| Project Name: Care of Mental, Physical and Substance Use Syndromes (COMPASS) |
| Principal Investigator: Sanne Magnan, MD PhD; Evaluation Director: Leif Solberg, MD |
| Principal Investigator Contact Information: sannemagnan@gmail.com; Leif.I.Solberg@Healthpartners.com |
| Principal Investigator institution: Institute for Clinical Systems Improvement; HealthPartners Institute |
| Funder Centers for Medicare & Medicaid Services (CMS) / Center for Medicare & Medicaid Innovation (CMMI) |
| Funding Period: 07/2012 – 06/2015 |
| Abstract: Health care increasingly needs to develop ways to manage individuals with multiple coexisting chronic conditions. COMPASS is a partnership among 9 organizations and 18 care delivery systems nationally to implement the Collaborative Care model for patients in primary care suffering from depression as well as diabetes and/or cardiovascular disease that are not under control. The initiative reached approximately 4,000 patients in seven states, and improved depression in 40% and achieved control in 23% with diabetes and 58% with hypertension while improving patient satisfaction with care and physician satisfaction with the resources needed to manage such patients. |
| Grant Number: CMS-ICI-12-001 |
| Participating Sites: AIMS (Advancing Integrated Mental Health Solutions) Center at the University of Washington Community Health Plan of Washington (CHPW) HealthPartners Institute Kaiser Permanente Colorado (KPCO) Kaiser Permanente Southern California (KPSC) Michigan Center for Clinical Systems Improvement (Mi-CCSI) Mount Auburn Cambridge Independent Practice Association (MACIPA) Pittsburgh Regional Health Initiative (PRHI) Institute for Clinical Systems Improvement (ICSI) |
| Investigators: Sanne Magnan, MD, PhD Claire Neeley, MD Leif Solberg, MD Arne Beck, PhD Karen Coleman, PhD Jurgen Unutzer, MD Rebecca Rossom, MD, MS Lauren Crain, PhD Michael Maciosek, PhD Robin Whitebird, PhD, MSW, LISW |
| Major Goals: The major goals are to increase the proportion of these complex uncontrolled patients who are now under control by 20% for patients with diabetes or hypertension, and to improve depression in 40%, while reducing healthcare costs |
| Description of study sample: This was a demonstration project aimed at adults with active depression plus either diabetes or cardiovascular disease that were not under control. We initially targeted patients with Medicare or Medicaid, but later added other patient groups because of the unexpected difficulty of identifying and recruiting such patients. |
| Current Status: The project was completed in 6/15, but most participating medical groups have continued it with a variety of modifications to fit their settings and needs |
| Study Registration: N/A |
| Publications: Coleman KJ, Hemmila T, Valenti MD, Smith 4, Quarrell R, Ruona LK, Brandenfels E, Hann B, Hinnenkamp T, Parra MD, Monkman J, Vos S, Rossom RC. Understanding the experience of care managers and relationship with patient outcomes: the COMPASS initiative. Gen Hosp Psychiatry. 2016 Aug 18. pii: S0163-8343(16)30164-5. doi: 10.1016/j.genhosppsych.2016.03.003. [Epub ahead of print]Coleman KJ, Magnan S, Neely C, Solberg L, Beck A, Trevis J, Heim C, Williams M, Katzelnick D, Unützer J, Pollock B, Hafer E, Ferguson R, Williams S. The COMPASS initiative: description of a nationwide collaborative approach to the care of patients with depression and diabetes and/or cardiovascular disease. Gen Hosp Psychiatry. 2016 Aug 18. pii: S0163-8343(16)30166-9. doi: 10.1016/j.genhosppsych.2016.05.007. [Epub ahead of print]Rossom RC, Solberg LI, Magnan S, Crain AL, Beck A, Coleman KJ, Katzelnick D, Williams MD, Neely C, Ohnsorg K, Whitebird R, Brandenfels E, Pollock B, Ferguson R, Williams S, Unützer J. Impact of a national collaborative care initiative for patients with depression and diabetes or cardiovascular disease. Gen Hosp Psychiatry. 2016 Aug 18. pii: S0163-8343(16)30165-7. doi: 10.1016/j.genhosppsych.2016.05.006. [Epub ahead of print]Solberg LI, Ferguson R, Ohnsorg KA, Crain AL, Williams MD, Ziegenfuss JY, et al. The challenges of collecting and using patient care data from diverse care systems: lessons from COMPASS. Am J Med Qual 2017;32(5):494-499.Whitebird RR, Solberg LI, Crain AL, Rossom RC, Beck A, Neely C, Dreskin M, Coleman KJ. Clinician burnout and satisfaction with resources in caring for complex patients. Gen Hosp Psychiatry. 2017;44(1):91-95. Jul 16. pii: S0163-8343(16)30167-0. doi: 10.1016/j.genhosppsych.2016.03.004. [Epub ahead of print]Solberg LI, Ohnsorg KA, Parker ED, Ferguson R, Magnan S, Whitebird RR, Neely C, Brandenfels E, Williams MD, Dreskin M, Hinnenkamp T, Ziegenfuss JY. Preventable hospital and emergency department events: lessons from a large innovation project. The Permanente Journal 2018 (In press). |
