A. Coventry, Peter Bower, Karina Lovell, Chris Dickens, Carolyn Chewgraham, Mark Hann, Andrea Cherrington, Charlotte Garrett, Damien Mcelvenny, Chris GibbonsAbstract:Objective To test the effectiveness of an integrated Collaborative Care model for people with depression and long term physical conditions. Design Cluster randomised controlled trial. Setting 36 general practices in the north west of England. Participants 387 patients with a record of diabetes or heart disease, or both, who had depressive symptoms (≥10 on patient health questionaire-9 (PHQ-9)) for at least two weeks. Mean age was 58.5 (SD 11.7). Participants reported a mean of 6.2 (SD 3.0) long term conditions other than diabetes or heart disease; 240 (62%) were men; 360 (90%) completed the trial. Interventions Collaborative Care included patient preference for behavioural activation, cognitive restructuring, graded exposure, and/or lifestyle advice, management of drug treatment, and prevention of relapse. Up to eight sessions of psychological treatment were delivered by specially trained psychological wellbeing practitioners employed by Improving Access to Psychological Therapy services in the English National Health Service; integration of Care was enhanced by two treatment sessions delivered jointly with the practice nurse. Usual Care was standard clinical practice provided by general practitioners and practice nurses. Main outcome measures The primary outcome was reduction in symptoms of depression on the self reported symptom checklist-13 depression scale (SCL-D13) at four months after baseline assessment. Secondary outcomes included anxiety symptoms (generalised anxiety disorder 7), self management (health education impact questionnaire), disability (Sheehan disability scale), and global quality of life (WHOQOL-BREF). Results 19 general practices were randomised to Collaborative Care and 20 to usual Care; three practices withdrew from the trial before patients were recruited. 191 patients were recruited from practices allocated to Collaborative Care, and 196 from practices allocated to usual Care. After adjustment for baseline depression score, mean depressive scores were 0.23 SCL-D13 points lower (95% confidence interval −0.41 to −0.05) in the Collaborative Care arm, equal to an adjusted standardised effect size of 0.30. Patients in the intervention arm also reported being better self managers, rated their Care as more patient centred, and were more satisfied with their Care. There were no significant differences between groups in quality of life, disease specific quality of life, self efficacy, disability, and social support. Conclusions Collaborative Care that incorporates brief low intensity psychological therapy delivered in partnership with practice nurses in primary Care can reduce depression and improve self management of chronic disease in people with mental and physical multimorbidity. The size of the treatment effects were modest and were less than the prespecified effect but were achieved in a trial run in routine settings with a deprived population with high levels of mental and physical multimorbidity. Trial registration ISRCTN80309252.
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characteristics of effective Collaborative Care for treatment of depression a systematic review and meta regression of 74 randomised controlled trials
PLOS ONE, 2014Co-Authors: Peter A. Coventry, Evangelos Kontopantelis, Karina Lovell, Simon Gilbody, Chris Dickens, Janine Archer, David Richards, Linda Gask, Joanna L Hudson, Waquas WaheedAbstract:Background Collaborative Care is a complex intervention based on chronic disease management models and is effective in the management of depression. However, there is still uncertainty about which components of Collaborative Care are effective. We used meta-regression to identify factors in Collaborative Care associated with improvement in patient outcomes (depressive symptoms) and the process of Care (use of anti-depressant medication). Methods and Findings Systematic review with meta-regression. The Cochrane Collaboration Depression, Anxiety and Neurosis Group trials registers were searched from inception to 9th February 2012. An update was run in the CENTRAL trials database on 29th December 2013. Inclusion criteria were: randomised controlled trials of Collaborative Care for adults ≥18 years with a primary diagnosis of depression or mixed anxiety and depressive disorder. Random effects meta-regression was used to estimate regression coefficients with 95% confidence intervals (CIs) between study level covariates and depressive symptoms and relative risk (95% CI) and anti-depressant use. The association between anti-depressant use and improvement in depression was also explored. Seventy four trials were identified (85 comparisons, across 21,345 participants). Collaborative Care that included psychological interventions predicted improvement in depression (β coefficient −0.11, 95% CI −0.20 to −0.01, p = 0.03). Systematic identification of patients (relative risk 1.43, 95% CI 1.12 to 1.81, p = 0.004) and the presence of a chronic physical condition (relative risk 1.32, 95% CI 1.05 to 1.65, p = 0.02) predicted use of anti-depressant medication. Conclusion Trials of Collaborative Care that included psychological treatment, with or without anti-depressant medication, appeared to improve depression more than those without psychological treatment. Trials that used systematic methods to identify patients with depression and also trials that included patients with a chronic physical condition reported improved use of anti-depressant medication. However, these findings are limited by the observational nature of meta-regression, incomplete data reporting, and the use of study aggregates.
