The presentation, recognition and management of bipolar depression in primary care.
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ABSTRACT:
SUBMITTER: Cerimele JM
PROVIDER: S-EPMC3832714 | biostudies-other | 2013 Dec
REPOSITORIES: biostudies-other
Publications
The presentation, recognition and management of bipolar depression in primary care.
Cerimele Joseph M JM Chwastiak Lydia A LA Chan Ya-Fen YF Harrison David A DA Unützer Jürgen J
Journal of general internal medicine 20131201 12
Bipolar disorder is a mood disorder characterized by episodes of major depression and mania or hypomania. Most patients experience chronic symptoms of bipolar disorder approximately half of the time, most commonly subsyndromal depressive symptoms or a full depressive episode with concurrent manic symptoms. Consequently, patients with bipolar depression are often misdiagnosed with major depressive disorder. Individual patient characteristics and population screening tools may be helpful in improv ...[more]
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Project description:BackgroundDepression is prevalent in primary care (PC) practices and poses a considerable public health burden in the United States. Despite nearly four decades of efforts to improve depression care quality in PC practices, a gap remains between desired treatment outcomes and the reality of how depression care is delivered.ObjectiveThis article presents a real-world PC practice model of depression care, elucidating the processes and their influencing conditions.DesignGrounded theory methodology was used for the data collection and analysis to develop a depression care model. Data were collected from 70 individual interviews (60 to 70 min each), three focus group interviews (n = 24, 2 h each), two surveys per clinician, and investigators' field notes on practice environments. Interviews were audiotaped and transcribed for analysis. Surveys and field notes complemented interview data.ParticipantsSeventy primary care clinicians from 52 PC offices in the Midwest: 28 general internists, 28 family physicians, and 14 nurse practitioners.Key resultsA depression care model was developed that illustrates how real-world conditions infuse complexity into each step of the depression care process. Depression care in PC settings is mediated through clinicians' interactions with patients, practice, and the local community. A clinician's interactional familiarity ("familiarity capital") was a powerful facilitator for depression care. For the recognition of depression, three previously reported processes and three conditions were confirmed. For the management of depression, 13 processes and 11 conditions were identified. Empowering the patient was a parallel process to the management of depression.ConclusionsThe clinician's ability to develop and utilize interactional relationships and resources needed to recognize and treat a person with depression is key to depression care in primary care settings. The interactional context of depression care makes empowering the patient central to depression care delivery.
| S-EPMC3797334 | biostudies-literature
Project description:BackgroundAs a major public health issue in China and worldwide, late-life depression is associated with physical limitations, greater functional impairment, increased utilization and cost of health care, and suicide. Like other chronic diseases in elders such as hypertension and diabetes, depression is a chronic disease that the new National Health Policy of China indicates should be managed in primary care settings. Collaborative care, linking primary and mental health specialty care, has been shown to be effective for the treatment of late-life depression in primary care settings in Western countries. The primary aim of this project is to implement a depression care management (DCM) intervention, and examine its effectiveness on the depressive symptoms of older patients in Chinese primary care settings.Methods/designThe trial is a multi-site, primary clinic based randomized controlled trial design in Hangzhou, China. Sixteen primary care clinics will be enrolled in and randomly assigned to deliver either DCM or care as usual (CAU) (8 clinics each) to 320 patients (aged ≥ 60 years) with major depression (20/clinic; n = 160 in each treatment condition). In the DCM arm, primary care physicians (PCPs) will prescribe 16 weeks of antidepressant medication according to the treatment guideline protocol. Care managers monitor the progress of treatment and side effects, educate patients/family, and facilitate communication between providers; psychiatrists will provide weekly group psychiatric consultation and CM supervision. Patients in both DCM and CAU arms will be assessed by clinical research coordinators at baseline, 4, 8, 12, 18, and 24 months. Depressive symptoms, functional status, treatment stigma and clients' satisfaction will be used to assess patients' outcomes; and clinic practices, attitudes/knowledge, and satisfaction will be providers' outcomes.DiscussionThis will be the first trial of the effectiveness of a collaborative care intervention aiming to the management of late-life depression in China primary care. If effective, its finding will have relevance to policy makers who wish to scale up DCM treatments for late-life depression in national wide primary care across China.Study registrationThe DCM project is registered through the National Institutes of Health sponsored by clinical trials registry and has been assigned the identifier: NCT01287494.
