Cost-utility of collaborative care for the treatment of comorbid major depressive disorder in outpatients with chronic physical conditions : A randomized controlled trial in the general hospital setting (CC-DIM)

The study was undertaken to establish if collaborative care (CC) is a cost-effective treatment model when provided in the general hospital outpatient setting, rather than the primary care setting, for patients with chronic physical conditions, such as diabetes mellitus (DM), chronic heart failure (CHF), and chronic obstructive pulmonary disease (COPD), with comorbid major depressive disorder (MDD). The researchers performed a randomized controlled trial (RCT) evaluating CC provided by a consultant psychiatric nurse (CPN) as care manager; a consultation–liaison (CL) psychiatrist for diagnosis, supervision, and the prescription of antidepressant medication; and a medical specialist who provided treatment for the chronic physical condition. They found CC to be cost-effective with an incremental cost-effectiveness ratio (ICER) of €24,690 per quality-adjusted life year (QALY). Due to the high disease burden in this patient group, this may indicate that the CC model and setting may be preferable. However, the study was small, so replication in a larger study is warranted

The Depression Initiative. Description of a collaborative care model for depression and of the factors influencing its implementation in the primary care setting in the Netherlands

BACKGROUND: In the Depression Initiative, a promising collaborative care model for depression that was developed in the US was adapted for implementation in the Netherlands. AIM: Description of a collaborative care model for major depressive disorder (MDD) and of the factors influencing its implementation in the primary care setting in the Netherlands. DATA SOURCES: Data collected during the preparation phase of the CC:DIP trial of the Depression Initiative, literature, policy documents, information sheets from professional associations. RESULTS: Factors facilitating the implementation of the collaborative care model are continuous supervision of the care managers by the consultant psychiatrist and the trainers, a supportive web-based tracking system and the new reimbursement system that allows for introduction of a mental health care-practice nurse (MHC-PN) in the general practices and coverage of the treatment costs. Impeding factors might be the relatively high percentage of solo-primary care practices, the small percentage of professionals that are located in the same building, unfamiliarity with the concept of collaboration as required for collaborative care, the reimbursement system that demands regular negotiations between each health care provider and the insurance companies and the reluctance general practitioners might feel to expand their responsibility for their depressed patients. CONCLUSION: Implementation of the collaborative care model in the Netherlands requires extensive training and supervision on micro level, facilitation of reimbursement on meso- and macro level and structural effort to change the treatment culture for chronic mental disorders in the primary care settin

The Geochemistry of Rocks from Asama Volcano, Japan. New Approaches in the Quantitative Interpretation of the Chemical Composition of Volcanic Rocks

In dealing with the geochemistry of volcanic rocks, it appears imperative, first, to refine the procedure of rock analysis with respect to both major and minor components, and second, to improve present methods of interpreting analytical data on common rock suites such as basalts, andesites and dacites. In regard to the first problem, the rapid method of silicate analysis as described by Shapiro and Brannock (1956) and by Riley (1958) deserves special attention. With such a method it is possible to estimate the accuracy and precision of data with far greater ease than is possible with a classical one, yet without any loss of quality. For the determination of some components, however, it is felt that the procedures recommended previously lack precision and/or simplicity. In Part I of this paper, new methods are suggested for these components. The sum of Mg, Ca and Mn is titrated with EDTA in the presence of Al, Fe and other metals, using thymolphthalein complexone as indicator at pH 10-10.5. The sum of Al and Fe is determined by the back-titration of excess EDTA with the standard Cu solution. PAN is used as indicator at pH about 4, and tartrate is added as the masking agent of Ti. Na and K are determined by flame photometry using very dilute solutions (1-5ppm Na or K), without the separation of other metals and without the use of the internal standard. Sr is included in the scheme of analysis, and is determined by flame photometry according to the standard addition technique. These procedures are tested for their accuracy using the standard samples G-1 and W-1 (Tables 3, 5, 9, 12 and 15). Procedures for other components are also described in the text in full detail. The system of analytical procedures recommended is shown in Table 16. To investigate the problem of the interpretation of compositional variation, typical rocks from Asama volcano and the surrounding area were selected, namely, andesites and dacites of calc-alkaline type. Twenty-one samples, described in Tables 18 and 19, are analyzed according to the above procedures. Results are shown in Table 20. Variation diagrams are presented in Figs. 3 to 5. Since it may be questioned whether the "trend" seen in the diagrams implies a genetic relationship, a least squares approximation technique has been introduced in order to determine whether the composition of the main components of a rock (F) can be expressed by the linear combination of a selected set of compositions of a magma and the phenocrysts crystallized from it : F(o)=F(1)x(1)+F(2)x(2)+······+F(m)x(m) ······(1) where F(1), F(2), ... denote the compositions of a magma and minerals, and F(o) is the calculated composition of F. These calculations lead to the conclusion that there are at least two series of rocks in Asama (Tables 25 to 30 and Fig. 9), distinguished from each other mainly by their K(2)O content. Those rocks showing features of assimilation (Aramaki, 1963) all belong to the K(2)O-rich series. Contents of minor components such as TiO(2), MnO, P(2)O(5) and SrO are analyzed by the linear regression technique in two ways, for example : TiO(2)(o)=C(1)x(1)+C(2)x(2)+ ······(2) and TiO(2)(o)=aMgO+bFe(o) +cK(2)O ······(3) These methods are found useful in discriminating rocks of different ongm and in distinguishing the characteristic behavior of each component. Results of calculations (Tables 31 to 34) support the conclusion reached by calculations based on the contents of major components

