A Toddler Parenting Intervention in Primary Care for Caregivers With Depression Symptoms

Caregiver depression impacts parenting behaviors and has deleterious effects on child behavior. Evidence-based interventions to address parenting have not been adapted for use with depressed caregivers in pediatric primary care settings. Our study examined the feasibility and explored outcomes of an evidence-based parenting program implemented in primary care and adapted for caregivers with depressive symptoms caring for toddlers. We conducted a randomized controlled trial with a wait-list control. Participants were caregivers who screened positive for depressive symptoms in pediatric settings with a toddler. Our study was implemented from July 2011 to June 2012. We adapted the Incredible Years Parents, Babies and Toddlers program with the addition of depression psychoeducation (12 weekly sessions), and assessed caregivers at baseline and immediately post-intervention. We assessed participation rates, depressive symptoms, parenting discipline practices, social support, and parenting stress. Our results revealed that 32 caregivers participating in the intervention group had significantly greater improvement in self-reported parenting discipline practices compared to the 29 wait-list control group caregivers. We found no differences between groups in depressive symptoms, social support, or parenting stress. Our study demonstrated that the average attendance was poor (mean attendance = 3.7 sessions). We adapted an evidence-based parenting intervention for caregivers with depressive symptoms and toddlers in primary care; however, participation was challenging. Alternative intervention strategies are needed to reach and retain low-income caregivers with depression symptoms as they face multiple barriers to participation in groups within center-based services. Trial Registration Clinical Trials.gov identifier NCT01464619.     

Depression and Coleman Care Transitions Intervention

ABSTRACT

The Coleman Care Transitions Intervention (CTI) is a “Patient Activation Model.” Depression can be a barrier to activation and may challenge CTI. This study addressed whether CTI coaches modified the intervention for older adults who screened positive for depression. Over 4,500 clients in a Centers for Medicare and Medicaid Services demonstration completed screening for depression with the PHQ-9; one in five screened positive (score = 9+). Our findings suggest that coaches modified CTI and played a more directive role for clients who screened positive for depression, resulting in similar 30-day readmission rates among patients who screened positive for depression risk and those who did not. That finding stands in contrast to the widely reported higher readmission rates among people screening positive for depression.     

Long-Term Clinical Outcomes of Care Management for Chronically Depressed Primary Care Patients: A Report From the Depression in Primary Care Project

PURPOSE Recent studies examining depression disease management report improvements in short-term outcomes, but less is known about whether improvements are sustainable over time. This study evaluated the sustained clinical effectiveness of low-intensity depression disease management in chronically depressed patients.METHODS The Depression in Primary Care (DPC) intervention was introduced in 5 primary care practices in the University of Michigan Health System, with 5 matched practices selected as control sites. Clinicians were free to refer none, some, or all of their depressed patients at their discretion. Core clinical outcomes of remission and serial change in Patient Health Questionnaire (PHQ-8) scores for 728 DPC enrollees observed for up to 18 months after enrollment were compared with those for 78 patients receiving usual care who completed mailed questionnaires at baseline, 6, 12, and 18 months.RESULTS DPC enrollees had sustained improvement in remission rates and reduced-function days over the full 18 months. Mean change in the PHQ-8 score over each 6-month interval was more favorable for DPC enrollees than for usual care patients, and the proportion of DPC enrollees in remission was higher at 6 months (43.4% vs 33.3%; P = .11), 12 months (52.0% vs 33.9%; P=.012), and 18 months (49.2% vs 27.3%; P = .004). Multivariate analysis controlling for age, sex, ethnicity, baseline severity, and comorbid medical illness confirmed that DPC enrollees had significantly more reduction in depressive symptom burden over 18 months.CONCLUSIONS The DPC intervention produced sustained improvement in clinical outcomes over 18 months in a cohort of chronically depressed patients with persistent symptoms despite active treatment.     

Depression in Public Community Long-Term Care: Implications for Intervention Development

The objective of this paper is to increase understanding of geriatric depression in the public community long-term care system to guide intervention development. Protocols included screening 1,170 new clients of a public community long-term care agency and interviewing all clients with major, dysthymia, or subthreshold depression (n = 299) and a randomly selected subset of nondepressed older adults (n = 315) at baseline, 6-month, and 1 year. Six percent had major depression, one-half of a percent had dysthymia only, and another 19% had subthreshold depression. Over the year observation period, 40% were persistently depressed; 32% were assessed as depressed only at the first observation; and the remainder was intermittently depressed. There were high levels of comorbid medical, functional, and psychosocial conditions. Mental health service use was low, and clients reported attitudinal and other barriers to depression treatment. Findings suggest the need for universal screening for depression with some strategies for triaging the most severely and persistently depressed for treatment. Although there will be challenges to the development of depression interventions, the public community long-term care system has high potential to assist vulnerable older adults receive help with depression. Presented at Improving Chronic Care Quality Conference, Columbia, Missouri, September. 2004.     

