Dataset Information

The Role of Primary Care Experiences in Obtaining Treatment for Depression.

ABSTRACT:

Background

Managing depression in primary care settings has increased with the rise of integrated models of care, such as patient-centered medical homes (PCMHs). The relationship between patient experience in PCMH settings and receipt of depression treatment is unknown.

Objective

In a large sample of Veterans diagnosed with depression, we examined whether positive PCMH experiences predicted subsequent initiation or continuation of treatment for depression.

Design and participants

We conducted a lagged cross-sectional study of depression treatment among Veterans with depression diagnoses (n?=?27,362) in the years before (Y1) and after (Y2) they completed the Veterans Health Administration's national 2013 PCMH Survey of Healthcare Experiences of Patients.

Main measures

We assessed patient experiences in four domains, each categorized as positive/moderate/negative. Depression treatment, determined from administrative records, was defined annually as 90 days of antidepressant medications or six psychotherapy visits. Multivariable logistic regressions measured associations between PCMH experiences and receipt of depression treatment in Y2, accounting for treatment in Y1.

Key results

Among those who did not receive depression treatment in Y1 (n?=?4613), positive experiences in three domains (comprehensiveness, shared decision-making, self-management support) predicted greater initiation of treatment in Y2. Among those who received depression treatment in Y1 (n?=?22,749), positive or moderate experiences in four domains (comprehensiveness, care coordination, medication decision-making, self-management support) predicted greater continuation of treatment in Y2.

Conclusions

In a national PCMH setting, patient experiences with integrated care, including care coordination, comprehensiveness, involvement in shared decision-making, and self-management support predicted patients' subsequent initiation and continuation of depression treatment over time-a relationship that could affect physical and mental health outcomes.

SUBMITTER: Jones AL

PROVIDER: S-EPMC6082202 | biostudies-literature | 2018 Aug

REPOSITORIES: biostudies-literature

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Publications

The Role of Primary Care Experiences in Obtaining Treatment for Depression.

Jones Audrey L AL Mor Maria K MK Haas Gretchen L GL Gordon Adam J AJ Cashy John P JP Schaefer James H JH Hausmann Leslie R M LRM

Journal of general internal medicine 20180608 8

<h4>Background</h4>Managing depression in primary care settings has increased with the rise of integrated models of care, such as patient-centered medical homes (PCMHs). The relationship between patient experience in PCMH settings and receipt of depression treatment is unknown.<h4>Objective</h4>In a large sample of Veterans diagnosed with depression, we examined whether positive PCMH experiences predicted subsequent initiation or continuation of treatment for depression.<h4>Design and participan ...[more]

PMID: 29948804

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Project description:BackgroundPrimary care providers encounter a large proportion of the population with depression. Yet, many primary care patients with depression remain undiagnosed and untreated.ObjectiveThis study aims to examine depression screening patterns and the role of screening in depression diagnosis and treatment in the outpatient primary care setting.DesignThis is a cross-sectional analysis of nationally representative survey data of visits to outpatient physician offices from the 2005 to 2015 National Ambulatory Medical Care Surveys.ParticipantsThe sample included the first visit in the past year to a primary care provider by patients 12 years and older (N?=?16,887).MethodsThe associations of visit characteristics with depression screening and of depression screening with depression diagnosis and treatment during the visit were assessed using logistic regression. Logistic regression with propensity score weighting was used to estimate the odds of depression diagnosis and treatment under the counterfactual scenario in which patients who visited providers with lower depression screening rates had visited providers with higher screening rates instead. All models were adjusted for patient and visit characteristics.Key resultsA small proportion of sample visits involved depression screening (3.0%). Visits by patients with depressive symptom complaints were associated with higher odds of depression screening than other visits. When visits were weighted to have similar demographic and clinical characteristics, visits to providers with higher screening rates had higher odds of diagnosis (OR?=?1.99, p?<?0.001) and treatment (OR?=?1.61, p?=?0.001) compared to visits to providers with lower screening rates.ConclusionsPhysicians appear to use depression screening selectively based on patients' presenting symptoms. Higher screening rates were associated with higher odds of depression diagnosis and treatment, and even modest increases in screening rates could meaningfully increase population-level rates of depression identification and treatment in primary care. Future research is needed to identify barriers to depression care and implement systematic interventions to improve services and patient outcomes.