Validation of the PHQ-9 as a screening instrument for depression in diabetes patients in specialized outpatient clinics

Background. For the treatment of depression in diabetes patients, it is important that depression is recognized at an early stage. A screening method for depression is the patient health questionnaire (PHQ-9). The aim of this study is to validate the 9-item Patient Health Questionnaire (PHQ-9) as a screening instrument for depression in diabetes patients in outpatient clinics. Methods. 197 diabetes patients from outpatient clinics in the Netherlands filled in the PHQ-9. Within 2 weeks they were approached for an interview with the Mini Neuropsychiatric Interview. DSM-IV diagnoses of Major Depressive Disorder (MDD) were the criterion for which the sensitivity, specificity, positive- and negative predictive values and Receiver Operator Curves (ROC) for the PHQ-9 were calculated. Results. The cut-off point of a summed score of 12 on the PHQ-9 resulted in a sensitivity of 75.7% and a specificity of 80.0%. Predictive values for negative and positive test results were respectively 93.4% and 46.7%. The ROC showed an area under the curve of 0.77. Conclusions. The PHQ-9 proved to be an efficient and well-received screening instrument for MDD in this sample of diabetes patients in a specialized outpatient clinic. The higher cut-off point of 12 that was needed and somewhat lower sensitivity than had been reported elsewhere may be due to the fact that the patients from a specialized diabetes clinic have more severe pathology and more complications, which could be recognized by the PHQ-9 as depression symptoms, while instead being diabetes symptom

Comparative effect of collaborative care, pain medication, and duloxetine in the treatment of depression and comorbid pain in outpatient care: results of a randomized, placebo-controlled, multi-center trial

Objective: Evidence exists for efficacy of collaborative care (CC) against MDD, for efficacy of consequent use of pain medication against pain, and for efficacy of duloxetine against both MDD and neuropathic pain. However, their relative effectiveness in comorbid major depression (MDD) and pain has never been established so far. This study evaluates the effectiveness of CC, pain medication and duloxetine, and CC, pain medication and placebo, compared to duloxetine alone, on depressive and pain outcomes. Methods: Three armed cluster randomized multi-centre placebo controlled trial in consecutive patients presented at three specialized mental health outpatient clinics who screened positive for MDD. All interventions lasted 12 weeks. In the CC groups duloxetine or placebo was prescribed. Pain medication was administered according to an algorithm that avoids opiate prescription as much as possible as an alternative to the current WHO pain ladder, with paracetamol, COX inhibitors and pregabalin as steps before opiates are considered. Patients who did not show up for three or more sessions were registered as noncompliant. Explorative, intention-to-treat and per protocol, multilevel regression analyses were performed. The trial is listed in the trial registration (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1089; NTR number: NTR1089). Results: This study was prematurely terminated because of massive reorganisations and reimbursement changes for mental health care during the study. 60 patients completed the study. Patients in all treatment groups reported significant less depressive and pain symptoms after 12 weeks. CC with placebo condition showed the fastest decrease of depressive symptoms compared to the duloxetine alone group (b = -.78; p = .01), Noncompliant patients did not improve over the 12 weeks period. Pain outcomes did not differ between the three groups. Conclusions: In MDD and pain, compliance of patients and placebo effects are more important than choice of one of the three treatments. Active pain management in CC with COX inhibitors and pregabalin as alternatives to Tramadol or other opiates might provide an attractive alternative to the current WHO pain ladder as it avoids opiate prescription as much as possible. The study was sufficiently powered to show an exploratory result, but the generalizability is limited due to the small sample size. Larger studies are needed

Cost-effectiveness of collaborative care for the treatment of major depressive disorder in primary care. A systematic review

