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Clinical Outcomes

There is extensive evidence of the benefits of integrated behavioral health care across the following areas:

Effects on Depression

  • Enhancing primary care depression management on an ongoing basis resulted in substantial long-term treatment effectiveness. It increased the number of days free of depression impairment for two years when compared with usual care (647.6 days vs. 588.2 days, P <.01).
    • Katherine Rost, “Cost-Effectiveness of Enhancing Primary Care Depression Management on an Ongoing Basis”, Annals of Family Medicine, 2005, 3:7-14.
  • A review of 78 articles on the effectiveness of collaborative chronic care models for mental health conditions found significant effects across disorders and care settings for depression, physical quality of life and social functioning.
    • Emily Woltmann et al., “Comparative Effectiveness of Collaborative Chronic Care Models for Mental Health Conditions Across Primary, Specialty and Behavioral Health Care Settings: Systematic Review and Meta-Analysis”, Amer. J. Psychiatry, 2012: 169
  • Half of the 250 mood-disordered primary care patients receiving co-located behavioral health services improved at least 50% in their pre-to-post depression scores over three months.  There was not, however, a significant relationship between depression improvement and number of behavioral visits.
    • Bill McFeature, et al., “Primary Care Behavioral Health Consultation Reduces Depression Levels Among Mood Disordered Patients” J. of Health Disparities for Research and Practice, 2012.
  • Relative to usual care, older adults with diabetes and depression who received depression collaborative care (a depression care manager offered education, behavioral activation, and a choice of problem-solving treatment or support of antidepressant management by the primary care physician) experienced 115 more depression-free days over 24 months.
    • Wayne Katon et al. “Cost-Effectiveness and Net Benefit of Enhanced Treatment of Depression for Older Adults with Diabetes and Depression.” Diabetes Care 29:265-270, 2006.
  • At 12 months, older primary care ethnic minority clients (Blacks and Latinos) assigned to an intervention had lower depression severity and less health-related functional impairment than usual care participants (64%, 95%).
    • Patricia Arean et al., “Improving Depression Care for Older, Minority Patients in Primary Care” Medical Care, 2005, 43(4).
  • The reported level of suicide ideation in older primary care clients who received collaborative treatment tailored to the elderly declined significantly more than care as usual clients. Differences peaked at eight months. Intervention patients had a more favorable course of depression in both degree and speed of symptom reduction.
    • Martha Bruce et al., “Reducing Suicidal Ideation and Depressive Symptoms in Depressed Older Primary Care Patients” JAMA 2004, Vol. 291, No. 9.
  • Based on an analysis of 36 studies, authors concluded that “Strategies effective in improving patient outcome [regarding depression in primary care settings] were those with complex interventions that incorporated clinician education, an enhanced role of the nurse (nurse case manager), and a greater intervention between primary and secondary care (consultation-liaison). Telephone medication consultation delivered by practical nurses or trained counselors was also effective.”
    • Simon Gilbody et al., “Educational and Organizational Interventions to Improve the Management of Depression in Primary Care: A Systematic Review”, JAMA, June 18, 2003. Vol. 289.
  • Over two years, primary care clients randomly assigned to depression intervention (access to a depression care manager supervised by a psychiatrist and primary care physician) patients experienced 107 more depression-free days than usual-care clients.
    • Wayne Katon et al., Arch Gen Psychiatry. 2005; 62.
  • A meta-analysis of 37 randomized studies including 12,555 patients with depression receiving primary care found that depression outcomes were significantly improved at six months as compared with standard treatment and evidence of longer-term benefit was found for up to five years, Effectiveness was directly related to medication compliance and to the professional background and method of supervision of case managers.
    • Gilbody et al, “Collaborative Care For Depression”, Arch Intern Med, Vol. 166, Nov. 27, 2006.
  • Depressed high-utilizers of an HMO system enrolled in a depression management program were more likely to have their antidressant prescriptions filled than a matched usual care group (69.3% vs. 18.5%). They also evidenced less depression and improved mental health, social functioning, and general health perceptions as measured by assessment scales.
    • David Katzelnick et al., “Randomized Trial of a Depression Management Program in High Utilizers of Medical Care”, Arch Fam Med. 2000;9.