Project description:Importance:Nonadherence to antidepressant medication is common and leads to poor outcomes. Early nonadherence is especially problematic. Objective:To test the effectiveness of a psychosocial intervention to improve early adherence among older patients whose primary care physician newly initiated an antidepressant for depression. Design, Setting, and Participants:The Treatment Initiation and Participation Program (TIP) was offered in a 2-site randomized clinical effectiveness study between January 2011 and December 2014 at primary care practices in New York, New York, and Ann Arbor, Michigan. Analyses began in February 2016. All participants were middle-aged and older adults (aged ?55 years) who received newly initiated depression treatment by their primary care physician and recruited within 10 days of their prescription. Analyses were intention-to-treat. Interventions:Participants were randomly assigned to the intervention (TIP) or treatment as usual. Participants in the TIP group identified and addressed barriers to adherence, including stigma, misconceptions, and fears about treatment, before developing a personalized adherence strategy. The Treatment Initiation and Participation Program was delivered in three 30-minute contacts scheduled during a 6-week period just after the antidepressant was prescribed. Main Outcomes and Measures:The primary outcome was self-reported adherence on the Brief Medication Questionnaire, with adequate early adherence defined as taking 80% or more of the prescribed doses at 6 and 12 weeks. The secondary outcome was depression severity. Results:In total, 231 middle-aged and older adults (167 women [72.3%] and 64 men [27.7%]) without significant cognitive impairment were randomly assigned to the TIP intervention (n?=?115) or treatment as usual (n?=?116). Participants had a mean (SD) age of 67.3 (8.4) years. Participants in the TIP group were 5 times more likely to be adherent at 6 weeks (odds ratio,?5.54; 95% CI, 2.57 to 11.96; ?21?=?19.05; P?<?.001) and 3 times more likely to be adherent at both 6 and 12 weeks (odds ratio,?3.27; 95% CI, 1.73 to 6.17; ?21?=?13.34; P?<?.001). Participants in the TIP group showed a significant earlier reduction (24.9%) in depressive symptoms (95% CI, 13.9 to 35.9; t337?=?4.46; adjusted P?<?.001). In both groups, participants who were 80% adherent at weeks 6 and 12 had a 15% greater improvement in depressive symptoms from baseline over the course of treatment (95% CI, -0.2 to -30; t369?=?1.93; P?=?.051). Conclusions and Relevance:The Treatment Initiation and Participation Program is an effective intervention to improve early adherence to pharmacotherapy. Improved adherence can promote improvement in depression. Trial Registration:clinicaltrials.gov Identifier: NCT01301859.

Project description:INTRODUCTION:Nearly 50% of depressed primary care patients referred to mental health services do not initiate mental health treatment. The most promising interventions for increasing depression treatment initiation in primary care settings remain unclear. METHODS:We performed a systematic search of publicly available databases from inception through August 2017 to identify interventions designed to increase depression treatment initiation. Two authors independently selected, extracted data, and rated risk of bias from included studies. Eligible studies used a randomized or pre-post design and assessed depression treatment initiation (i.e., ≥ 1 mental health visit or antidepressant fill) among adults, the majority of whom met criteria for depression. Interventions were classified as simple or complex and sub-classified into intervention strategies that were graded for strength of evidence. RESULTS:Of 9516 articles identified, we included 14 unique studies representing 16 (4 simple and 12 complex) interventions and 8 treatment initiation strategies. We found low to moderate strength of evidence for collaborative/integrated care (3 studies), treatment preference matching (2 studies), and case management (2 studies) strategies. However, there was insufficient evidence to determine the benefit of cultural tailoring (2 studies), motivation (alone, with reminders or with cultural tailoring (5 studies)), education (1 study), and shared decision-making strategies (1 study). Overall, we found moderate strength of evidence for complex interventions (8 of 12 complex interventions demonstrated statistically significant effects on treatment initiation). DISCUSSION:Collaborative/integrated care, preference treatment matching, and case management strategies had the best evidence for improving depression treatment initiation, but none of the strategies had high strength of evidence. While primary care settings can consider using some of these strategies when referring depressed patients to treatment, our review highlights the need for further rigorous research in this area.

Dataset Information

The Role of Primary Care Experiences in Obtaining Treatment for Depression.

Background

Objective

Design and participants

Main measures

Key results

Conclusions

Publications

The Role of Primary Care Experiences in Obtaining Treatment for Depression.

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