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Epidemiology

DEPRESSION CARE: USING THE chronic CARE MODEL IN A UNIVERSITY HEALTH CENTER By Roxanne Wolfram, DnP , RN, FNP-BC ACHA Annual Meeting, Thursday, June 3, 2010 rwolfram@iusb.edu. Epidemiology. Worldwide 5%-10% of population 121 million affected ½ depressed adults get treatment WHO, 2009.

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Epidemiology

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  1. DEPRESSION CARE: USING THE chronic CAREMODEL IN A UNIVERSITY HEALTH CENTERByRoxanne Wolfram, DnP, RN, FNP-BCACHA Annual Meeting, Thursday, June 3, 2010rwolfram@iusb.edu

  2. Epidemiology Worldwide • 5%-10% of population • 121 million affected • ½ depressed adults get treatment WHO, 2009

  3. Epidemiology Nationally Life-time prevalence 15.3% - 16.9% University Student • Higher prevalence 8.7% - 43.4% Andrade et al., 2003; CDC, n.d.; Kessler, 2003; Ohayon, 2007; ACHA, 2009; Steptoe, Tsuda, Tanaka, & Wardle, 2007; Wardle et al., 2004; Vasquez & Blanco, 2008; Wong, Cheung, Chan, Ma & Tang, 2006; Stecker, 2004; Dahlin, Joneborg & Runeson, 2005, WHO, 2009

  4. Epidemiology ACHA NCHA II • 22.7% felt very sad in the past 12 months • 20% felt hopeless in the past 12 months • 13.7% felt so depressed it was difficult to function

  5. Epidemiology ACHA NCHA II • 11.1% of students felt depression affected their academic performance • 9.2% of students were diagnosed or treated by a professional for depression • 3.8% seriously considered suicide • 0.8% attempted suicide

  6. Complications of Depression • Suicide • Reduced quality of life • Reduced social functioning • Role impairment • Excess disability WHO, 2009; CDC, n.d.; Kessler, 2003; Kessler & Walters, 2003

  7. Complications of Depression • Occurs with anxiety • More likely to have CVD, DM, asthma, and obesity • More likely to smoke, be physically inactive, and drink alcohol Andrade et al., 2003; CDC, n.d., Kessler, 2003; Ohayon, 2007

  8. Diagnosis and Treatment Insufficient • 30% properly diagnosed and treated Chizobam et al., 2009; WHO, 2009; Wittchen, 2009

  9. Recommendations • USPSTF (2002) recommends screening for depression in clinical practices that have systems in place that assure accurate diagnosis, effective treatment, and adequate follow-up

  10. Recommendations • Healthy Campus 2010 goal: “improve mental health and ensure access to appropriate, quality mental health services” ACHA, 2002 p. 66

  11. Definition of Depression Unipolar depression: • Major depressive disorder (MDD) • Dysthymic disorder • Depressive disorder not otherwise specified (NOS) APA, 1994

  12. Major Depressive Disorder • Depressed mood • Diminished interest (anhedonia) APA, 1994

  13. Major Depressive Disorder • Significant weight loss or gain or decreased or increase in appetite • Insomnia or hypersomnia • Psychomotor agitation or retardation • Fatigue or loss of energy • Feelings of worthlessness or excessive or inappropriate guilt • Diminished ability to think or concentrate or indecisiveness • Recurrent thoughts of death, recurrent suicidal ideation without a specified plan or a suicide attempt, or a specific plan for committing suicide

  14. Dysthymic Disorder • A depressive disorder that is characterized by at least two years of depressed mood for more days than not • Accompanied by two of the following: • Poor appetite or overeating • Insomnia or hypersomnia • Low energy or fatigue • Low self-esteem • Poor concentration or difficulty making decisions • Feelings of hopelessness

  15. Depressive Disorder NOS • Included for diagnostic coding of depression that has features that do not meet criteria for the other depressive disorder

  16. Significance of the Problem • Improve depression care • Sample of 50 students • 18% were diagnosed with depression • 24% had a history of depression

  17. Purpose/Question • What are the effects of using the Chronic Care Model (CCM) on depression outcomes with a group of students compared with a group using current practice at a Midwestern university health and wellness center?

