Collaborative Care Improves Control of Depression, Other Chronic Illnesses

Deborah Brauser

January 04, 2011

January 4, 2010 — Coordinated care management improves disease control and decreases adverse outcomes in patients with both depression and other chronic conditions, including diabetes and coronary heart disease, new research suggests.

Investigators found patients randomized to receive a collaborative care intervention (which included nurse care managers working closely with physicians) had significantly greater improvements across several categories, including depression scores, glycated hemoglobin levels, low-density lipoprotein cholesterol (LDL-C) levels, and systolic blood pressure, than patients who received standard care.

"We found that the intervention patients compared to usual primary care had marked improvements across the 4 joint outcomes we aimed at, and they also reported less disability, greater quality of life, and greater satisfaction with their medical care," Wayne Katon, MD, professor and vice chair in the Department of Psychiatry and Behavioral Sciences at the University of Washington School of Medicine in Seattle, told Medscape Medical News.

"One of the surprises was that when we took care of these patients' diabetes, heart disease, and depression, we not only had a good effect on their medical disease control but the effect on their depression was twice as good as when we aimed to just improve depression alone," said Dr. Katon.

The study is published in the December 30 issue of the New England Journal of Medicine.

Co-occurring Illnesses Expensive

According to investigators, coordinating care among specialties for patients with multiple chronic illnesses can often be inadequate and expensive.

Although previous studies found that nurse care management of patients with heart disease and/or diabetes did not improve outcomes, "these interventions were primarily delivered by telephone, had no physician supervision, did not include medication recommendations to primary care physicians, and were not integrated into primary care."

Because major depression is prevalent among those with diabetes and coronary heart disease, the investigators sought to determine whether coordinating care of depression and multiple conditions, while addressing the above concerns, would improve overall disease control.

"There is more and more evidence that people with 2 or more illnesses are the most expensive folks in our medical system and take up much of the Medicare costs. We also know that diabetes, heart disease, and depression are among the most common illnesses in primary care. And when they co-occur together, they tend to have more adverse outcomes, including more complications and mortality," said Dr. Katon.

He added that those who have co-occurring depression also tend to have problems with motivation and energy to do the self-care that is needed to manage chronic illnesses.

The study included 214 patients with "poorly controlled" diabetes, coronary heart disease, or both and coexisting depression. Subjects were enrolled at 14 primary care clinics in Washington State between May 2007 and October 2009 and randomized to receive either usual care (control group, n = 108; 56% female; mean age, 56.3 years) or the collaborative care intervention (n = 106; 48% female; mean age, 57.4 years).

The 12-month intervention involved "a medically supervised nurse, working with each patient's primary care physician, providing guideline-based, collaborative care management, with the goal of controlling risk factors associated with multiple diseases."

In addition, patients in the intervention group worked with primary care physicians and nurses to create individualized clinical goals and participated in structured nurse-monitored visits every 2 to 3 weeks.

"We basically trained 1 case manager to take care of all the co-occurring illnesses in each of these patients," explained Dr. Katon.

The control group received care only from their primary care physicians.

The outcome measures of health risk behaviors and care satisfaction were assessed for all patients at baseline, 6 months, and 12 months by telephone interview.

At the same time points, blood pressure and glycated hemoglobin levels were measured in person, whereas LDL-C and depression scores on the Symptom Checklist-20 (SCL-20) were evaluated in person only at baseline and at 12 months.

Significantly Better Outcomes

Results showed that the intervention group had greater overall 12-month improvement than the control group, as seen by lower glycated hemoglobin levels (difference, 0.58%), LDL-C levels (difference, 6.9 mg/dL), systolic blood pressure (difference, 5.1 mm Hg), and SCL-20 depression scores (difference, 0.40 points).

In addition, the intervention group had a significantly higher score than controls on the Patient Global Rating of Improvement "and a higher proportion had a 50% or greater reduction in the SCL-20 depression score" (both P < .001), report the researchers.

The intervention group was also significantly more likely to have 1 or more adjustments of insulin (P = .006), as well as adjustments of antihypertensive and antidepressant medications, a better quality of life score, and greater satisfaction with depression care and care for diabetes, coronary heart disease, or both (all P < .001).

At the 12-month point, significantly more of the intervention patients also had "values on all 3 medical risk factors that were either below guidelines or showed clinically significant improvement" (P = .024) and were more likely to have a decrease of 1% or more in glycated hemoglobin level (P = .006) and a decrease of 10 mm Hg or more in systolic blood pressure (P = .016).

For adverse events, 27 intervention group patients and 23 of those in the control group had at least 1 hospitalization during the 12-month study period, and 1 intervention patient and 2 controls died.

"When depression is associated with chronic medical illnesses, patients tend to have worse outcomes in both areas. The model we came up with can be used for patients who have 2 or more different illnesses in terms of a team approach to take care of all those illnesses," said Dr. Katon.

"I think this study shows that when you take care of the whole patient, and everything they're up against, then they tend to do better with depression control than if you only take care of the depression alone," he said.

The study was funded by grants from the Services Division of the National Institute of Mental Health and by institutional support from Group Health Cooperative. The study authors report several financial disclosures, which are listed in the original article.

N Engl J Med. 2010;363:2611-2620. Abstract

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