HSR&D Home » Research » MNT 05-152 – QUERI Project
HIV Translating Initiatives for Depression into Effective Solutions
Jeffrey M Pyne, MD
Central Arkansas Veterans Healthcare System Eugene J. Towbin Healthcare Center, Little Rock, AR
No. Little Rock, AR
Funding Period: April 2006 - March 2011
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.
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DRA: Mental, Cognitive and Behavioral Disorders, Infectious Diseases
DRE: Treatment - Observational
Keywords: HIV/AIDS, Implementation
MeSH Terms: none