Collaborative Care Model

Randomized controlled trials have demonstrated the effectiveness of the collaborative care model, in which primary care treatment of depression is provided by a team (depression care manager, primary physician, consulting psychiatrist and others). The work group recommends three key references (Gilbody, 2006; Hunkeler, 2006; Katon, 1999). This model has demonstrated improvement in treatment adherence, patient quality of life and depression outcomes (Archer, 2012; Gilbody, 2006; Hunkeler, 2006; Katon, 1999).

Beneficial impact on direct medical costs can also be found. Further dissemination of this model has been recommended (Simon, 2001a). Katon, 2008 summarizes and solidifies the argument for collaborative care in the treatment of depression, the direct and indirect economic benefits of collaborative care, as well as improved outcomes (Katon, 2008). Evidence suggests the collaborative care model is also effective for depression during pregnancy and postpartum (Gjerdingen, 2007).

Improved Patient Outcomes

Better medication compliance and reduced risk of relapse. The use of a collaborative care model can help with medication compliance by providing closer follow-up than is possible without a care manager. Three or more follow-up visits in the first three months reduced the risk of relapse/recurrence of depression, as did continuous use of antidepressants (Kim, 2011). Care management facilitates continuous use of antidepressants by providing close follow-up and early intervention when side effects occur.

Reduced suicidal ideation. In the Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) study, suicidal ideation rates declined in patients receiving care based on treatment guidelines and use of a care manager (Bruce, 2004).

In the Improving Mood Providing Access to Collaborative Treatment (IMPACT) study, 1,801 primary care patients were randomly assigned to collaborative care or usual care. Intervention subjects had less suicidal ideation at 6 and 12 months, and there were no completed suicides for either group in 18 months (Unützer, 2006).

Improved Provider Satisfaction

The rewards for health care organizations that implement collaborative care models for their depressed patients are substantial, not only for the patients, but also for physician satisfaction. Of physicians participating in the IMPACT trial (Levine, 2005), only 54% were satisfied with the resources they had to treat depressed patients before the trial. This satisfaction was independent of practice setting (fee-for-service versus capitated).

Sixty-four percent of physicians self-rated their ability to provide at least "very good" depression care before IMPACT. Eighty-five percent of clinicians before IMPACT felt that a collaborative care model would be helpful in treating patients with depression, diabetes or heart failure (Levine, 2005).

Afterwards, 90% of physicians described the collaborative care program as helpful in treating patients with depression. Ninety-three percent of physicians were at least somewhat satisfied with the resources available for treating depressed patients assigned to the IMPACT model, whereas only 61% were somewhat satisfied if their patients were assigned to usual care (Levine, 2005).

Ninety-four percent of clinicians rated the care managers as somewhat or very helpful in treating depression, and 82% indicated that IMPACT program improved their patients' clinical outcomes. Clinicians identified the two most helpful features of the program as "proactive patient follow-up" and "patient education" (Levine, 2005).

Implementing a Collaborative Care Approach

Design. The design of a team-based collaborative care approach (Unützer, 2002) involves:

• Primary care clinicians using evidence-based approaches to depression care and a standard tool for measuring severity, response to treatment plan and remission
• A systematic way of tracking and reminding patients at appropriate intervals of visits with their primary care physician and monitoring of treatment adherence and effectiveness
• A team member (care manager role) to utilize the tracking system and make frequent contacts with the patients to provide further education and self-management support, and monitor for response in order to aid in facilitating treatment changes and in relapse prevention
• Communication between primary care team and psychiatry to consult frequently and regularly regarding patient under clinical supervision, as well as direct patient visits as needed

A 2013 systematic review and meta-analysis of nurse-delivered collaborative care showed that there was no statistical difference between deciding on type of delivery approach of intervention (phone versus in person) (Ekers, 2013).

Telemedicine technologies now make possible the virtual co-location of mental health specialists and primary care providers. This is achieved using telephones, video conferencing and electronic health records. Compared with usual practice-based care, telemedicine has shown to have significantly and substantially greater treatment response, remission rates, reductions in depression severity, and increases mental health status and quality of life. These outcomes were achieved without increasing the number of primary care visits (Fortney, 2013).

Challenges. There are challenges in providing the collaborative care model that need to be acknowledged and addressed by the health care organization. Some of these challenges include (Belnap, 2006):

• Identifying depressed patients in the practice
• Identifying the desired background experience for care managers
• Establishing the responsibilities and scope of practice of the care managers
• Locating the care managers (centrally versus clinic-based)
• Determining level of supervision by psychiatrists
• Seeking adequate reimbursement for services provided to ensure program sustainability
• Clinic size: typically not feasible for small clinics to employ on-site mental health specialists or full time care managers (Fortney, 2013)

See the "Implementation Recommendations" and "Implementation Tools and Resources Table" sections of this guideline for suggestions and information on implementing the collaborative care model.

Educate and Engage Patient

Successful care of major depression as an illness requires active engagement of each patient and his/her family, plus ongoing patient education, beginning at the time of diagnosis.

Often, the depressed patient's pessimism, low motivation, low energy, and sense of social isolation and guilt may lead to non-adherence with treatment (American Psychiatric Association, 2010).

However, there are ways to improve engagement and adherence.