| S-EPMC3105939 | biostudies-literature
Project description:BackgroundEvidence-based quality improvement models for depression have not been fully implemented in routine primary care settings. To date, few studies have examined the organizational factors associated with depression management in real-world primary care practice. To successfully implement quality improvement models for depression, there must be a better understanding of the relevant organizational structure and processes of the primary care setting. The objective of this study is to describe these organizational features of routine primary care practice, and the organization of depression care, using survey questions derived from an evidence-based framework.MethodsWe used this framework to implement a survey of 27 practices comprised of 49 unique offices within a large primary care practice network in western Pennsylvania. Survey questions addressed practice structure (e.g., human resources, leadership, information technology (IT) infrastructure, and external incentives) and process features (e.g., staff performance, degree of integrated depression care, and IT performance).ResultsThe results of our survey demonstrated substantial variation across the practice network of organizational factors pertinent to implementation of evidence-based depression management. Notably, quality improvement capability and IT infrastructure were widespread, but specific application to depression care differed between practices, as did coordination and communication tasks surrounding depression treatment.ConclusionsThe primary care practices in the network that we surveyed are at differing stages in their organization and implementation of evidence-based depression management. Practical surveys such as this may serve to better direct implementation of these quality improvement strategies for depression by improving understanding of the organizational barriers and facilitators that exist within both practices and practice networks. In addition, survey information can inform efforts of individual primary care practices in customizing intervention strategies to improve depression management.
| S-EPMC2813228 | biostudies-literature
Project description:OBJECTIVE:This study examined whether psychiatric case review was associated with depression medication modification in a large implementation program of collaborative care for depression in safety-net primary care clinics. METHODS:Registry data were examined from an implementation of the collaborative care model in Washington State. A total of 14,960 adults from 178 primary care clinics who initiated care between January 1, 2008, and September 30, 2014, and who had a baseline Patient Health Questionnaire-9 (PHQ-9) score of 10 or higher were included. Rates of psychiatric case reviews and receipt of new depression medications were extracted from the registry for all patients and for a subset of patients who did not improve by eight weeks of treatment (did not achieve a PHQ-9 score of less than 10 or a reduction in PHQ-9 score of 50% or more, compared with baseline). RESULTS:One-half of patients received a new depression medication. Psychiatric case review in any given month was associated with a doubling of the probability of receiving a new medication in the following month. Among patients who did not improve by eight weeks of treatment, a psychiatric case review during weeks 8-12 was associated with a higher rate of receipt of new medications during weeks 8-16 or weeks 8-20. CONCLUSIONS:In a collaborative care program, psychiatric case review was associated with higher rates of subsequent receipt of a new depression medication. This finding supports the importance of psychiatric case review in reducing clinical inertia in collaborative care treatment of depression.