Self-report Depression Scales for Elderly Patients in Primary Care: A Preliminary Study

In a primary care setting, the prevalence of depression in elderlypatients was studied, and the reliability and validity of thegeriatric depression scale (GDS) were assessed. In 141 consecutiveelderly attenders (64–90) of four general practices, weestimated the point prevalence of depression with two self-ratingdepression scales. The results of the two scales were compared.Fourteen patients (12%) scored above cut-off on the Zung self-ratingdepression scale and 14 (12%) on the GDS. In 10 patients bothscales indicated depression. The psychometric quality of bothscales was adequate. The results of the investigation establishedprevalences found in other countries. The GDS may be a usefulcase-finding instrument aiding the general practitioner in theidentification of depression in elderly patients.     

Improving Depression Screening in Primary Care: A Quality Improvement Initiative

The increase in depression during the COVID-19 pandemic underscores the importance of systematic approaches to identify individuals with mental health concerns. Primary care is often underutilized for depression screening, and it is not clear how practices can successfully increase screening rates. This study describes a quality improvement initiative to increase depression screening in five Family Medicine clinics. The initiative included four Plan-Do-Study-Act cycles that resulted in implementing a standardized workflow for depression screening, collaborative efforts with health information technology to prompt providers to perform screening via the medical record, delivering educational materials for providers and clinic staff and conducting follow-up education. Between September 2020 and April 2021 there were 23,745 clinic encounters with adult patients that were analyzed to determine whether patients were up-to-date on depression screening following their visit. A multi-level logistic regression model was constructed to determine the changes in likelihood of a patient being up-to-date on screening over the study period, while controlling for patient demographics and comorbidities. The average proportion of up-to-date patients increased from 61.03% in September 2020 to 82.33% in April 2021. Patients aged 65+ and patients with comorbidities were more likely to be up-to-date on screening; patients with telemedicine visits had lower odds of being up-to-date on depression screening. Overall, this paper describes a feasible, effective intervention to increase depression screening in a primary care setting. Additionally, we discuss lessons learned and recommendations to inform the design of future interventions.

     

Reinvention of Depression Instruments by Primary Care Clinicians

PURPOSE Despite the sophisticated development of depression instruments during the past 4 decades, the critical topic of how primary care clinicians actually use those instruments in their day-to-day practice has not been investigated. We wanted to understand how primary care clinicians use depression instruments, for what purposes, and the conditions that influence their use.METHODS Grounded theory method was used to guide data collection and analysis. We conducted 70 individual interviews and 3 focus groups (n = 24) with a purposeful sample of 70 primary care clinicians (family physicians, general internists, and nurse practitioners) from 52 offices. Investigators’ field notes on office practice environments complemented individual interviews.RESULTS The clinicians described occasional use of depression instruments but reported they did not routinely use them to aid depression diagnosis or management; the clinicians reportedly used them primarily to enhance patients’ acceptance of the diagnosis when they anticipated or encountered resistance to the diagnosis. Three conditions promoted or reduced use of these instruments for different purposes: the extent of competing demands for the clinician’s time, the lack of objective evidence of depression, and the clinician’s familiarity with the patient. No differences among the 3 clinician groups were found for these 3 conditions.CONCLUSIONS Depression instruments are reinvented by primary care clinicians in their real-world primary care practice. Although depression instruments were originally conceptualized for screening, diagnosing, or facilitating the management of depression, our study suggests that the real-world practice context influences their use to aid shared decision making—primarily to suggest, tell, or convince patients to accept the diagnosis of depression.     

Improving the Management of Depression in Primary Care

Depression is a common and important problem in the primary care setting. Despite the fact that effective treatments are available, the recognition, management and outcomes of depression in primary care are far from optimal. A variety of approaches to remedy these problems have been evaluated, including: physician education programs; depression screening and feedback; protocol-based treatment by mental health specialists in the primary care setting; and a variety of disease management strategies. Based on this work, we have learned that improving the care and outcomes of depression in primary care requires some or all of the following: a systematic approach to the recognition and assessment of depression; evidence-based decision support; patient education and activation; ongoing monitoring and feedback regarding patient adherence and outcomes; integration of mental health specialists for patients who are not improving as expected; and physician education. However, interventions that include these components have not been sustained or widely disseminated because of the time, energy, commitment and resources that are required. Successful interventions must be low cost, easy to implement, and they must meet the needs of all stakeholders (i.e. payors, providers, patients and behavioral healthcare companies). Innovative programs that take advantage of new technologies have been recently developed to address these challenges, but require further evaluation.     