  • Older adults with diabetes assigned to a care manager offering education and problem-solving treatment or supporting antidepressant management by the patient’s primary care physician had less severe depression and greater improvement in overall functioning than a care as usual care group.
    • John Williams “The Effectiveness of Depression Care Management on Diabetes-Related Outcomes in Older Patients”,  Annals of Internal Medicine, 2004,Volume 140 Issue 12.
  • Older adults who received active intervention with a depression manager in primary care clinics had better depression outcomes at one year than did controls regardless of their baseline cognitive impairment.
    • David Steffins et al., “Cognitive impairment and depression outcomes in the IMPACT study”,The American Journal of Geriatric Psychiatry 2006, 14.
  • Primary care clients with major depression who took part in a multifaceted intervention (more frequent and intense visits for the first 4-6 weeks and medication follow-ups) had significantly greater adherence than the usual care controls to adequate dosage of antidepressant medication, and were more likely to rate antidepressant medications as helping somewhat to helping a great deal (88.1% vs 63.3%; P < .01). Seventy-four percent of intervention patients with major depression showed 50% or more improvement on a depression scale compared with 43.8% of controls (P < .01), and the intervention patients also demonstrated a significantly greater decrease in depression severity over time compared with controls (P < .004).
    • Wayne Katon et al., “Collaborative management to achieve treatment guidelines: Impact on depression in primary care”, JAMA, April 5, 1995, Vol. 273, No. 13.
  • Women with major depression in Santiago, Chili who participated in a multi-component stepped-care program led by a nonmedical health care worker in primary care clinics had a mean of 50 additional depression-free days over six months relative to clients allocated to usual care.
    • Ricardo Araya, “Cost-Effectiveness of a Primary Care Treatment Program for Depression in Low-Income Women in Santiago, Chile”, Am J Psychiatry August 2006, 163.
  • Older primary care clients randomly assigned to enhanced depression treatment had significantly lower rates of suicidal ideation than controls at 6 months (7.5% vs 12.1%) and 12 months (9.8% vs 15.5%) and even after intervention resources were no longer available at 18 months (8.0% vs 13.3%) and 24 months (10.1% vs 13.9%).
    • Jurgen Unutzer et al., “Reducing Suicidal Ideation in Depressed Older Primary Care Patients”, “Journal of the American Geriatrics Society” , 2006, VoL. 54 (10).
  • After one year, older primary care clients with diabetes who received depression-related education, problem-solving treatment, or support for antidepressant management by their primary care physician had less severe depression as measured by a checklist and greater improvement in overall functioning than did usual care clients.
    • John Williams Jr. et al., “The effectiveness of depression care management on diabetes-related outcomes in older patients”, Ann Intern Med 2004, 140 (12).
  • Primary care clients receiving enhanced education and increased psychiatric visits had significantly greater adherence to adequate dosage of medication for 90 days or more, showed a significantly greater decrease in severity of depressive symptoms compared with usual care controls over time and were more likely to have fully recovered at 3 and 6 months.
    • Wayne Katon et al., “Stepped Collaborative Care for Primary Care Patients with Persistent Symptoms of Depression”, Arch Gen Psychiatry. 1999 (56).
  • Over 24 months, clients having both diabetes and depression who were assigned to a stepped-care depression treatment program had an average of 61 more days free of depression than clients continuing in usual care. The authors conclude that “for adults with diabetes, systematic depression treatment significantly increases time free of depression”.
    • Gregory Simon et al., “Cost-effectiveness of Systematic Depression Treatment Among People With Diabetes Mellitus”, Archives of General Psychiatry, Vol. 64, No. 1, January, 2007.
  • After 12 months, older depressed primary care clients with panic disorder or PTSD receiving collaborative-care treatment showed the same improvement as those without these conditions receiving the same treatment, though they had a slower treatment response. Results suggest that the collaborative care is more effective than usual care for depressed older adults both with and without co-morbid panic disorder and PTSD, though those with PTSD had a slower treatment response.
    • Mark Hegel et al., “Impact of co-morbid panic and posttraumatic stress disorder on outcomes of collaborative-care for late-life depression in primary care.” Am J Geriatr Psychiatry, 2005, 13(1).
  • Older primary care clients assigned to a 12 month collaborative care intervention (including education, behavioral activation, antidepressants, problem solving treatment and relapse prevention) fared significantly better than controls regarding continuation of antidepressant treatment, depressive symptoms, remission of depression, physical functioning, quality of life, self efficacy, and satisfaction with care at 18 and 24 months. Thus, even after the resources were withdrawn, the intervention group continued to do significantly better than the controls.
