BACKGROUND/RATIONALE:
Implementing collaborative care for depression in small rural Primary Care (PC) practices without on-site mental health specialists presents unique challenges. We adapted the collaborative care model using telemedicine (e.g., telephone, interactive video, electronic medical records) to support antidepressant therapy initiated by PC providers in small rural practices. The Telemedicine Enhanced Antidepressant Management (TEAM) collaborative care intervention is implemented by offsite personnel including a Nurse Depression Manager, Clinical Pharmacist, and Consult Psychiatrists. The TEAM intervention has seven main components targeting the CBOC Primary Care Provider (PCP) and the patient: 1) academic detailing, 2) screening to establish caseness for major depressive disorder (MDD), 3) patient education/activation and barrier assessment/resolution, 4) outcomes monitoring and feedback, 5) medication management, 6) psychiatric consultation, and 7) treatment recommendations. All of these components are implemented using telemedicine technologies. Screening, patient education/activation and barrier assessment/resolution, symptom and medication monitoring, and medication management are conducted by telephone. Patient educational materials and provider toolkits are available on the TEAM website. Academic detailing and psychiatric consultations are conducted via interactive video. Feedback and treatment recommendations are provided to PCPs using electronic medical records.
OBJECTIVE(S):
Specific Aim 1: Determine whether the TEAM intervention improves quality and outcomes compared to usual care. Specific Aim 2: Determine whether the TEAM intervention will be cost-effective in routine practice settings.
METHODS:
Seven CBOCs in MS, AR, LA and TX are participating in the study. CBOCs were included if they 1) treated >1,000 and <5,000 unique veterans, 2) had no on-site psychiatrists, and 3) had interactive video equipment. . CBOCs were pair-matched by parent VAMC and then randomized to receive the intervention or usual care. Of the 24,882 clinic patients, 73.6% (n=18,306) were successfully screened and 6.9% screened positive for depression (PHQ9 =12). Patients were considered ineligible if they were already being seen in mental health, had acute suicide ideation, schizophrenia, mania, substance dependence (but not abuse), cognitive impairment, bereavement, were pregnant, had a guardian, or did not expect to receive treatment at the clinic during the course of the next year. Of those eligible for the study, 91.3% agreed to participate, and 91.9% of those attended their appointment and were consented. Over an 18-month period, 395 patients were enrolled, and 91.1% (n=360) were followed-up at six months. Telephone research interviews were conducted at baseline, six and twelve months. Hypotheses for Specific Aim 1 will be tested using an intent-to-treat analysis with patients defined as the unit of analysis. There will be 98% power to detect a 20% difference in the proportion of patients responding to treatment (i.e., 50% decrease in severity). The cost-effectiveness analysis will be conducted from the perspective of both the VA and society, and will include intervention costs, encounter/ancillary costs, and patient costs.
FINDINGS/RESULTS:
The sample comprised mostly elderly low-income males who had an average of 5.5 chronic physical health illnesses. On average, subjects had moderate depression severity at baseline, 3.7 prior depression episodes, and 61% were receiving depression treatment prior to study enrollment. Compared to patients at usual care sites, intervention patients were equally as likely to receive antidepressant therapy. Compared to patients at usual care sites, intervention patients reported better medication adherence at both six (OR=2.0, p=0.04) and twelve months (OR=2.1, p=0.02). Intervention patients were more likely to experience a response to treatment at six months (OR=1.9, p=0.02), and were more likely to experience remission at twelve months (OR=2.4, p=0.02). Intervention patients reported larger increases in MCS scores at twelve months (p<0.01). Intervention patients also reported larger increases in quality of life at six months (p<0.01). Intervention patients reported higher satisfaction at both six (p=0.01) and twelve months (p=0.03). The intervention also significantly increased Quality Adjusted Life Years (QALY) based on the Quality of Well Being Scale (p=0.03) and the SF12V (p=0.01).
IMPACT:
VA leadership has committed to widespread implementation of collaborative care throughout the VA health care system in response to the President’s New Freedom Commission on Mental Health. These results suggest that collaborative care models can be successfully adapted using telemedicine to address rural health disparities. These results provide the evidence-base needed to justify the implementation of telemedicine-based collaborative care models in the hundreds of small rural CBOCs that do not have on-site mental health specialists.
PUBLICATIONS:
Journal Articles
- Edlund MJ, Fortney JC, Reaves CM, Pyne JM, Mittal D. Beliefs about depression and depression treatment among depressed veterans. Medical Care. 2008; 46(6): 581-9.
- Mittal D, Fortney JC, Pyne JM. Impact of comorbid anxiety disorders on health-related quality of life among patients with major depressive disorder. Psychiatric Services. 2006; 57(12): 1731-7.
- Fortney JC, Pyne JM, Edlund MJ, Robinson DE, Mittal D, Henderson KL. Design and implementation of the telemedicine-enhanced antidepressant management study. General Hospital Psychiatry. 2006; 28(1): 18-26.