| Resources: N/A |
| Lessons Learned: It is possible to have multiple diverse health care organizations collaborate on a common improvement project and to use a common data system to aggregate data for reporting and analysis, although there are many challenges to doing so. Other lessons are available in the above publications. Additional publication in development describes the relation between care manager contacts and systematic case review to depression improvement. |
| What’s next? Most participating organizations are continuing to use individually adapted versions of the COMPASS model for care but there will be no follow-on group project. |
Tag: Depressive disorders
Diversity Supplement – Understanding factors that lead to disparities in depression treatment
| Project Name: Diversity Supplement – Understanding factors that lead to disparities in depression treatment |
| Principal Investigator: Karen J Coleman, PhD |
| Principal Investigator Contact Information: Karen.J.Coleman@kp.org |
| Principal Investigator institution: Kaiser Permanente Southern California |
| Funder NIMH |
| Funding Period: 09/2014 – 06/2016 (no-cost extension through 06/2017) |
| Abstract: Depression and other mental illnesses lead to more disability than the most prevalent physical chronic illnesses such as heart disease, diabetes, and cancer, and may cost the U.S. healthcare system as much as 300 billion dollars annually. There are clear racial and ethnic differences in depression treatment, however, it is unknown if these are patient, provider, or healthcare system driven. The diversity supplement was designed to build on previous work funded within the Mental Health Research Network (MHRN) on practice variation in the treatment of depression. The original aims of the diversity supplement were as follows: Aim 1: To understand the healthcare system-, provider-, and patient-level factors that predict taking the initial antidepressant medication prescribed and/or attendance at the initial psychotherapy visit (primary adherence) within 30 days of an initial depression diagnosis. Aim 2: To identify the healthcare system-, provider-, and patient-level factors that predict continuation of depression-related treatment once started (secondary adherence). AIM 3: To characterize racial/ethnic disparities in the achievement of depression improvement or remission with treatment as assessed with the patient health questionnaire (PHQ9), and to understand the role of adherence in this response to treatment. |
| Grant Number: U19MH092201 (Supplement under MHRN II) |
| Participating Sites Contributing Data: Kaiser Permanente Southern California, Pasadena, CA Group Health Cooperative, Seattle, Washington HealthPartners Institute, Minneapolis, Minnesota Kaiser Permanente Colorado, Denver, Colorado Kaiser Permanente Hawaii, Honolulu, Hawaii Henry Ford Healthcare Systems, Detroit, Michigan |
| Additional Sites Participating in the Study: Baylor Scott & White, Temple, Texas University of Utah, Salt Lake City, Utah |
| Investigators: Karen J. Coleman, PhD Gregory Simon, MD MPH Rebecca Rossom, MD Arne Beck, PhD Beth Waitzfelder, PhD John Zieber, PhD Brian Ahmedani, PhD Zach Imel, PhD |
| Major Goals: To provide a high-level understanding of how race/ethnicity contributes independently to the variation for initiation and continuation of depression treatment. To provide a dataset and documentation associated with this dataset and its analyses that can be used by other researchers interested in the treatment of depression in large healthcare systems. To provide a basis for testing culturally tailored or appropriate interventions that improve the adherence to depression treatment in a variety of patient populations. |
