Depressed patients benefit from team model in managing numerous illnesses

People with depression are less likely to be drug-compliant or keep their diabetes or hypertension under control. Weekly case reviews can help change that.

By — Posted Jan. 25, 2012

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A team-based approach to primary care can help patients with depression and other chronic conditions better achieve their clinical goals, said a study in Annals of Family Medicine's January/February issue.

More than 200 patients with depression and at least one other chronic condition such as diabetes, hypertension or high cholesterol were studied in a randomized controlled trial. The study was conducted at 14 primary care clinics that are part of the Group Health Cooperative integrated system based in Seattle.

Half of the patients were cared for under a collaborative model that incorporated weekly case reviews and nurse care managers who spurred patients to take their medications and stick to lifestyle and self-monitoring plans. The patients who received this team-based care showed improved glycated hemoglobin levels, blood pressures, depression-screening scores and low-density lipoprotein levels compared with patients in the usual care group.

The frequent case reviews helped the clinics move more quickly to start or change medication for patients who were failing to show improvement, the study found. For example, the initiation and adjustment of antidepressants was six times higher in the collaborative care group. Meanwhile, these patients were three times as likely to have their insulin adjusted and doubly likely to have their antihypertensive medications changed, said the study (link).

Depression's toll

Depressed patients with other chronic conditions are 76% less likely to take their medications, research has shown. Helping patients with depression tackle their comorbid conditions can be especially vexing for the primary care physicians often tasked with caring for mental and physical illnesses, said Elizabeth H.B. Lin, MD, MPH, the study's lead author.

"When a patient is depressed, they feel hopeless," said Dr. Lin, a family physician at Group Health. "What's the point of getting up and moving and eating better? They have a lack of self-efficacy and empowerment. And then you combine those two features with the necessity of what one needs to do to take care of diabetes or blood pressure, and it can feel overwhelming."

The integrated health care setting at Group Health, which has 640,000 patients in Washington state, differs greatly from that of most physician practices. But Dr. Lin said she believes that a team-care model is within the grasp of most clinics. Basic training to help a nurse learn care-manager skills in working with patients takes just days, she said.

The weekly case reviews take an hour or two, and practices can start by prioritizing with more complex cases of patients who are struggling to manage several chronic conditions, Dr. Lin said.

"Supporting patient self-care is a really good cornerstone," she added. "By doing that, which most practices can do with the existing staff they have, they can help motivate patients and help them solve problems."

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How team-based care works

Helping patients meet their goals in managing multiple chronic conditions such as cardiovascular disease and diabetes is not easy, especially when they also have depression. Physician practices that incorporate nurse care managers and other consultants are likelier to succeed, said a study examining a team-based approach that included these elements.

Identify goalsFormulate measurable targets such as lowered blood pressure or HbA1cPatient, primary care physicians, care managers
Support self-carePromote self-monitoring, medication adherence, lifestyle changePatient, care managers
Monitor progressSystematic, population-based trackingPatient, care manager, consultant
Treat-to-target case reviewsWeekly caseload review, make recommendations to primary care physicianPhysician consultants, care manager
Care coordinationCommunicate using EMR, phone, fax and in personCare manager

Source: "Treatment Adjustment and Medication Adherence for Complex Patients with Diabetes, Heart Disease, and Depression: A Randomized Controlled Trial," Annals of Family Medicine, January/February (link)

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