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impact of telephone delivered case management on the effectiveness of Collaborative Care for depression and anti depressant use a systematic review and meta regression
PLOS ONE, 2019Co-Authors: Joanna L Hudson, Peter Bower, Evangelos Kontopantelis, Simon Gilbody, Janine Archer, David Richards, Penny Bee, Rose Clarke, Andrew S Moriarty, Karina LovellAbstract:Background The health service delivery framework Collaborative Care is an effective intervention for depression. However, uncertainties remain about how to optimise its delivery at scale. Structured case management is a core component of Collaborative Care; its delivery via the telephone may improve access. Aims To examine using meta-regression if telephone delivered case management diminishes the clinical effectiveness of Collaborative Care on depressive symptoms and anti-depressant use relative to face-to-face delivery methods. Methods Randomised controlled trials were eligible if they included Collaborative Care interventions for adults with depression identified using self-report measures or diagnostic interviews and reported depression outcomes. Sociodemographics, intervention characteristics, depressive symptoms, and anti-depressant use were extracted. Random effects univariable and multivariable meta-regression analyses were used to examine the moderating effect of telephone delivered case-management on outcomes. Results Ninety-four trials were identified comprising of 103 comparisons across 24, 132 participants with depression outcomes and 67 comparisons from 15,367 participants with anti-depressant use outcomes. Telephone delivered case management did not diminish the effects of Collaborative Care on depressive symptoms (β = -0.01, 95% CI -0.12 to 0.10; p = 0.86). Telephone delivered case management decreased anti-depressant medication use (relative risk 0.76, 95% CI 0.63 to 0.92; p = 0.005); this effect remained when assessed simultaneously alongside other study-level moderators of Collaborative Care. Conclusion Using remote platforms such as the telephone to deliver case management may be a feasible way to implement Collaborative Care with no loss of effectiveness on depressive symptoms. However, adherence to anti-depressant medication may decrease when telephone case management is used.
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association between chronic physical conditions and the effectiveness of Collaborative Care for depression an individual participant data meta analysis
JAMA Psychiatry, 2016Co-Authors: Maria Panagioti, Peter Bower, Evangelos Kontopantelis, Karina Lovell, Simon Gilbody, Waquas Waheed, Chris Dickens, Janine Archer, Gregory E Simon, Kathleen EllAbstract:IMPORTANCE: Collaborative Care is an intensive Care model involving several health Care professionals working together, typically a physician, a case manager, and a mental health professional. Meta-analyses of aggregate data have shown that Collaborative Care is particularly effective in people with depression and comorbid chronic physical conditions. However, only participant-level analyses can rigorously test whether the treatment effect is influenced by participant characteristics, such as chronic physical conditions. OBJECTIVE: To assess whether the effectiveness of Collaborative Care for depression is moderated by the presence, type, and number of chronic physical conditions. DATA SOURCES: Data were obtained from MEDLINE, EMBASE, PubMed, PsycINFO, CINAHL Complete, and Cochrane Central Register of Controlled Trials, and references from relevant systematic reviews. The search and collection of eligible studies was ongoing until May 22, 2015. STUDY SELECTION: This was an update to a previous meta-analysis. Two independent reviewers were involved in the study selection process. Randomized clinical trials that compared the effectiveness of Collaborative Care with usual Care in adults with depression and reported measured changes in depression severity symptoms at 4 to 6 months after randomization were included in the analysis. Key search terms included depression, dysthymia, anxiety, panic, phobia, obsession, compulsion, posttraumatic, Care management, case management, Collaborative Care, enhanced Care, and managed Care. DATA EXTRACTION AND SYNTHESIS: Individual participant data on baseline demographics and chronic physical conditions as well as baseline and follow-up depression severity symptoms were requested from authors of the eligible studies. One-step meta-analysis of individual participant data using appropriate mixed-effects models was performed. MAIN OUTCOMES AND MEASURES: Continuous outcomes of depression severity symptoms measured using self-reported or observer-rated measures. RESULTS: Data sets from 31 randomized clinical trials including 36 independent comparisons (N = 10 962 participants) were analyzed. Individual participant data analyses found no significant interaction effects, indicating that the presence (interaction coefficient, 0.02 [95% CI, -0.10 to 0.13]), numbers (interaction coefficient, 0.01 [95% CI, -0.01 to 0.02]), and types of chronic physical conditions do not influence the treatment effect. CONCLUSIONS AND RELEVANCE: There is evidence that Collaborative Care is effective for people with depression alone and also for people with depression and chronic physical conditions. Existing guidance that recommends limiting Collaborative Care to people with depression and physical comorbidities is not supported by this individual participant data meta-analysis.