    • Enid Hunkeler et al. “Long Term Outcomes from the IMPACT Randomized Trial for Depressed Older Primary Care Patients.” British Medical Journal, 2006, 332(7536).
  • Depressed primary care clients aged 13-23 received either usual care or a six month quality improvement intervention (including care managers who supported the primary care clinician in evaluating and managing the clients’ depression). The intervention group reported significantly fewer depressive symptoms and a higher quality of life.
    • Joan Asarnow et al., “Effectiveness of a Quality Care Intervention for Adolescent Depression in Primary Care”, JAMA, January 19, 2005, Vol. 293, No. 3.
  • Over nine months, veterans with depression randomly assigned to collaborative care experienced an average of 14.6 more depression-free days than their counterparts receiving regular care.
    • Chuan-Fen Liu et al., “Cost-Effectiveness of Collaborative Care for Depression in a Primary Care Veteran Population”, Psychiatric Services, 2003, Vol. 54.
  • Over one year, high-utilizing adults (having frequent HMO medical visits) who were randomly assigned to an organized primary care depression management program experienced 47.7 more depression-free days than their counterparts receiving regular care.
    • Gregory Simon et al., “Cost-effectiveness of Systematic Depression Management for High Utilizers of General Medical Care”, Arch Gen Psychiatry, 2001, 58.
  • Older primary care clients who received treatment tailored for the elderly with care management for one year experienced less suicidal ideation than their counterparts who continued treatment as usual. Intervention clients had “a more favorable course of depression in both degree and speed of symptom reduction; group differences peaked at four months.”
    • Martha Bruce, et al., “Reducing Suicidal Ideation and Depressive Symptoms in Depressed Older Primary Care Patients”, J of the American Med Ass’n, 2004, 291.
  • Adults at HMO primary care clinics who had both diabetes and comorbid major depression were randomly assigned to either a case management intervention or usual care. At six months the intervention clients showed less depression and a reported a greater rate of global improvement (69.4% vs. 39.3%) than the usual care clients.
    • Wayne Katon et al., “The Pathways Study: A Randomized Trial of Collaborative Care in Patients with Diabetes and Depression”, Arch Gen Psychiatry, 2004, 61.
  • Over a six month period, primary care clients receiving collaborative care (education, visit with a psychiatrist, 2-4 months of shared care by the psychiatrist and primary care physician), experienced an average of 16.7 depression-free days compared to care-as-usual clients.
    • Gregory Simon et al “Cost-effectiveness of a Collaborative Care Program for Primary Care Patients with Persistent Depression”, American Journal of Psychiatry, 2001, 158.
  • Clients 60 years and older receiving primary care services were randomly assigned to depression intervention or care as usual. At the end of a year, 45% of the intervention clients had a 50% or greater reduction in depressive symptoms compared with 19% of the usual care participants, indicating that the intervention was more than twice as effective as usual care.
    • Jurgen Unutzer et al., “Collaborative Care Management of Late-Life Depression in the Primary Care Setting”, JAMA, Dec. 11, 2002, Vol. 288.
  • “A collaborative care intervention was associated with sustained improvement in depressive outcomes without additional health care costs in approximately two thirds of primary care patients with persistent depressive symptoms.”
    • Wayne Katon, “Long-term effects of a collaborative care intervention in persistently depressed primary care patients”, J Gen Intern Med, 2002 (10):811.
  • In a randomized controlled trial at four primary HMO clinics, clients scoring high in depression who were assigned to stepped care intervention (including client education, adjustment of pharmacotherapy, and proactive outcome monitoring) experienced less interference in their family, work, and social activities than patients receiving usual primary care.
    • Elizabeth Lin, “Can Depression Treatment in Primary Care Reduce Disability?” Arch Fam Med. 2000 (9).
  • At six months, counseled primary care clients demonstrated a significantly greater reduction in psychological symptoms such as depression and anxiety than those receiving usual care.
    • [no author named],“Counseling in Primary Care”, Effectiveness Matters, 2001, Vol. 5, Issue 1.
  • A review of the literature suggests that exercise may reduce depressive symptoms following smoking cessation in persons with major depressive disorders.
    • Bernard, P. et al., “Smoking Cessation, Depression and Exercise: Empirical Evidence, Clinical Needs and Mechanisms“, Oxford Journals, 2013

