Improving primary care management of depression in adults with comorbid chronic illnesses

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1 Executive summary of current research Improving primary care management of depression in adults with comorbid chronic illnesses Principal Investigator Jane McCusker, MD DrPH Co-Investigators Martin Cole, MD Kim Lavoie, PhD Maida Sewitch, PhD Erin Strumpf, PhD Tamara Sussman, PhD Mark Yaffe, MDCM MClSc October,

2 IMPROVING PRIMARY CARE MANAGEMENT OF DEPRESSION IN ADULTS WITH COMORBID CHRONIC ILLNESSES Date of Report: October 1, 2009 Funding Agency: Principal Investigator: Co-Investigators: Fonds de la recherche en santé du Québec (FRSQ) May April 2013 Jane McCusker, MD DrPH Professor, Department of Epidemiology, Biostatistics and Occupational Health, McGill Head, Department of Clinical Epidemiology and Community Studies, St. Mary s Hospital Center 3830 Lacombe Ave. Montreal (QC) H3T 1M5 Tel: (514) x5060 Fax: (514) Martin Cole, MD Professor, Department of Psychiatry, McGill Psychiatrist, Geriatric Psychiatry Division, St. Mary s Hospital Center Kim Lavoie, PhD Associate Professor, Department of Psychology, Université du Québec à Montréal Researcher, Hôpital du Sacré-Coeur de Montréal and Montreal Heart Institute Maida Sewitch, PhD Assistant Professor, Department of Medicine, McGill Erin Strumpf, PhD Assistant Professor, Department of Economics and Department of Epidemiology, Biostatistics and Occupational Health, McGill Tamara Sussman, PhD Assistant Professor, School of Social Work, McGill Mark Yaffe, MDCM MClSc Associate Professor, Departments of Family Medicine, McGill and St. Mary's Hospital Center 1

3 Collaborators: Antonia Arnaert, PhD Assistant Professor, School of Nursing; Associate Member, Department of Oncology; Faculty Member, Programs in Whole- Person Care, McGill Simon Bacon, PhD Assistant Professor, Department of Exercise Science, Concordia Researcher, Hôpital du Sacré-Coeur de Montréal and Montreal Heart Institute Dan Bilsker, PhD Adjunct Professor, Faculty of Health Sciences, Simon Fraser Clinical Assistant Professor, Faculty of Medicine, of British Columbia Antonio Ciampi, PhD Associate Professor, Department of Epidemiology, Biostatistics and Occupational Health, McGill Eric Latimer, PhD Associate Professor, Department of Psychiatry; Associate Member, Department of Epidemiology, Biostatistics, and Occupational Health, McGill Jean-Frédéric Lévesque, MD PhD Physician specializing in community health, Quebec Institute of Public Health and of Montreal Hospital Centre Pasquale Roberge, PhD Adjunct Researcher CRCHUM (Research Centre of the of Montreal Hospital Centre), Department of Social and Preventative Medicine, of Montreal Associate Professor, Department of psychology, Université du Québec à Montréal Ellen Rosenberg, MD Associate Professor, Department of Family Medicine, McGill Pierre Tousignant, MD, MSc Associate Professor, Department of Epidemiology, McGill Alain Vanasse, MD PhD Full professor and researcher, Department of family medicine, Université de Sherbrooke 2

4 Student trainees: Mengzhu Jiang (MSc candidate) Department of Epidemiology, Biostatistics and Occupational Health, McGill Maria Mireault (PhD candidate) School of Social Work, McGill Russell Simco (MSc candidate) Department of Epidemiology, Biostatistics and Occupational Health, McGill 3

