Collaborative Care for Depressed Patients With Chronic Medical Conditions: A Randomized Trial in Puerto Rico
| Autor: | Mae Lynn Reyes-Rodríguez, Mildred Vera, Coralee Pérez-Pedrogo, Aracelis Huertas, Sarah E. Huertas, Deborah Juarbe, William F. Chaplin, María L Reyes-Rabanillo |
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| Jazyk: | angličtina |
| Rok vydání: | 2010 |
| Předmět: |
Adult
Male medicine.medical_specialty Interprofessional Relations Collaborative Care Comorbidity Article Quality of life (healthcare) Ambulatory care Sertraline Health care Medicine Humans Cooperative Behavior Psychiatry Curative care Aged Patient Care Team Depressive Disorder Major Cognitive Behavioral Therapy business.industry Public health Managed Care Programs Puerto Rico Primary care physician Middle Aged Mental health Combined Modality Therapy Antidepressive Agents Psychiatry and Mental health Treatment Outcome Chronic Disease Female business Social Adjustment Selective Serotonin Reuptake Inhibitors geographic locations |
| DOI: | 10.17615/j07s-0t45 |
| Popis: | Major depression, one of the most common mental disorders worldwide, is associated with substantial disability, reduced quality of life, and increased mortality (1,2). Individuals living with depression often have comorbid general medical conditions (3,4). The World Health Organization (WHO) World Health Survey found that although the prevalence of depression among participants without chronic general medical conditions was 3.2%, the prevalence among those with such co-occurring conditions ranged from 9.3% for people with one condition to up to 23% for those with two or more chronic conditions (5). Furthermore, the worst health status was experienced by individuals with comorbid depression and chronic general medical conditions. These findings indicate that depression contributes to the burden of disease worldwide, and they highlight the importance of addressing depression as a public health priority (5). Despite the major impact of depression, most of those in need of treatment do not receive care. Although depressed individuals tend to be high users of primary care services, few cases are recognized at this critical point of entry into the health system (6). Even among those who received a diagnosis, rates of adequate treatment are low (7,8). Improving the management of depression in primary care is fundamental to the WHO global policy for mental health (7). Recently, WHO issued a report calling for action to scale up the integration of mental health into primary care systems around the world. This population-based strategy is considered to be essential to reach the large number of depressed individuals who are managed solely in primary care. Over the past decades, a variety of approaches to improve the recognition and management of depression in primary care have been implemented (9). Initial interventions focused on clinician educational strategies such as individual and group-based teaching, dissemination of guidelines, and use of local opinion leaders. A synthesis report that examined the effectiveness of these capacity-building strategies concluded that they were largely ineffective in improving patient recognition or outcomes when provided alone (10). In recent years, a substantial number of rigorous studies have focused on evaluating the impact of collaborative care interventions. Particular attention has been directed toward high-risk groups, such as patients with coexisting general medical illnesses (11–15). Gilbody and colleagues (16) conducted a formal meta-analysis of studies that met the criteria for collaborative care. Collaborative care was defined as a comprehensive intervention in which at least two out of three types of professional (care manager, primary care physician, and mental health specialist) worked collaboratively in a primary care setting. Strategies common to most models included a redesign of the delivery of services to include screening, training, and routine follow-up of patients during and after treatment. The results of this review overwhelmingly supported the effectiveness of collaborative care models in improving patient adherence to treatment and clinical outcomes. The authors concluded that in the United States sufficient evidence had emerged by 2000 to demonstrate the effectiveness of collaborative care models. However, they noted that further research was needed to examine whether these findings could be replicated in health settings other than in the United States. The past several years have shown an increased interest in improving collaboration between the mental health and general health care systems in Puerto Rico, for several reasons. Approximately 1.5 million residents, or 38% of Puerto Rico's population, are enrolled in public insurance programs where mental health services are provided by carve-out specialty groups (17). The Health Evaluation Commission, appointed in 2005 by the governor of Puerto Rico to assess the status of the health care system, noted that mental health care is fragmented and disjointed, lacking a comprehensive response to the nature and scope of existing mental health problems (18). The commission concluded that the existing model of health services delivery needed to be changed and called for integrated general medical and mental health programs focused on the delivery of services in a unified and holistic manner. An important step in paving the way for the integration of services in Puerto Rico is to identify models for managing depression that contribute to improved treatment outcomes in the general health care system. The randomized controlled trial reported here was designed to examine whether a collaborative care model for depression would improve clinical and functional outcomes for depressed primary care patients with chronic medical conditions in Puerto Rico. We focused on patients with comorbid conditions because they have been shown to have increased use of health services (19–21) and worse depression treatment outcomes (22). We hypothesized that patients with comorbid conditions in the collaborative care model would have fewer depression symptoms and higher levels of functioning compared with patients in usual care. |
| Databáze: | OpenAIRE |
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