Depression is a common and debilitating mental disorder in HIV infected patients. Depression is under-diagnosed and under-treated in routine HIV care. In general adult primary care, collaborative care for depression is effective and cost-effective. Collaborative care models are based on the chronic care model, facilitating collaboration between primary care and specialty mental health providers to improve the quality of depression care and outcomes. Compared to referral specialty mental health care models, collaborative care allows patients to receive care in more accessible and less stigmatizing settings. Many patients with complex chronic illnesses (e.g. HIV) consider specialty physical health clinics their primary source of health care and therefore do not benefit from the collaborative care provided in the general VA primary care clinics. HI-TIDES or HIV Implementation of Translating Initiatives for Depression into Effective Solutions used evidence-based quality improvement (EBQI) for depression methods to adapt and implement the depression collaborative care model for the HIV clinic setting.
The objectives of this proposal are to: 1) Develop and evaluate the process of adapting, implementing, and sustaining collaborative care for depression in VA HIV clinics, 2) Compare the quality of depression care and the clinical effectiveness (depression severity, health-related quality of life, antidepressant and HIV medication adherence, treatment satisfaction, HIV viral load, and CD4 count) of HI-TIDES to usual care in the HIV clinics, and 3) Evaluate the cost-effectiveness of patients assigned to HI-TIDES relative to patients assigned to usual care in HIV clinics.
The intervention was based on a previously tested off-site depression collaborative care model. The structure of the HITIDES intervention was multi-faceted (applied a combination of complementary strategies to improve care) and multi-targeted (focused on both providers and patients). The intervention used a stepped-care model for depression treatment which began with watchful waiting, antidepressant medication, or counseling. Treatment intensity increased for participants failing to respond or adhere to their current level of care. Although the HITIDES depression care team (nurse depression care manager, clinical pharmacist, and psychiatrist) did not recommend watchful waiting, patient/provider treatment negotiations sometimes resulted in this approach. The depression care manager contacted patients every 2 weeks during acute treatment and every 4 weeks during the continuation treatment for up to one year. Treatment decisions were made by patients and their treating clinicians. The intervention was implemented at three VA HIV clinics (Little Rock, Houston, and Atlanta).
Patients who screened positive for depression (PHQ-9 score>10) were referred to on-site research assistants to complete the consent process. Exclusion criteria were: (a) no telephone access, (b) current suicidal ideation, (c) significant cognitive impairment, and (d) chart diagnosis of schizophrenia. Qualitative data was collected from HIV patients, mental health and HIV providers prior, during, and after intervention implementation. The qualitative data was used to inform the EBQI approach to adapting and implementing the intervention. Quantitative data was collected at baseline, 6-, and 12 months using patient interviews and VA administrative data. Depression symptom severity was measured using the Symptom Checklist 20 (SCL-20). Depression-free days (DFDs) were calculated as a summative measure of depression severity based on methods developed by Lave and colleagues and adapted for the SCL-20.
Pre-implementation interviews were conducted with 8 HIV patients and 25 HIV or mental health providers. Barriers and facilitators to depression identification, treatment, and the HITIDES intervention were identified and used during 13 pre-implementation EBQI discussions. Evidence of sustainability included: 2/3 sites continued to screen for depression; one site obtained additional co-located mental health resources which included care management services.
Participants in the intervention trial included 249 HIV-infected patients with depression (123 intervention; 126 usual care). The intervention was delivered with high fidelity. Of the 123 intervention patients, 119 (96.7%) were contacted by the DCM. Initial patient education and activation was completed for 99.2% (118/119), initial treatment barriers assessment was completed for 97.5% (116/119), and 100% of all DCM contacts completed the PHQ-9 and medication adherence and/or counseling adherence assessment depending on current treatment. During the acute phase of treatment, there were a total of 231 intervention group treatment trials (mean=1.94): 110 (47.6%) watchful waiting, 94 (40.7%) pharmacotherapy, 7 (3%) counseling, and 20 (8.7%) combination pharmacotherapy and counseling. Mean number of DCM intervention phone contacts per patient during the acute and continuation phases of treatment was 7.2 (SD=4.5, range=0 to 19).
