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Improving Depression Treatment in Primary Care: The Collaborative Care Model

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Improving Depression Treatment in Primary Care: The Collaborative Care Model

 

July 26, 2010

Wayne J. Katon, MD

 

Professor and Vice-Chair, Department of Psychiatry & Behavioral Sciences; Director, Health Services Research and Psychiatric Epidemiology Division; University of Washington School of Medicine

First published in Psychiatry Weekly, Volume 5, Issue 18, on July 26, 2010.


Introduction

In 1995, Dr. Wayne Katon and colleagues published the first study on a “multifaceted intervention” for patients with depression who were receiving treatment from a primary care physician (PCP), which they termed collaborative care. Patients receiving this type of care had more frequent and more intense clinical visits—alternating between PCP and psychiatrist visits—in the weeks following diagnosis and onset of treatment, and additional education about their diagnosis. A 2006 meta-analysis on collaborative care included 37 like studies, with others emerging since then.

“The bottom line is that collaborative care models demonstrably increased adherence to antidepressants at proper doses by about two-fold, improved the quality of care, and improved depression outcomes in the first 6 months to 1 year of treatment,” says Dr. Katon. “In some instances, the quality of care improvements and improvement in depressive outcomes extended to 2–5 years.” Collaborative care has also been shown to improve patient satisfaction and quality of life compared to usual primary care.

Key Components of Collaborative Care

“Collaborative care has been done in different ways in different studies, but there are key components that have to be present,” says Dr. Katon. “The vast majority of studies embrace a team care approach that usually involves a care manager, who provides closer follow-up with the patient, provides enhanced education, and monitors the patient with phone calls and visits. A psychiatrist usually supervises the care manager, conducting weekly caseload supervision and recommending either initiation or adjustments to medications, which the care manager passes along to the PCP. Most trials have included a depression registry, logging dates, patients’ standard depression scale ratings, and details of medication or other therapy.”

Essentially, collaborative care provides a more direct and patient-centered treatment experience, hewing closer to existing treatment guidelines for depression and relieving the burden of care often placed on a single PCP. The data show clearly that patients receiving depression care from a PCP alone are more likely to be diagnosed inaccurately (or not at all), have poor medication adherence, and receive infrequent follow-up.

Models of Care

Dr. Katon also participated in the just completed TEAMCARE study (in revision for publication) comparing collaborative care to usual care for patients with natural clusters of illness—illnesses that tend to co-occur in primary care and adversely affect the outcomes of the other illnesses.

“Patients with poor control of diabetes or coronary artery disease were then screened for depression,” explains Dr. Katon. “If they had a PHQ-9 score of ≥10, a nurse was assigned to not only improve their depression care in the collaborative care realm but also their medical care. Similar to other studies, the nurses were supervised by a psychiatrist and PCP to provide decision support regarding medications. Our collaborative care intervention was associated with improved depression outcomes, as well as enhanced medical control.”

Collaborative care has also been shown to improve depressive outcomes in patients with comorbid depression and chronic medical comorbidities (“complicated” patients) and anxiety and depressive outcomes among patients with panic disorder, who frequently have comorbid depression. Cost effectiveness analyses suggest that collaborative care (and its improved outcomes) for uncomplicated depression costs slightly more than usual care—between $100−$500 more over the course of 12-month follow-up. For patients with depression and comorbid diabetes, as shown by the Pathways trial, improvement in the quality of depression care and depressive outcomes was associated with slightly higher mental healthcare costs that were offset by lower medical healthcare costs, resulting in less overall health spending. Patients with panic disorder plus depression, who often present in emergency departments with chest pain and undergo expensive diagnostics, also show reduced overall healthcare costs associated with collaborative care.

“Most new medical technologies cost more but lead to better outcomes,” says Dr. Katon. “I would argue that mental health is probably the only place where people hold us to a higher standard, in the sense that if you provide better care and get better outcomes you still have to save money before anyone gets interested. The cost-offset standard that mental healthcare is held to really buys into the stigma that it is different from other medical care, despite clear evidence that depression, for instance, is associated with equal or more impairment than people with any other chronic illness.”

Collaborative Care in Practice

This model is being disseminated in many organized healthcare systems. The Veterans Administration has mandated the integration of collaborative care in multiple primary care clinics throughout the US, and Kaiser Permanente has instituted collaborative care for 3−4 million patients in southern California. The state of Minnesota, along with the Institute for Clinical Systems Improvement, helped a group of health insurers to develop the Diamond Project, integrating collaborative care for ~80% of primary care patients in that state and, perhaps most importantly, devising payment mechanisms to properly reimburse the collaborative care manager and psychiatric supervision.

Conclusion

“There’s no doubt that collaborative care has been implemented more rapidly in large, organized systems of care,” says Dr. Katon. “The HMOs and VA probably have an easier time organizing care for chronic illness compared to small group practices. With the great success of the Diamond Project in Minnesota, it’s clear that if the insurance industry is provided proper incentives for improved patient outcomes, there will be more widespread implementation of collaborative care, not only for depression, but for diabetes, hypertension, etc., because the same problems we face in treating depression are also apparent in the lack of guideline-based care for many other chronic illnesses.”


Disclosure: Dr. Katon has served on the advisory board of Eli Lilly and Wyeth; and has received honoraria from Eli Lilly, Forest, Pfizer, and Wyeth.