Background. The effectiveness of collaborative care for patients with major depressive disorder in primary care has been established. Assessing its cost-effectiveness is important for deciding on implementation. This review therefore evaluates the cost-effectiveness of collaborative care for major depressive disorder in primary care. Methods. A systematic search on economic evaluations of collaborative care was conducted in Pubmed and PsychInfo. Quality of the studies was measured with the Cochrane checklist and the CHEC-list for economic evaluations. Cost-effectiveness and costs per depression-free days were reported. Results. 8 studies were found, involving 4868 patients. The quality of the cost effectiveness studies, according to the CHEC-list, could be improved. Generally, the studies did not include all relevant costs and did not perform sensitivity analysis. Only 4 out of 8 studies reported cost per QALY, 6 out of 8 reported costs per depression-free days. The highest costs per QALY reported were $49,500, the highest costs per depression-free day were$24. Conclusions. Although studies did not fulfil all criteria of the CHEC-list, collaborative care is a promising intervention and it may be cost-effective. However, to conclude on the cost-effectiveness, depression research should follow economic guidelines to improve the quality of the economic evaluations

Norwegian GPs' participation in multidisciplinary meetings: A register-based study from 2007

<p>Abstract</p> <p>Background</p> <p>An increasing number of patients with chronic disorders and a more complex health service demand greater interdisciplinary collaboration in Primary Health Care. The aim of this study was therefore to identify factors related to general practitioners (GPs), their list populations and practice municipalities associated with a high rate of GP participation in multidisciplinary meetings (MDMs).</p> <p>Methods</p> <p>A national cross-sectional register-based study of Norwegian general practice was conducted, including data on all GPs in the Regular GP Scheme in 2007 (N = 3179). GPs were grouped into quartiles based on the annual number of MDMs per patient on their list, and the groups were compared using one-way analysis of variance. Binary logistic regression was used to analyse associations between high rates of participation and characteristics of the GP, their list population and practice municipality.</p> <p>Results</p> <p>On average, GPs attended 30 MDMs per year. The majority of the meetings concerned patients in the age groups 20-59 years. Psychological disorders were the motivation for 53% of the meetings. In a multivariate logistic regression model, the following characteristics predicted a high rate of MDM attendance: younger age of the GP, with an OR of 1.6 (95% CI 1.2-2.1) for GPs < 45 years, a short patient list, with an OR of 4.9 (3.2-7.5) for list sizes below 800 compared to lists ≥ 1600, higher proportion of psychological diagnosis in consultations (OR3.4 (2.6-4.4)) and a high MDM proportion with elderly patients (OR 4.1 (3.3-5.4)). Practising in municipalities with less than 10,000 inhabitants (OR 3.7 (2.8-4.9)) and a high proportion of disability pensioners (OR 1.6 (1.2-2.2)) or patients receiving social assistance (OR 2.2 (1.7-2.8)) also predicted high rates of meetings.</p> <p>Conclusions</p> <p>Psychological problems including substance addiction gave grounds for the majority of MDMs. GPs with a high proportion of consultations with such problems also participated more frequently in MDMs. List size was negatively associated with the rate of MDMs, while a more disadvantaged list population was positively associated. Working in smaller organisational units seemed to facilitate cooperation between different professionals. There may be a generation shift towards more frequent participation in interdisciplinary work among younger GPs.</p

Comparison of the Factor Structure of the Patient Health Questionnaire for somatic symptoms (PHQ-15) in Germany, the Netherlands, and China : A Transcultural Structural Equation Modeling (SEM) Study

BackgroundPersistent somatic symptoms are associated with psychological distress, impaired function, and medical help-seeking behavior. The Patient Health Questionnaire (PHQ)-15 is used as a screening instrument for somatization and as a monitoring instrument for somatic symptom severity. A bifactorial model has been described, with one general factor and four orthogonal specific symptom factors. The objective of the present study was to assess and to clarify the factor structure of the PHQ-15 within and between different countries in Western Europe and China.MethodCross-sectional secondary data analysis performed in three patient data samples from two Western European countries (Germany N = 2,517, the Netherlands N = 456) and from China (N = 1,329). Confirmatory factor analyses (CFA), and structural equation modeling (SEM) analysis were performed.ResultsThe general factor is found in every sample. However, although the outcomes of the PHQ-15 estimate severity of somatic symptoms in different facets, these subscales may have different meanings in the European and Chinese setting. Replication of the factorial structure was possible in the German and Dutch datasets but not in the dataset from China. For the Chinese dataset, a bifactorial model with a different structure for the cardiopulmonary factor is suggested. The PHQ-15 could discern somatization from anxiety and depression within the three samples.ConclusionThe PHQ-15 is a valid questionnaire that can discern somatization from anxiety and depression within different cultures like Europe or China. It can be fitted toa bifactorial model for categorical data, however, the model can only be recommended for use of the general factor. Application of the orthogonal subscales in non-European samples is not corroborated by the results. The differences cannot be ascribed to differences in health care settings or by differences in concomitant depression or anxiety but instead, a cultural factor involving concepts of disease may play a role in this as they may play a role in the translation of the questionnaire. Further research is needed to explore this, and replication studies are needed regarding the factorial structure of the PHQ-15 in China