Follow-up data collection interviews were completed for 91% (226/249) of all participants at 6-months and 86% (215/249) at 12-months. Intervention participants were more likely to report depression response and remission at 6-months but not 12-months. The treatment response rates at 6-months were 17.5% (22/126) for usual care and 33.3% (41/123) for intervention (p=0.004). The treatment remission rates at 6-months were 11.9% (15/126) for usual care and 22.0% (27/123) for intervention (p=0.03). Intervention participants reported more DFDs over 12-months. Significant intervention effects were observed for lowering HIV symptom severity at 6- and 12-months. Intervention effects were not significant for health-related quality of life, health status, treatment satisfaction, antidepressant prescribing, antidepressant or HIV medication adherence, viral load, or CD4 count.
We also found evidence for antidepressant adherence not predicting HIV medication adherence and vice versa and no intervention outcome differences by race.
To our knowledge, this is the first effectiveness trial of a depression collaborative care intervention in a chronic, specialty physical health setting. The HITIDES intervention improved depression and HIV outcomes relative to usual care. The HITIDES intervention may serve as a model for collaborative care interventions in other specialty physical health care settings where patients find their medical home.
External Links for this Project
- Fortney JC, Pyne JM, Steven CA, Williams JS, Hedrick RG, Lunsford AK, Raney WN, Ackerman BA, Ducker LO, Bonner LM, Smith JL. A Web-based clinical decision support system for depression care management. The American journal of managed care. 2010 Nov 1; 16(11):849-54. [view]
- Ackerman B, Pyne JM, Fortney JC. Challenges associated with being an off-site depression care manager. Journal of Psychosocial Nursing and Mental Health Services. 2009 Apr 1; 47(4):43-9. [view]
- Bottonari KA, Tripathi SP, Fortney JC, Curran G, Rimland D, Rodriguez-Barradas M, Gifford AL, Pyne JM. Correlates of antiretroviral and antidepressant adherence among depressed HIV-infected patients. AIDS Patient Care and Stds. 2012 May 1; 26(5):265-73. [view]
- Painter JT, Fortney JC, Gifford AL, Rimland D, Monson T, Rodriguez-Barradas MC, Pyne JM. Cost-Effectiveness of Collaborative Care for Depression in HIV Clinics. Journal of acquired immune deficiency syndromes (1999). 2015 Dec 1; 70(4):377-85. [view]
- Curran GM, Pyne J, Fortney JC, Gifford A, Asch SM, Rimland D, Rodriguez-Barradas M, Monson TP, Kilbourne AM, Hagedorn H, Atkinson JH. Development and implementation of collaborative care for depression in HIV clinics. AIDS Care. 2011 Dec 1; 23(12):1626-36. [view]
- Pyne JM, Fortney JC, Curran GM, Tripathi S, Atkinson JH, Kilbourne AM, Hagedorn HJ, Rimland D, Rodriguez-Barradas MC, Monson T, Bottonari KA, Asch SM, Gifford AL. Effectiveness of collaborative care for depression in human immunodeficiency virus clinics. Archives of internal medicine. 2011 Jan 10; 171(1):23-31. [view]
- Curran GM, Bauer M, Mittman B, Pyne JM, Stetler C. Effectiveness-implementation hybrid designs: combining elements of clinical effectiveness and implementation research to enhance public health impact. Medical care. 2012 Mar 1; 50(3):217-26. [view]
- Drummond KL, Painter JT, Curran GM, Stanley R, Gifford AL, Rodriguez-Barradas M, Rimland D, Monson TP, Pyne JM. HIV patient and provider feedback on a telehealth collaborative care for depression intervention. AIDS Care. 2017 Mar 1; 29(3):290-298. [view]
- Pyne JM, Asch SM, Lincourt K, Kilbourne AM, Bowman C, Atkinson H, Gifford A. Quality indicators for depression care in HIV patients. AIDS Care. 2008 Oct 1; 20(9):1075-83. [view]
- Fortney JC, Pyne JM, Smith JL, Curran GM, Otero JM, Enderle MA, McDougall S. Steps for implementing collaborative care programs for depression. Population health management. 2009 Apr 1; 12(2):69-79. [view]
- Curran GM. “Hybrid Designs” Combining Elements of Clinical Effectiveness and Implementation Research. Advanced Topics in Dissemination & Implementation Research webinar hosted by the National Cancer Institute (NCI) Division of Cancer Control & Population Sciences Implementation Science Team. [Cyberseminar]. 2015 Jul 23. [view]