Promotoras as Mental Health Practitioners in Primary Care: A Multi-Method Study of an Intervention to Address Contextual Sources of Depression

We assessed the role of promotoras--briefly trained community health workers--in depression care at community health centers. The intervention focused on four contextual sources of depression in underserved, low-income communities: underemployment, inadequate housing, food insecurity, and violence. A multi-method design included quantitative and ethnographic techniques to study predictors of depression and the intervention's impact. After a structured training program, primary care practitioners (PCPs) and promotoras collaboratively followed a clinical algorithm in which PCPs prescribed medications and/or arranged consultations by mental health professionals and promotoras addressed the contextual sources of depression. Based on an intake interview with 464 randomly recruited patients, 120 patients with depression were randomized to enhanced care plus the promotora contextual intervention, or to enhanced care alone. All four contextual problems emerged as strong predictors of depression (chi square, p < .05); logistic regression revealed housing and food insecurity as the most important predictors (odds ratios both 2.40, p < .05). Unexpected challenges arose in the intervention's implementation, involving infrastructure at the health centers, boundaries of the promotoras' roles, and "turf" issues with medical assistants. In the quantitative assessment, the intervention did not lead to statistically significant improvements in depression (odds ratio 4.33, confidence interval overlapping 1). Ethnographic research demonstrated a predominantly positive response to the intervention among stakeholders, including patients, promotoras, PCPs, non-professional staff workers, administrators, and community advisory board members. Due to continuing unmet mental health needs, we favor further assessment of innovative roles for community health workers.     

Differential Effectiveness of Depression Disease Management for Rural and Urban Primary Care Patients

CONTEXT: Federally qualified health centers across the country are adopting depression disease management programs following federally mandated training; however, little is known about the relative effectiveness of depression disease management in rural versus urban patient populations. PURPOSE: To explore whether a depression disease management program has a comparable impact on clinical outcomes over 2 years in patients treated in rural and urban primary care practices and whether the impact is mediated by receiving evidence-based care (antidepressant medication and specialty care counseling). METHODS: A preplanned secondary analysis was conducted in a consecutively sampled cohort of 479 depressed primary care patients recruited from 12 practices in 10 states across the country participating in the Quality Enhancement for Strategic Teaming study. FINDINGS: Depression disease management improved the mental health status of urban patients over 18 months but not rural patients. Effects were not mediated by antidepressant medication or specialty care counseling in urban or rural patients. CONCLUSIONS: Depression disease management appears to improve clinical outcomes in urban but not rural patients. Because these programs compete for scarce resources, health care organizations interested in delivering depression disease management to rural populations need to advocate for programs whose clinical effectiveness has been demonstrated for rural residents.     

Inner City Primary Care Providers' Breast Cancer Screening Knowledge: Implications for Intervention

Low income and minority women continue to have relatively low breast cancer screening rates. Since physician recommendation is one of the most important determinants of mammography participation, we aimed to characterize the breast cancer screening knowledge of primary care providers serving a socially disadvantaged population. The study was conducted at the Adult Medicine Clinic of Seattle's county hospital. All attending physicians, resident physicians, and mid-level practitioners were asked to complete a questionnaire in the spring of 1995. Forty-nine of 52 (94%) eligible providers completed the survey. The respondents generally agreed with published guidelines for screening mammography use. In contrast, they had relatively low levels of knowledge about breast cancer risk factors and the effectiveness of other breast cancer screening methods. Additionally, providers tended to over-estimate their breast cancer screening knowledge and skills. For example, 69% believed that they could answer patients' questions about mammography, but only 23% were aware of Medicaid's reimbursement policy for the procedure. For some variables, attending physicians were no more knowledgeable than resident physicians. Our results reinforce the need for increased preventive care training in medical schools and primary care residency programs. Educational programs for providers serving disadvantaged populations might usefully focus on pragmatic issues such as institutional costs and public payor reimbursement policies.     