Therapeutic alliance: It is essential to know the patient and cultivate a therapeutic alliance-defined as a collaborative bond between patient and clinician (Krupnick, 1996). This alliance can have a greater effect on outcomes than the actual treatment used (psychotherapy vs. pharmacotherapy) and can have a large effect even when the treatment is pharmacotherapy (Krupnick, 1996).

It is essential that both the patient and the clinician feel invested in the outcome. Within the context of what the clinician is able to recommend, patient's preferences matter. In a study by Kocsis, 2009, patients who preferred psychotherapy but received medication had a 7.7% remission rate vs 50.0% if they received psychotherapy. Those who preferred medication but received psychotherapy had a 22.2% remission rate vs 45.5% if they received medication (Kocsis, 2009b).

Past history's influence on adherence

• Accurate history-taking remains the cornerstone of medical treatment. A patient's past experience with depression predicts adherence to the treatment plan, and past history is common given the lifetime prevalence of major depression of 17% (Johnston, 2013). Other findings from Johnston's review of patients' experience influence on adherence include:
• Patients who had endured a prior episode of depression were found to have higher adherence to treatment with antidepressant agents.
• People who know someone with a history of depression tended to view depression as a biomedical condition and were more accepting of medication.
• Interactions with providers, receiving information, feeling heard and understood, and gaining experience with medication all have a major influence on decisions to continue treatment.
• Patient-provider relationships and overall treatment experience were crucial, especially when many realized that long-term treatment was likely required.

Patient Education

Topics to cover: Education topics should include:

• The cause, symptoms and natural history of major depression
• Treatment options and the process of finding the best fit for a given individual
• Information on what to expect during the course of treatment
• How to monitor symptoms and side effects
• Follow-up protocol (office visits and/or telephone contacts). See the "Establish Follow-Up Plan" section for information on frequency of follow-ups
• Early warning signs of relapse or recurrence
• Length of treatment
• Communication with the caregiver

Patient education should include diagnosis, prognosis and treatment options including costs, duration, side effects and expected benefits.

While the clinician goal of utilizing the PHQ-2 and PHQ-9 is detecting and diagnosing depression, these tools are, in real-world use, often used primarily in shared decision-making with patients to "suggest, tell, or convince patients to accept the diagnosis of depression" (Baik, 2010).

Support and education in the primary care setting are critical and contribute to the likelihood of good follow-through on treatment. It may help patients understand their options and resources if the primary care clinic explains that the support-plus-education component of treatment is not the same as a course of psychotherapy. Clinic staff may also want to identify a family member or support person of the patient's choosing and establish his/her role within the patient's treatment plan.

Key messages for patients and families: Emphasize the following points:

• Depression is a medical illness, not a character defect.
• Treatment is effective for most patients.
• The aim of treatment is remission – being predominately free of symptoms.
• Relapse prevention is a key aspect of management – not just getting better, but also staying well. The risk of recurrence is significant: 50% after one episode, 70% after two episodes, 90% after three episodes (NIMH/NIH Consensus Development Conference Statement, 1985). Patient and family should be alert to early signs and symptoms of recurrence and seek treatment early if depression returns.

People of differing racial/ethnic groups can be successfully treated using currently available evidence-based interventions as long as distinctive personal elements, from biological to environmental to cultural, are considered during the treatment planning process (Schraufnagel, 2006).

Patient Engagement

Patient self-management

It is important for the patient to consider and adopt some self-care responsibilities. These responsibilities may range from simply demonstrating reliable behavior in taking medications and notifying the clinician about side effects to agreeing to participate in sessions, or journaling and completing homework, which is necessary for some cognitive behavioral therapies. Written materials are helpful to reinforce information shared during the discussion. Bibliotherapy, a therapy approach wherein the patient is encouraged to read self-help books and other relevant materials, has modest empirical support for benefitting patients who are motivated to augment their professional care with self-help literature (Bower, 2013; Anderson, 2005; Gregory, 2004).

See the "Implementation Tools and Resources Table" for examples of book titles.

Decision-making capacity

The ICSI shared decision-making model is a useful primer on the collaborative conversation with the main focus on things the clinician can do to assist the patient in making a shared decision regarding treatment. This means factoring in patient values and preferences in decisions regarding treatment. See Appendix B, "ICSI Shared Decision-Making Model," for full description of ICSI Shared-Decision Making model. It is important to keep in mind what is required of the patient in order to make informed decisions. Some patients, especially those with neurocognitive disorders, lack the required capacities to truly participate in the process. There are four abilities adults need in order to decide on treatments for depression (Applebaum, 2007):

1. The ability to express a choice
2. The ability to understand information for treatment decision-making
3. The ability to appreciate the significance of that information for one's own situation, especially concerning one's illness and the probable consequences of one's treatment options
4. The ability to reason with the relevant information in order to engage in a logical process of weighing treatment options

Although competency is a legal termination, medical opinions regarding the patient's cognitive capacities are typically sought, and the ability to assess these capacities is a necessary skill set for physicians.

General vs. specific competency

When the clinician decides to consult psychiatry, referral questions should address a specific competency such as "Is this patient competent to refuse surgery?" rather than the general question "Is this patient competent?" A person can be competent to do some things (make a will) but incompetent to do others (live independently) (Nichita, 2007).

In questions of competency, patients need to have had the information provided to them in order to make informed decisions. Since patients' abilities may fluctuate, it is important that the information is presented at least twice. A patient whose decisions vary each time lacks reliability (Sorrentino, 2014).