- Curran GM, Mittman B, Bauer M, Stetler C, Pyne JM, Fortney JC, Smith JL. A New ‘Hybrid’? Combining Elements of Clinical Effectiveness and Implementation Research Trials. Poster session presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 28; Little Rock, AR. [view]
- Curran G, Bauer MS. A New Hybrid?: Combining Elements of Clinical Effectiveness and Implementation Research Trials. Paper presented at: VA CIPRS Enhancing Implementation Science in the VA Training Conference; 2010 Jul 19; Denver, CO. [view]
- Davis TD, Pyne JM. Assessing Racial Disparities in Clinical Outcomes Following A Collaborative Care Intervention for Depression Among HIV+ Patients. Poster session presented at: Association of Psychologists in Academic Health Centers Early Career Boot Camp Conference; 2011 Mar 3; Boston, MA. [view]
- Pyne JM. Conducting Research with Military Personnel, Veterans and Their Families: Considerations and Implications. Paper presented at: National Institute on Drug Abuse Annual Workshop; 2009 Jan 6; Bethesda, MD. [view]
- Painter JT, Pyne JM, Fortney JC. Cost Effectiveness of Collaborative Care for Depression in Human Immunodeficiency Virus Clinics. Paper presented at: AcademyHealth Annual Research Meeting; 2013 Jun 22; Baltimore, MD. [view]
- Pyne JM, Fortney JC, Curran GM, Tripathi S, Atkinson JH, Kilbourne AM, Hagedorn HJ, Rimland D, Rodriguez-Barradas MC, Monson T, Bottonari KA, Asch SM, Gifford AL. Effectiveness of Collaborative Care for Depression in HIV Clinics. Paper presented at: VA HSR&D Field-Based Mental Health and Substance Use Disorders Meeting; 2010 Apr 28; Little Rock, AR. [view]
- Gifford A, Pyne JM, Fortney JC, Curran GM, Tripathi S, Atkinson JH, Kilbourne AM, Hagedorn H, Bottonari K, Asch S. Effectiveness of Collaborative Care for Depression in HIV Clinics: The HI-TIDES Study. Paper presented at: International AIDS Conference; 2010 Jul 19; Vienna, Austria. [view]
- Mittman B, Curran GM. Effectiveness-Implementation Hybrid Designs: Clarifications, Refinements, and Additional Guidance Based on a Systematic Review and Reports from the Field - Hybrid Type 1 Designs. Paper presented at: National Institutes of Health / AcademyHealth Conference on the Science of Dissemination and Implementation; 2015 Dec 14; Washington, DC. [view]
- Pyne M, Fortney C, Curran. HIV Translating Initiatives for Depression into Effective Solutions. Poster session presented at: VA QUERI National Meeting; 2008 Dec 12; Phoenix, AZ. [view]
- Smith JL. Hybrid Designs. Paper presented at: VA MIRECC Implementation Conference; 2011 Sep 19; Houston, TX. [view]
- Hamilton A, Curran GM. Hybrid effectiveness/implementation study designs in addictions health services research: A pre-conference workshop. Paper presented at: Addiction Health Services Research Conference; 2013 Oct 23; Portland, OR. [view]
- Bauer M, Curran G, Mittman B, Stetler C, Hagedorn HJ. Hybrid Effectiveness-Implementation Trial Designs for Enhanced Research Impact. Paper presented at: VA HSR&D National Meeting; 2011 Feb 17; National Harbor, MD. [view]
- Wright PB, Stewart KE, Booth BM, Curran GM. If You Build It, They Still Won’t Come: Individual and Social Barriers to HIV Testing among Rural African American Cocaine Users. Poster session presented at: Addiction Health Services Research Conference; 2011 Oct 3; Fairfax, VA. [view]
- Curran GM. Incorporating Implementation Research into Clinical Effectiveness Trials: Toward using Hybrid Effectiveness-Implementation Designs. Paper presented at: Wake Forest University Clinical and Translational Science Institute Meeting; 2016 Sep 1; Winston-Salem, NC. [view]
- Painter JT, Fortney JC, Pyne JM. Net health benefits of collaborative care for depression in HIV clinics. Poster session presented at: AcademyHealth Annual Research Meeting; 2014 Jun 9; San Diego, CA. [view]
- Pyne JM, Triapthi S. Predictors of Health-related Quality of Life in HIV Patients with Depression. Paper presented at: International Society for Quality of Life Research Annual Meeting; 2009 Jul 20; Italy. [view]
Infectious Diseases, Mental, Cognitive and Behavioral Disorders
Treatment - Observational