Primary Health Care Intervention Reduces Added Sugars Consumption During Childhood

ObjectiveTo investigate the effectiveness of a training program for health workers regarding infant feeding practices to reduce sugar consumption in children.DesignA cluster randomized trial was conducted at 20 health centers in southern Brazil randomly assigned to an intervention (n = 9) or control (n = 11) group.ParticipantsThe 715 pregnant women enrolled were assessed when their children were aged 6 months, 3 years, and 6 years.InterventionA training session for primary care workers based on the Brazilian National Guidelines for Children.Main Outcome MeasureMothers were asked when sugar was first offered to children. Added sugars intake was obtained from dietary recalls.AnalysisThe effectiveness of the intervention was modeled using generalized estimation equations and Poisson regression with robust variance.ResultsChildren attending intervention health centers had a 27% reduced risk of sugar introduction before 4 months of age (relative risk, 0.73; 95% confidence interval [CI], 0.61-0.87) as well as lower added sugars consumption (difference, −6.36 g/d; 95% CI, −11.49 to −1.23) and total daily energy intake (difference, −116.90 kcal/d; 95% CI, −222.41 to −11.40) at 3 years of age.Conclusions and ImplicationsHealth care worker training in infant feeding guidelines may be an effective intervention to delay the introduction of added sugars and lower the subsequent intake of added sugars in infants and toddlers.     

Primary Care Service Areas: A New Tool for the Evaluation of Primary Care Services

Objective. To develop and characterize utilization-based service areas for the United States which reflect the travel of Medicare beneficiaries to primary care clinicians.
Data Source/Study Setting. The 1996–1997 Part B and 1996 Outpatient File primary care claims for fee-for-service Medicare beneficiaries aged 65 and older. The 1995 Medicaid claims from six states (1995) and commercial claims from Blue Cross Blue Shield of Michigan (1996).
Study Design. A patient origin study was conducted to assign 1999 U.S. zip codes to Primary Care Service Areas on the basis of the plurality of beneficiaries' preference for primary care clinicians. Adjustments were made to establish geographic contiguity and minimum population and service localization. Generality of areas to younger populations was tested with Medicaid and commercial claims.
Data Collection/Extraction Methods. Part B primary care claims were selected on the basis of provider specialty, place of service, and CPT code. Selection of Outpatient File claims used provider number, type of facility/service, and revenue center codes.
Principal Findings. The study delineated 6,102 Primary Care Service Areas with a median population of 17,276 (range 1,005–1,253,240). Overall, 63 percent of the Medicare beneficiaries sought the plurality of their primary care from within area clinicians. Service localization compared to Medicaid (six states) and commercial primary care utilization (Michigan) was comparable but not identical.
Conclusions. Primary Care Service Areas are a new tool for the measurement of primary care resources, utilization, and associated outcomes. Policymakers at all jurisdictional levels as well as researchers will have a standardized system of geographical units through which to assess access to, supply, use, organization, and financing of primary care services.     

The Inventory to Diagnose Depression (IDD) in Primary Care Patients

Major depressive disorder (MDD) is highly prevalent in ambulatoryprimary care patients. Severe functional impairment and riskof suicide are features of the condition. Although treatmentcan reduce morbidity, detection of MDD by primary care physiciansis suboptimal. The aim of this study is to assess the inventoryto diagnose depression (IDD) as compared with clinical psychiatricassessment for case finding in primary care patients. Adultmembers of an Israeli kibbutz (communal settlement), where allpsychiatric diagnoses made by the family physician are confirmedby psychiatric consultation, were asked to complete the IDD;a 22 question, self-administered questionnaire. Patients whosescores indicated MOD, if not previously diagnosed, were alsoreferred to psychiatrists. Patients' medical charts were reviewedfor the diagnosis of MDD and response to therapy prior to theadministration of the IDD. Of the sample of 312 patients, 207(66.3%) completed the IDD. Refusers were younger (p = 0.04),more likely to be native born Israelis (p = 0.02), and had ahigher prevalence of known MDD (p = 0.05) than participants.MDD by IDD scores was present in seven patients, in three ofwhom the diagnosis had previously been established; the otherfour were newly diagnosed. In the three previously diagnosedpatients, one (metastatic carcinoma) refused treatment and twowere receiving psychotherapy; all were clinically depressed.Four additional previously diagnosed patients whose IDD scoreswere insufficient for MDD had had a successful response to currenttherapy. A full test of the validity of the IDD as a diagnosticinstrument as com pared with clinical psychiatric assessmentas the criterion standard, requires concurrent assessment withboth methods of all patients studied. Although patients withnegative IDD scores did not receive psychiatric assessment,the diagnosis of MDD was confirmed by psychiatrists in all patientswith positive scores.