| S-EPMC6063310 | biostudies-literature
Project description:ObjectivesTo describe the population presenting to out-of-hours primary care with insect bites, establish their clinical management and the factors associated with antibiotic prescribing.DesignAn observational study using routinely collected data from a large out-of-hours database (BORD, Birmingham Out-of-hours general practice Research Database).SettingA large out-of-hour primary care provider in the Midlands region of England.ParticipantsAll patients presenting with insect bites between July 2013 and February 2020 were included comprising 5774 encounters.Outcome measuresThis cohort was described, and a random subcohort was created for more detailed analysis which established the clinical features of the presenting insect bites. Logistic regression was used to model variables associated with antibiotic prescribing.ResultsOf the 5641 encounters solely due to insect bites, 67.1% (95% CI 65.8% to 68.3%) were prescribed antibiotics. General practitioners were less likely to prescribe antibiotics than advanced nurse practitioners (60.5% vs 71.1%, p<0.001) and there was a decreasing trend in antibiotic prescribing as patient deprivation increased. Pain (OR 2.13, 95% CI 1.18 to 3.86), swelling (OR 2.88, 95% CI 1.52 to 5.46) and signs of spreading (OR 3.45, 95% CI 1.54 to 7.70) were associated with an increased frequency of antibiotic prescribing. Extrapolation of the findings give an estimated incidence of insect bite consultations in England of 1.5 million annually.ConclusionTwo-thirds of the patients presenting to out-of-hours primary care with insect bites receive antibiotics. While some predictors of prescribing have been found, more research is required to understand the optimal use of antibiotics for this common presentation.
| S-EPMC10503338 | biostudies-literature
Project description:BACKGROUND: Most evidence on the effect of collaborative care for depression is derived in the selective environment of randomised controlled trials. In collaborative care, practice nurses may act as case managers. The Primary Care Services Improvement Project (PCSIP) aimed to assess the cost-effectiveness of alternative models of practice nurse involvement in a real world Australian setting. Previous analyses have demonstrated the value of high level practice nurse involvement in the management of diabetes and obesity. This paper reports on their value in the management of depression. METHODS: General practices were assigned to a low or high model of care based on observed levels of practice nurse involvement in clinical-based activities for the management of depression (i.e. percentage of depression patients seen, percentage of consultation time spent on clinical-based activities). Linked, routinely collected data was used to determine patient level depression outcomes (proportion of depression-free days) and health service usage costs. Standardised depression assessment tools were not routinely used, therefore a classification framework to determine the patient's depressive state was developed using proxy measures (e.g. symptoms, medications, referrals, hospitalisations and suicide attempts). Regression analyses of costs and depression outcomes were conducted, using propensity weighting to control for potential confounders. RESULTS: Capacity to determine depressive state using the classification framework was dependent upon the level of detail provided in medical records. While antidepressant medication prescriptions were a strong indicator of depressive state, they could not be relied upon as the sole measure. Propensity score weighted analyses of total depression-related costs and depression outcomes, found that the high level model of care cost more (95% CI: -$314.76 to $584) and resulted in 5% less depression-free days (95% CI: -0.15 to 0.05), compared to the low level model. However, this result was highly uncertain, as shown by the confidence intervals. CONCLUSIONS: Classification of patients' depressive state was feasible, but time consuming, using the classification framework proposed. Further validation of the framework is required. Unlike the analyses of diabetes and obesity management, no significant differences in the proportion of depression-free days or health service costs were found between the alternative levels of practice nurse involvement.
| S-EPMC3897884 | biostudies-other
Project description:Major depression is common in the primary care setting. In the final article of this series, we illustrate the approach to the management of depression in primary care. Psychotherapy has been shown to be as effective as antidepressants for mild to moderate major depression. The common myth that antidepressants are addictive should be addressed. Antidepressants should be started at a subtherapeutic dose to assess tolerability, then gradually increased until a minimally effective dose is achieved. Apart from pharmacotherapy and psychotherapy, management of depression should include managing stressors, engaging social and community support, dealing with stigma and discrimination, and managing concomitant comorbidities. A strong therapeutic relationship and empathic listening are important between the primary care physician and patient.