| Major Limitations: Questions about depression treatment outcomes cannot be addressed with this dataset because PHQ9 data collection in the five healthcare systems during the study period was not widespread. Questions about healthcare system variation in policies and guidelines for depression treatment cannot be addressed with this dataset as these variables were not available for study. Questions about provider-level variation in the treatment of depression can only be addressed for two sites in the study due to the lack of data collected for providers in the other sites. Thus, conclusions about provider-level variation and its contribution to depression treatment modalities and adherence cannot generalize to other healthcare settings. |
| Description of study sample: There are two study samples included in this study. One is for initiation of treatment for patients newly diagnosed with depression and one is for adherence to a new episode of antidepressant medication and/or formal psychotherapy treatment in patients diagnosed with depression. Treatment in the Newly Diagnosed Patients 18 and older who had a new depression diagnosis in primary care clinics between 1/1/2009 and 12/31/2013 were included. Patients were excluded if they had a diagnosis of bipolar disorder, schizophrenia spectrum disorder, or other psychosis in the prior two years to the diagnosis date. To ensure the availability of data needed to create the patient sample for all analyses, the sample was limited to those who were continuously enrolled in the healthcare systems for at least 360 days prior to the diagnosis date, allowing a 60-day gap. New episodes of depression were defined as an ICD-9 code for depression made in a primary care setting, with no diagnosis or treatment for depression (either psychotherapy or antidepressant medication) during the 360 days prior to the diagnosis. These patients were followed for 90 days after the diagnosis date to look for the initiation of treatment (see definitions below for treatment). Patients who disenrolled from the healthcare systems in less than 90 days after diagnosis were excluded. Adherence in the Newly Treated Patients 18 and older who had a new episode of formal psychotherapy treatment (PT) between 1/1/2010 and 12/31/2013 or a new antidepressant treatment (AD) between 1/1/2010 and 12/31/2013 were included. Patients were excluded if they had a diagnosis of bipolar disorder, schizophrenia spectrum disorder, or other psychosis in the prior two years to index date. The sample was also limited to those who were continuously enrolled in the healthcare systems for at least 270 days prior to the index AD/PT episode, allowing a 60-day gap. A new episode of AD/PT treatment was defined as not having any evidence of the same type of treatment (AD or PT) during the previous 270 days before the date of the new episode. AD episodes with a prescription for trazodone were excluded because this drug is primarily prescribed for sleep disturbance and not depression. We did not consider appointments that were less than 30 minutes and/or clearly designated as only medication management to be formal psychotherapy. |
| Current Status: The analytic dataset and its documentation have been compiled. Further analyses funded by the project are limited to the following manuscripts which are currently in process: The Mental Health Provider as a Source of Racial and Ethnic Disparities in Adherence to Antidepressant Medication and Psychotherapy (Imel et al.) |
| Study Registration: N/A |
| Publications: Coleman KJ, Stewart C, Waitzfelder BE, Zeber JE, Morales LS, Ahmed AT, Ahmedani BK, Beck A, Copeland LA, Cummings JR, Hunkeler EM, Lindberg NM, Lynch F, Lu CY, Owen-Smith AA, Trinacty CM, Whitebird RR, Simon GE. Racial-Ethnic Differences in Psychiatric Diagnoses and Treatment Across 11 Health Care Systems in the Mental Health Research Network. Psychiatr Serv. 2016 Jul 1;67(7):749-57. doi: 10.1176/appi.ps.201500217. Epub 2016 Apr 15.Rossom RC, Shortreed S, Coleman KJ, Beck A, Waitzfelder BE, Stewart C, Ahmedani BK, Zeber JE, Simon GE. Antidepressant adherence across diverse populations and healthcare settings. Depress Anxiety. 2016 Aug;33(8):765-74. doi: 10.1002/da.22532. Epub 2016 Jun 20.Simon GE, Coleman KJ, Waitzfelder BE, Beck A, Rossom RC, Stewart C, Penfold RB. Adjusting Antidepressant Quality Measures for Race and Ethnicity. JAMA Psychiatry. 