Ochoa-Frongia Lisa, Garcia Maria E, Bendahan Tamara, Ponce Andrea N, Calderon Cristina, Pumar Margo, Yee Karen, Schillinger Dean, Loewy Rachel, Mangurian Christina
Division of General Internal Medicine Department of Medicine Zuckerberg San Francisco General Hospital University of California, San Francisco San Francisco California USA.
Division of General Internal Medicine Department of Medicine Multiethnic Health Equity Research Center University of California San Francisco California USA.
Psychiatr Res Clin Pract. 2024 Jan 22;6(2):42-50. doi: 10.1176/appi.prcp.20230060. eCollection 2024 Summer.
Over 90 clinical trials demonstrate the efficacy of the collaborative care model (CoCM) to treat depression in primary care but there is significant variability in real-world CoCM implementation and scalability. This study aimed to determine the feasibility and effectiveness of an adapted CoCM in a safety-net primary care setting.
Bring It Up! (BIU) is a pilot trial comparing an adapted CoCM (intervention group) to usual care (historical controls) for primary care safety-net clinic patients with depression. Inclusion criteria: (1) age ≥18; (2) Patient Health Questionnaire-9 (PHQ-9) score ≥10; and (3) major depressive disorder diagnosis. Patients who completed ≥6 months of treatment upon rolling enrollment (April 1, 2018-October 31, 2019) were included. Historical controls completed ≥6 months of usual care in 2017. BIU included all aspects of CoCM except accountable care and leveraged existing staff rather than a dedicated care manager. The primary outcome was depression remission (PHQ-9 <5) within 6 months. Secondary outcomes included depression response, adherence to treatment guidelines and care coordination process. Data were extracted from the electronic health record.
Thirty-six patients received the intervention; 41 controls received usual care. Depression remission was achieved in 33.3% of intervention patients and 0% of controls ( = 0.001). Of intervention patients, 44.4% achieved ≥50% reduction in PHQ-9 compared to 4.9% of controls ( = 0.003). Further, 66.7% of intervention patients had guideline-recommended antidepressant medication titration compared to 26.9% of controls ( = 0.003); 94.4% of intervention patients had PHQ-9 repeated compared to 53.7% of controls ( < 0.001).
An adapted CoCM was feasible and improved depression care in a safety-net clinic.
超过90项临床试验证明了协作护理模式（CoCM）在初级保健中治疗抑郁症的疗效，但在实际应用和推广CoCM时存在显著差异。本研究旨在确定在安全网初级保健环境中采用改良CoCM的可行性和有效性。
“振作起来！”（BIU）是一项试点试验，将改良的CoCM（干预组）与初级保健安全网诊所抑郁症患者的常规护理（历史对照）进行比较。纳入标准：（1）年龄≥18岁；（2）患者健康问卷-9（PHQ-9）评分≥10；（3）重度抑郁症诊断。滚动入组（2018年4月1日至2019年10月31日）期间完成≥6个月治疗的患者被纳入。历史对照在2017年完成了≥6个月的常规护理。BIU包括CoCM的所有方面，但不包括责任医疗，并利用现有工作人员而非专门的护理经理。主要结局是6个月内抑郁症缓解（PHQ-9<5）。次要结局包括抑郁症反应、对治疗指南的依从性和护理协调过程。数据从电子健康记录中提取。
36名患者接受了干预；41名对照接受了常规护理。干预组33.3%的患者实现了抑郁症缓解，而对照组为0%（P=0.001）。在干预组患者中，44.4%的患者PHQ-9降低了≥50%，而对照组为4.9%（P=0.003）。此外，干预组66.7%的患者进行了指南推荐的抗抑郁药物滴定，而对照组为26.9%（P=0.003）；干预组94.4%的患者重复进行了PHQ-9评估，而对照组为53.7%（P<0.001）。
改良的CoCM在安全网诊所是可行的，并改善了抑郁症护理。