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Clinical effectiveness and cost-effectiveness of Collaborative Care for depression in UK primary Care (CADET): a cluster randomised controlled trial
NIHR Journals Library, 2016Co-Authors: David A Richards, Peter Bower, Karina Lovell, Linda Gask, John Cape, Stephen Pilling, Ricardo Araya, David Kessler, Carolyn Chew-graham, Michael BarkhamAbstract:Background: Collaborative Care is effective for depression management in the USA. There is little UK evidence on its clinical effectiveness and cost-effectiveness. Objective: To determine the clinical effectiveness and cost-effectiveness of Collaborative Care compared with usual Care in the management of patients with moderate to severe depression. Design: Cluster randomised controlled trial. Setting: UK primary Care practices (n = 51) in three UK primary Care districts. Participants: A total of 581 adults aged ≥ 18 years in general practice with a current International Classification of Diseases, Tenth Edition depressive episode, excluding acutely suicidal people, those with psychosis, bipolar disorder or low mood associated with bereavement, those whose primary presentation was substance abuse and those receiving psychological treatment. Interventions: Collaborative Care: 14 weeks of 6–12 telephone contacts by Care managers; mental health specialist supervision, including depression education, medication management, behavioural activation, relapse prevention and primary Care liaison. Usual Care was general practitioner standard practice. Main outcome measures: Blinded researchers collected depression [Patient Health Questionnaire-9 (PHQ-9)], anxiety (General Anxiety Disorder-7) and quality of life (European Quality of Life-5 Dimensions three-level version), Short Form questionnaire-36 items) outcomes at 4, 12 and 36 months, satisfaction (Client Satisfaction Questionnaire-8) outcomes at 4 months and treatment and service use costs at 12 months. Results: In total, 276 and 305 participants were randomised to Collaborative Care and usual Care respectively. Collaborative Care participants had a mean depression score that was 1.33 PHQ-9 points lower [n = 230; 95% confidence interval (CI) 0.35 to 2.31; p = 0.009] than that of participants in usual Care at 4 months and 1.36 PHQ-9 points lower (n = 275; 95% CI 0.07 to 2.64; p = 0.04) at 12 months after adjustment for baseline depression (effect size 0.28, 95% CI 0.01 to 0.52; odds ratio for recovery 1.88, 95% CI 1.28 to 2.75; number needed to treat 6.5). Quality of mental health but not physical health was significantly better for Collaborative Care at 4 months but not at 12 months. There was no difference for anxiety. Participants receiving Collaborative Care were significantly more satisfied with treatment. Differences between groups had disappeared at 36 months. Collaborative Care had a mean cost of £272.50 per participant with similar health and social Care service use between Collaborative Care and usual Care. Collaborative Care offered a mean incremental gain of 0.02 (95% CI –0.02 to 0.06) quality-adjusted life-years (QALYs) over 12 months at a mean incremental cost of £270.72 (95% CI –£202.98 to £886.04) and had an estimated mean cost per QALY of £14,248, which is below current UK willingness-to-pay thresholds. Sensitivity analyses including informal Care costs indicated that Collaborative Care is expected to be less costly and more effective. The amount of participant behavioural activation was the only effect mediator. Conclusions: Collaborative Care improves depression up to 12 months after initiation of the intervention, is preferred by patients over usual Care, offers health gains at a relatively low cost, is cost-effective compared with usual Care and is mediated by patient activation. Supervision was by expert clinicians and of short duration and more intensive therapy may have improved outcomes. In addition, one participant requiring inpatient treatment incurred very significant costs and substantially inflated our cost per QALY estimate. Future work should test enhanced intervention content not Collaborative Care per se. Trial registration: Current Controlled Trials ISRCTN32829227. Funding: This project was funded by the Medical Research Council (MRC) (G0701013) and managed by the National Institute for Health Research (NIHR) on behalf of the MRC–NIHR partnership
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integrated primary Care for patients with mental and physical multimorbidity cluster randomised controlled trial of Collaborative Care for patients with depression comorbid with diabetes or cardiovascular disease