  18. Purpose/Questions • Outcomes measured • Detection of depression • Depression improvement • Patient compliance with medication • Patient satisfaction

  19. Review of Literature • Databases Searched • Cochrane • Academic Search Premier • CINAHL • Health Source: Nursing/Academic • MEDLINE • PsycArticles • ERIC

  20. Review of the Literature • Key Terms Used • Depression and multifaceted interventions • Depression and collaborative care • Depression and chronic care model • Depression and disease management

  21. Review of the Literature • Inclusion Criteria • January 1, 1999 to January, 31 2010 • English • Age 18 to 64 • More than one intervention • Primary care

  22. Review of the Literature • Exclusion Criteria • Patients with pre- or postnatal depression • Care specific to one gender

  23. Review of the Literature Abstracts identified using search terms N = 939 Excluded N = 901 Articles met criteria for review N = 38 Articles met criteria for review from hand searches N = 63 Excluded N = 87 Articles met inclusion criteria N = 14 Articles valid and reliable N = 9

  24. Review of the Literature

  25. Review of the Literature • Sample sizes: 10 – 55 articles • Patients described as depressed • 5-18 multifaceted interventions used

  26. Review of the Literature Models that guided the literature search and interventions: • Chronic Care Model (3 reviews) • Collaborative Care (3 reviews) • Disease Management Program (2 reviews) • 1 looked at multifaceted interventions

  27. Review of the Literature Interventions: • Delivery system design: • Case management • Regular follow-up • Culturally appropriate care • Defining each provider’s roles and tasks ICSI, 2009; Wagner et al., 1999

  28. Review of the Literature 2. Self-Management Support: • Educating patients about their disease • Providing emotional support • Helping set priorities and goal setting • Developing strategies for living with chronic illness ICSI, 2009; Wagner et al., 1999

  29. Review of the Literature 3. Clinical Information Systems • Electronic health records • Paper registry systems ICSI, 2009; Wagner et al., 1999

  30. Review of the Literature 4. Decision Support • Provider education to stay up to date • Evidence based guidelines in daily practice • Sharing of evidence based guidelines and information with patients to encourage their participation ICSI, 2009; Wagner et al., 1999

  31. Review of the Literature 5. Community Resources • Encouraging patients to participate in effective community programs • Forming partnerships with community organizations to support patient interventions • Advocating for policies to improve patient care ICSI, 2009; Wagner et al., 1999

  32. Review of the Literature 6. Health System • Leadership that visibly supports improvements at all levels • Leadership that provides incentives based on quality of care • Leadership that encourages open and systematic handling of quality problems to improve care ICSI, 2009; Wagner et al., 1999

  33. Review of Literature Outcomes from implementing multifaceted interventions caused improvement in: • Depression (all 9 articles) • Medication adherence (6 out of 6 articles) • Patient satisfaction (2 out of 2 articles) • Depression detection through screening (1 out of 1 article)

  34. Review of the Literature • Less likely to cause depression improvement: Provider education and feedback • More likely to cause depression improvement: Case management and patient preference

  35. Decision to Change Practice • Systematic reviews • Provider preference • CCM • PHQ-9 depression screening tool • Institute for Clinical Systems Improvement (ICSI; 2009) practice guideline

  36. RN Discuss the Project with Patient Usual Care Declines AlgorithmforDepressionCare Yes Randomly draw envelope Usual Care Unexposed Exposed Usual Care 2 simple questions No Yes PHQ-9 screening tool Usual Care Score 0-4

  37. Algorithm for Depression Care PHQ-9 screening tool Depressed No: Reevaluate Interview Assess comorbidites Treat Assess response Good: Continuation or Maintenance Phase

  38. Implementation or Methods • Ace Star Model • Quasi experimental design • Convenience sample • University students • Age 18 and older • Midwestern university health and wellness center • Randomly assigned • Consented

  39. Implementation or Methods Interventions based on the CCM: • Delivery system • Patient self-management • Clinical information system • Decision support • Community resources • Health care system

  40. Data Analysis/Evaluation Sample Size • 91 (65%) agreed to participate and 49 (35%) declined • Eight patients withdrew (8.8%) • Total of 83 patients, 47 (57%) exposed, 36 (43%) unexposed

  41. Data Analysis/Evaluation Sample Characteristics for Entire Group • 22 males (26.5%) and 61 females (73.5%) • Age range between 19-53 years, mean age 27 • 15 patients diagnosed with depression (18%)

  42. Data Analysis/Evaluation Demographic Data for Entire Patient Population in Study

  43. Data Analysis/Evaluation Demographic Data for Depressed Population

  44. Data Analysis/Evaluation Demographic Information for Depressed Patients (n = 10)

  45. Data Analysis/Evaluation (n = 10)

  46. Data Analysis/Evaluation • 10% declined medication/counseling • 70% used antidepressant medication • 90% used on-campus counseling • 30% referred to psychiatrist

  47. Outcome 1: Depression Detection • 21.3% detected in the exposed • 13.9% detected in the unexposed • X²(df) = .751(1) • p = .386 • No statistically significant difference

  48. Data Analysis/Evaluation Outcome 2: Changes in PHQ-9 Scores

  49. Data Analysis/Evaluation Outcome 3 and 4:

  50. Data Analysis/Evaluation • Patient Satisfaction with the Care Received • Of the questionnaires sent out • 4 (11%) completed with 2 (50%) in the exposed and 2 (50%) in the unexposed group • 5 (14%) returned with no forwarding address • 6 (16%) completed without a name

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