2015 Oct;72(10):1055-6. doi: 10.1001/jamapsychiatry.2015.1437.Simon GE, Rossom RC, Beck A, Waitzfelder BE, Coleman KJ, Stewart C, Operskalski B, Penfold RB, Shortreed SM. Antidepressants are not overprescribed for mild depression. J Clin Psychiatry. 2015 Dec;76(12):1627-32. doi: 10.4088/JCP.14m09162.Zeber JE, Coleman KJ, Fischer H, Yoon TK, Ahmedani BK, Beck A, Hubley S, Imel ZE, Rossom RC, Shortreed SM, Stewart C, Waitzfelder BE, Simon GE. The impact of race and ethnicity on rates of return to psychotherapy for depression. Depress Anxiety. 2017 Dec;34(12):1157-1163. doi: 10.1002/da.22696. Epub 2017 Nov 2. PubMed PMID: 29095538; PubMed Central PMCID: PMC5718939.Waitzfelder B, Stewart C, Coleman KJ, Rossom R, Ahmedani BK, Beck A, Zeber JE, Daida YG, Trinacty C, Hubley S, Simon GE. Treatment Initiation for New Episodes of Depression in Primary Care Settings. J Gen Intern Med. 2018 Aug;33(8):1283-1291. doi: 10.1007/s11606-017-4297-2. Epub 2018 Feb 8. PubMed PMID: 29423624. |
| Resources: A data dictionary and descriptive tables for the data file associated with this project will be available soon. Some research questions cannot be addressed by this dataset and require an initial review and possible discussion to make this determination. For immediate questions, contact Greg Simon at simon.g@ghc.org. |
| Lessons Learned: For all systems contributing data to this project, electronic medical records, insurance claims, and other data systems were organized in a Virtual Data Warehouse (VDW) to facilitate population-based research. The VDW is a collection of common data definitions and formats to ensure equivalent de-identified data for analysis. Because the VDW relies on data availability from a diverse set of healthcare settings in the Health Care Systems Research Network customizing data abstraction such as healthcare system policy variables or provider-level descriptive information is difficult and in some cases impossible. This needs to be considered when studies are proposed that examine the interplay of healthcare system-, provider-, and patient-level factors in mental health-related treatment choices and outcomes. |
| What’s next? Possible harvest of new PHQ9 data as implementation of screening and treatment follow-up have increased exponentially since 2013. Pursue an R01 to characterize heterogeneity of achievement of depression improvement or remission and incorporate more healthcare sites (only 6 of 13 MHRN sites were included) and use additional provider variation analytic methods. Other possible grant ideas that have been discussed: Culturally-tailored intervention to assist with the decisions around depression treatment (shared decision-making and motivational interviewing models) |
FDA Black Box Warning and Suicide
| Project Name: Longitudinal Analysis of SSRI Warnings and Suicide in Youth |
| Principal Investigator Stephen Soumerai, ScD |
| Principal Investigator Contact Information: ssoumerai@hms.harvard.edu |
| Principal Investigator institution: Harvard Pilgrim Health Care |
| Funder NIMH |
| Funding Period: 09/10 – 07/2013 |
| Abstract: Approximately 14-25% of youth experience major depression before adulthood; about 9% of adolescents attempt suicide and 2.9% make a suicide attempt requiring medical attention. Treatment with antidepressant medications has been shown to improve mood and decrease suicidal ideation. However, there has been concern that antidepressants paradoxically increase the risk of suicidal behaviors following initiation of SSRI treatment. The FDA issued several public health advisories and a boxed warning since October of 2003 and, beginning in 2005, all SSRI labeling has required a “black box” warning (BBW) regarding the increased risk of suicidality in children and adolescents taking antidepressants. However, conflicting evidence concerning the true effects of SSRIs on the risk of suicidal behaviors in youth has generated much controversy. Studies following the BBW reported decreased rates of pharmacologic treatment for depression. Another study reported an 18% increase in completed suicides among youth in 2004 and 2005. This research will contribute to research regarding unintended consequences of regulatory actions. The secondary aim is to assess the utility of sequential analysis for prospectively assessing signals of health policy impacts using the antidepressant warnings as a policy example. |