BMJ, 2015Co-Authors: Peter A. Coventry, Peter Bower, Karina Lovell, Chris Dickens, Carolyn Chewgraham, Mark Hann, Andrea Cherrington, Charlotte Garrett, Damien Mcelvenny, Chris GibbonsAbstract:Objective To test the effectiveness of an integrated Collaborative Care model for people with depression and long term physical conditions. Design Cluster randomised controlled trial. Setting 36 general practices in the north west of England. Participants 387 patients with a record of diabetes or heart disease, or both, who had depressive symptoms (≥10 on patient health questionaire-9 (PHQ-9)) for at least two weeks. Mean age was 58.5 (SD 11.7). Participants reported a mean of 6.2 (SD 3.0) long term conditions other than diabetes or heart disease; 240 (62%) were men; 360 (90%) completed the trial. Interventions Collaborative Care included patient preference for behavioural activation, cognitive restructuring, graded exposure, and/or lifestyle advice, management of drug treatment, and prevention of relapse. Up to eight sessions of psychological treatment were delivered by specially trained psychological wellbeing practitioners employed by Improving Access to Psychological Therapy services in the English National Health Service; integration of Care was enhanced by two treatment sessions delivered jointly with the practice nurse. Usual Care was standard clinical practice provided by general practitioners and practice nurses. Main outcome measures The primary outcome was reduction in symptoms of depression on the self reported symptom checklist-13 depression scale (SCL-D13) at four months after baseline assessment. Secondary outcomes included anxiety symptoms (generalised anxiety disorder 7), self management (health education impact questionnaire), disability (Sheehan disability scale), and global quality of life (WHOQOL-BREF). Results 19 general practices were randomised to Collaborative Care and 20 to usual Care; three practices withdrew from the trial before patients were recruited. 191 patients were recruited from practices allocated to Collaborative Care, and 196 from practices allocated to usual Care. After adjustment for baseline depression score, mean depressive scores were 0.23 SCL-D13 points lower (95% confidence interval −0.41 to −0.05) in the Collaborative Care arm, equal to an adjusted standardised effect size of 0.30. Patients in the intervention arm also reported being better self managers, rated their Care as more patient centred, and were more satisfied with their Care. There were no significant differences between groups in quality of life, disease specific quality of life, self efficacy, disability, and social support. Conclusions Collaborative Care that incorporates brief low intensity psychological therapy delivered in partnership with practice nurses in primary Care can reduce depression and improve self management of chronic disease in people with mental and physical multimorbidity. The size of the treatment effects were modest and were less than the prespecified effect but were achieved in a trial run in routine settings with a deprived population with high levels of mental and physical multimorbidity. Trial registration ISRCTN80309252.
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cost effectiveness of Collaborative Care for depression in uk primary Care economic evaluation of a randomised controlled trial cadet
PLOS ONE, 2014Co-Authors: Colin Green, Peter Bower, Karina Lovell, Carolyn Chewgraham, David Richards, Linda Gask, Jacqueline J Hill, John Cape, Stephen Pilling, Ricardo ArayaAbstract:Background Collaborative Care is an effective treatment for the management of depression but evidence on its cost-effectiveness in the UK is lacking. Aims To assess the cost-effectiveness of Collaborative Care in a UK primary Care setting. Methods An economic evaluation alongside a multi-centre cluster randomised controlled trial comparing Collaborative Care with usual primary Care for adults with depression (n = 581). Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICER) were calculated over a 12-month follow-up, from the perspective of the UK National Health Service and Personal Social Services (i.e. Third Party Payer). Sensitivity analyses are reported, and uncertainty is presented using the cost-effectiveness acceptability curve (CEAC) and the cost-effectiveness plane. Results The Collaborative Care intervention had a mean cost of �272.50 per participant. Health and social Care service use, excluding Collaborative Care, indicated a similar profile of resource use between Collaborative Care and usual Care participants. Collaborative Care offered a mean incremental gain of 0.02 (95% CI: ?0.02, 0.06) quality-adjusted life-years over 12 months, at a mean incremental cost of �270.72 (95% CI: ?202.98, 886.04), and resulted in an estimated mean cost per QALY of �14,248. Where costs associated with informal Care are considered in sensitivity analyses Collaborative Care is expected to be less costly and more effective, thereby dominating treatment as usual. Conclusion Collaborative Care offers health gains at a relatively low cost, and is cost-effective compared with usual Care against a decision-maker willingness to pay threshold of �20,000 per QALY gained. Results here support the commissioning of Collaborative Care in a UK primary Care setting.