5 IMPROVING PRIMARY CARE MANAGEMENT OF DEPRESSION IN ADULTS WITH COMORBID CHRONIC ILLNESSES INTRODUCTION The majority of adults with major depression are cared for entirely in primary care settings, where they usually seek care for health problems other than depression. Primary care doctors detect and adequately treat the depression (with antidepressant medication and/or psychological therapy) in only a minority of patients; this under-detection and inadequate treatment has significant impacts on patient morbidity, mortality, and healthcare costs. Depression is one of 7 frequent chronic illnesses with a high impact on the healthcare system (along with cancer, arthritis, hypertension, diabetes, heart disease, and chronic obstructive pulmonary disease). The prevalence of these 7 conditions increases markedly with age from 37% at age 40-59, to 71% and over at age 60+. Among adults with chronic physical illnesses, the consequences of inadequate treatment of depression include non-adherence to the treatments prescribed for these illnesses (e.g. medications, exercise, diet) and to routine medical appointments. This research program to detect and manage depression in primary care settings among adults with comorbid chronic medical illnesses is guided by two models, the Chronic Care Model (CCM) and the Kaiser Population Health Risk Pyramid. In the CCM, outcomes are improved through strategies to inform and empower patients (e.g., through self-management support and creation of a supportive environment) and to prepare practice teams to play a proactive role (e.g., using redesigned delivery systems, interdisciplinary teams, clinical information systems and strong community links). The CCM has been adopted widely as a guide to improving the management of many chronic diseases, including depression, in primary care settings, and its success is supported by a large body of research. To date, however, there has been little research on the feasibility and effectiveness of depression self-care methods and whether these methods can be incorporated into the Québec or Canadian healthcare system, particularly among adults with chronic medical conditions. The second model, the Kaiser Population Health Risk Pyramid, assists in the targeting of interventions to the needs of 3 population subgroups. Level 1 (about 70-80%) comprises people without a current chronic condition, who may benefit from preventive self-care. Level 2 (about 15-20%) comprises individuals with one or more chronic conditions who require proactive management and support from a multidisciplinary primary care team to manage their care and to prevent exacerbation and/or use of more costly services. Level 3 (5-6%) comprise sicker, highly complex patients who require active case-management. This model is an excellent match to the hierarchical approach of the Québec Plan d action en santé mentale, in which multidisciplinary mental health teams situated in the CSSS (Centres de santé et de services sociaux Health and social services centers) collaborate with and support primary care teams. In the initial 2 phases of research (over the next 4 years), the research team will focus on Kaiser level 2, and on the implementation of case-finding and self-management interventions needed at this level. Later phases may involve research on different components of the CCM at different levels of the Kaiser pyramid. 4

6 OBJECTIVES Specific objectives of the first 2 phases of the research program are: 1. To evaluate the feasibility, acceptability, and barriers to implementation of case-finding methods, self-management interventions, and delivery systems approaches to case-finding and self-management. 2. To identify patient characteristics (e.g., depression severity, age, sex, care setting, medical problems) that predict intervention acceptance and completion. 3. To explore roles that clinical team members and family caregivers may play in the patients attempts at self-care. 4. To determine the effectiveness and costs of selected interventions in comparison to usual care. METHODS The initial 2 phases of the research program will last about 2 years each. In PHASE 1, the case-finding methods, interventions, and delivery systems will be developed in consultation with partners, and pilot-tested in the selected settings (family medicine groups, other primary care settings) and among patients with the targeted chronic medical diseases. Case-finding methods to be evaluated include short validated screening tools for depression to identify patients who have current depression and/or antidepressant use. Depression self-management interventions to be evaluated will be based on cognitive-behavioral principles and will include assisted bibliotherapy and action plans. Delivery systems to be explored may include use of existing clinical team members versus a care manager, who would support and monitor the intervention primarily by telephone. The potential for involvement of members of clinical teams and/or family caregivers, and the use of community resources will also be considered. A cohort of 200 patients will be recruited and offered the self-management interventions. Quantitative outcome measures at 6-week and 6- month follow up will include measures of intervention completion, patient satisfaction, adherence, activation, and depression severity. Qualitative methods will comprise of semi-structured interviews with key participants: patients, family members, and clinical team members. In PHASE 2, a randomized controlled trial will formally evaluate the effectiveness and costs of selected approaches, using case-finding methods, interventions, and delivery systems that are determined to be the most feasible and acceptable in PHASE 1. Although the methods cannot yet be specified in detail, it is expected that eligibility criteria would include: age of 40 or more; homedwelling; depression that is clinically significant but not of sufficient severity to warrant more complex management; one or more of the selected chronic medical diseases; stable clinical condition; no significant cognitive impairment that might limit the patient s participation in a selfmanagement intervention. Patients who are eligible and consent to study participation would be randomized to receive either the selected self-management intervention or usual care for a period of up to 6 months. The care manager responsible for supporting and monitoring the intervention will work collaboratively with the patient s primary physician. The control group will receive care as usual from their primary care physician. Patient outcomes will be assessed at the end of the intervention period and at 12 months by a research assistant who is blind to study group. Outcome measures will include depression symptoms, quality of life, patient involvement in their care, 5

7 adherence to action plans and medications. Effects on health services utilization will be measured through linkage to provincial administrative databases. Qualitative semi-structured interviews and workshops will yield important information on the barriers and facilitators of implementation of the intervention. EXPECTED OUTCOMES Using integrated knowledge translation methods, this research will inform the further development and evaluation of the Plan d action en santé mentale. It will also increase the team s ability to obtain further research funding from other funding bodies (e.g., CIHR). 6

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