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Project description:Introduction:Depression is a common and serious mental health condition frequently encountered in pediatric primary care. Pediatricians report discomfort in managing depression due in part to limited training and limited access to mental health care, which is accentuated in rural areas. Methods:We developed an evidence-based, quality improvement project designed to help pediatricians increase screening and initial management of depression in the primary care setting. We recruited practices from a pediatric accountable care organization as part of a larger quality improvement portfolio that used a practice facilitation model to support practices with data collection and project management. Practitioners received training on quality improvement, depression screening, and a depression management plan (referred to as the depression management bundle). Practices completed Plan-Do-Study-Act cycles to improve their performance. Results:We recruited 4 practices in rural Ohio to participate. Screening increased from 0% to 81% within 6 months. All 4 practices measured documentation of the depression management bundle for patients diagnosed with depression. Composite data from these practices showed an increase in documentation from 59% to 86% by month 6. Conclusions:This study provides preliminary support for the use of practice facilitation combined with skills training to increase screening and improve documentation of depression management in rural primary care practices, where specialty mental health resources may be limited. Further research is needed to determine if this approach can be successfully disseminated and if patient outcomes improved.
| S-EPMC7297391 | biostudies-literature
Project description:OBJECTIVE:This study evaluated a large demonstration project of collaborative care of depression at community health centers by examining the role of clinic site on two measures of quality care (early follow-up and appropriate pharmacotherapy) and on improvement of symptoms (score on Patient Health Questionnaire-9 reduced by 50% or ? 5). METHODS:A quasi-experimental study examined data on the treatment of 2,821 patients aged 18 and older with depression symptoms between 2006 and 2009 at six community health organizations selected in a competitive process to implement a model of collaborative care. The model's key elements were use of a Web-based disease registry to track patients, care management to support primary care providers and offer proactive follow-up of patients, and organized psychiatric consultation. RESULTS:Across all sites, a plurality of patients achieved meaningful improvement in depression, and in many sites, improvement occurred rapidly. After adjustment for patient characteristics, multivariate logistic regression models revealed significant differences across clinics in the probability of receiving early follow-up (range .34-.88) or appropriate pharmacotherapy (range .27-.69) and in experiencing improvement (.36 to .84). Similarly, after adjustment for patient characteristics, Cox proportional hazards models revealed that time elapsed between first evaluation and the occurrence of improvement differed significantly across clinics (p<.001). CONCLUSIONS:Despite receiving similar training and resources, organizations exhibited substantial variability in enacting change in clinical care systems, as evidenced by both quality indicators and outcomes. Sites that performed better on quality indicators had better outcomes, and the differences were not attributable to patients' characteristics.
| S-EPMC3250309 | biostudies-literature
Project description:BackgroundPrimary care providers (PCPs) vary in skills to effectively treat depression. Key features of evidence-based collaborative care models (CCMs) include the availability of depression care managers (DCMs) and mental health specialists (MHSs) in primary care. Little is known, however, about the relationships between PCP characteristics, CCM features, and PCP depression care.ObjectiveTo assess relationships between various CCM features, PCP characteristics, and PCP depression management.DesignCross-sectional analysis of a provider survey.Participants180 PCPs in eight VA sites nationwide.Main measuresIndependent variables included scales measuring comfort and difficulty with depression care; collaboration with a MHS; self-reported depression caseload; availability of a collocated MHS, and co-management with a DCM or MHS. Covariates included provider type and gender. For outcomes, we assessed PCP self-reported performance of key depression management behaviors in primary care in the past 6 months.Key resultsResponse rate was 52 % overall, with 47 % attending physicians, 34 % residents, and 19 % nurse practitioners and physician assistants. Half (52 %) reported greater than eight veterans with depression in their panels and a MHS collocated in primary care (50 %). Seven of the eight clinics had a DCM. In multivariable analysis, significant predictors for PCP depression management included comfort, difficulty, co-management with MHSs and numbers of veterans with depression in their panels.ConclusionsPCPs who felt greater ease and comfort in managing depression, co-managed with MHSs, and reported higher depression caseloads, were more likely to report performing depression management behaviors. Neither a collocated MHS, collaborating with a MHS, nor co-managing with a DCM independently predicted PCP depression management. Because the success of collaborative care for depression depends on the ability and willingness of PCPs to engage in managing depression themselves, along with other providers, more research is necessary to understand how to engage PCPs in depression management.
| S-EPMC4061347 | biostudies-literature