Effects on Panic Disorder and Bipolar Disorder

  • Primary care clients with panic disorder randomly assigned to a collaborative care intervention (systematic patient education and approximately two visits with an on-site consulting psychiatrist) experienced an average of 74.2 more anxiety-free days during the 12-month intervention than clients receiving usual primary care.
    • Wayne Katon et al., “Cost-effectiveness and Cost Offset of a Collaborative Care Intervention for Primary Care Patients with Panic Disorder” , Arch Gen Psychiatry, 2002; 59.
  • Clients with panic disorder at six primary care clinics who were randomly assigned to an intervention of up to six sessions of cognitive-behavioral therapy and medications showed a “sustained and gradually increasing improvement relative to treatment as usual” with significantly higher rates of remission higher mental health functioning.
    • Peter Roy-Byrne, “A Randomized Effectiveness Trial of Cognitive-Behavioral Therapy and Medication for Primary Care Panic Disorder”, Arch Gen Psychiatry, 2005;62.
  • Primary care clients receiving collaborative care for panic disorder (educational material, pharmacotherapy, limited psychiatrist interaction) were more likely to receive adequate medication and more likely to adhere to the medication regimen than care-as-usual clients at three and six months.
    • Peter Roy-Byrne et al., “A Randomized Effectiveness Trial of Collaborative Care For Patients with Panic Disorder in Primary Care”, Archives of General Psychiatry, 2001, 58 (9).
  • Clients treated for bipolar disorder were randomly assigned to usual care or usual care plus a systematic care management program (initial assessment and care planning, monthly telephone monitoring including brief symptom assessment and medication monitoring, feedback to and coordination with the mental health treatment team, and a structured group psychoeducational program, all provided by a nurse care manager). Participants assigned to the care management program had significantly lower mean mania ratings averaged across the 12-month follow-up period and approximately one-third less time in hypomanic or manic episode (2·59 weeks v. 1·69 weeks). Mean depression ratings across the entire follow-up period did not differ significantly between the two groups, but the intervention group showed a greater decline in depression ratings over time.
    • Gregory Simon et al., “Randomized trial of a population-based care program for people with bipolar disorder” Psychological Medicine, Jan 2005, Volume 35, Issue 01.

Effects on Drug Abuse

  • Adult drug-abusers who met with an addiction peer counselor just once at during a routine doctor visit and received a follow-up booster phone call were less likely to continue drug use than their counterparts randomly assigned to routine care. Among cocaine users, 22.3% reported abstinence six months after enrollment compared to 16.9% of the control group. Among heroin users, the results were 40.2 compared to 30.6%.
    • Judith Bernstein et al., “Brief Encounters Can Provide Motivation to Reduce or Stop Drug Abuse”, Drug and Alcohol Dependence, Jan., 2005.
  • In a study of 598 chemical dependency patients, researchers found that those with higher primary care engagement were more likely to be in remission after five years.  The study highlights the potentially important role of medical care and the integration of substance abuse treatment with primary care.
    • Mertens, J R et al., “The role of medical conditions and primary care services in 5-year substance use outcomes among chemical dependency treatment patients” Drug Alcohol Dependence. 2008;98 (1-2):45-53.

Effects on Physical Health

  • Patients with serious mental illness receiving care in Veterans Affairs mental health programs with co-located general medical clinics were more likely to receive adequate medical care than patients in programs without co-located clinics based on a nationally representative sample.
    • Kilbourne, A et al., “Quality of General Medical Care Among Patients With Serious Mental Illness: Does Co-Location Matter?”, Psychiatric Services, 2011, Vol 62, No. 8.                          
  • Persons with serious mental illness receiving services in a mental health center who were randomly assigned to medical care management (care managers who provided communication and advocacy with medical providers as well as health education and assistance in overcoming barriers to healthcare) received a significantly higher level of preventative and evidence-based cardiometabolic services and scored higher on mental health screen than comparable treatment-as-usual group.
    • Druss, Benjamin et al., “A Randomized Trial of Medical Care Management for Community Mental Health   Settings: The Primary Care Access, Referral and Evaluation (PCARE) Study, Am. J. of Psychiatry, 2010, 167: 151-159.
  • Some of 291 overweight outpatients with serious mental disorders were randomly assigned to a weight management and exercise program.  Weight loss in this group increased progressively over 18 months and differered significantly from the control group.
    • Daumit, Gail et al., “A Behavioral Weight Loss Intervention in Persons with Serious Mental Illness:, N. Eng. J Med. 2013, 368; 1594-1602
  • Collaborative depression care delivered before cardiovascular disease (CVD) onset halved the excess risk of hard CVD events among older, depressed patients.
    • Stewart, J.C. et al., “Effect of collaborative care for depression on risk of cardiovascular events: data from the IMPACT randomized control trial”  Psychosom Med. 2014 Jan; 76(1):29-37