| Grant Number: U19MH092201 |
| Participating Sites: Harvard Pilgrim Health Care Institute (Lead Site) Harvard Medical School Northeastern University Baylor Scott & White Health jointly with Central Texas Veterans Health Care System Kaiser Permanente Washington HealthPartners Institute Henry Ford Health System Kaiser Permanente Colorado Georgia State University Kaiser Permanente Hawaii Kaiser Permanente Kaiser Permanente Northwest Kaiser Permanente Southern California University of Tennessee Health Science Center Harvard Medical School Brigham and Women’s Hospital |
| Investigators: Stephen B. Soumerai, ScD Christine Y. Lu, PhD Sengee Toh, ScD Jessica L. Sturtevant, ScM Jeanne M. Madden, PhD Laurel Anne Copeland, PhD Gregory Simon, MD, MPH Rebecca Rossom, MD, MS Brian K. Ahmedani, PhD Gregory Clarke, PhD Marsha A. Raebel, PharmD Ashli Owen-Smith, PhD Beth Waitzfelder, PhD Yihe Daida, PhD Robert Davis, MD, MPH Stacy Sterling (Enid M. Hunkeler retired), MA, FAHA Frances Lynch, PhD Karen J. Coleman, PhD Robert Penfold Martin Kulldorff, PhD |
| Major Goals: Examine the combined effects of FDA warnings and media coverage on changes in antidepressant use, suicide attempts, and suicides among children/adolescents, young adults and adults. Evaluate the utility of sequential analysis for prospectively assessing signals of health policy impacts using FDA antidepressant warnings and related media coverage as policy example. |
| Description of study sample: Records data from 11 MHRN health systems were used to examine time trends in rates of antidepressant use, suicide attempt, and suicide death before, during, and after FDA advisories regarding suicidality during antidepressant treatment. The combined sample included approximately 1.1 million adolescents aged 10-17, 1.4 million adults aged 18-29, and 5 million adults aged 30-64. |
| Current Status: (write 1-2 sentences describing the project status; include current date) Our latest publication in May 2018 evaluated the utility of sequential analysis for prospectively assessing signals of health policy impacts. As a policy example, we studied the consequences of the widely publicized Food and Drug Administration’s warnings cautioning that antidepressant use could increase suicidal risk in youth. Prospective, periodic evaluation of administrative health care data using sequential analysis can provide timely population-based signals of effects of health policies (see below). This method may be useful to use as new policies are introduced. Along with this publication Drs. Lu, Soumerai, Simon, and Kulldorff published point and counterpoint articles in Medical Care regarding the importance of surveillance (see below). Analysis for this project is complete and there will be no more publications. Using 28 years of US death certificate data collected and validated by the US CDC from 1990 to 2017, we are conducting the first longitudinal study of discontinuities in the trends of suicide rates before and after the warnings among adolescents and young adults. We hypothesized that the warnings and reductions in depression diagnosis and treatment would be associated with an increase in completed suicides among adolescents and young adults in the US. There are no extant national longitudinal data on the effects of this policy on completed suicides. |
| Study Registration: N/A |
| Publications:Lu CY, Stewart C, Ahmed AT, Ahmedani BK, Coleman K, Copeland LA, Hunkeler EM, Lakoma MD, Madden JM, Penfold RB, Rusinak D, Zhang F, Soumerai SB. How complete are E-codes in commercial plan claims databases? Pharmacoepidemiol Drug Saf. 2014 Feb;23(2):218-20. doi: 10.1002/pds.3551.Lu CY, Zhang F, Lakoma MD, Madden JM, Rusinak D, Penfold RB, Simon G, Ahmedani BK, Clarke G, Hunkeler EM, Waitzfelder B, Owen-Smith A, Raebel MA, Rossom R, Coleman KJ, Copeland LA, Soumerai SB. Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study. BMJ. 2014 Jun 18;348:g3596. doi: 10.1136/bmj.g3596.Lu, CY, Penfold RB, Toh S, Sturtevant J, Madden JM, Simon G, Ahmedani BK, Clarke G, Coleman KJ, Copeland L, Daida Y, Davis RL, Hunkeler EM, Owen-Smith A, Raebel MA, Rossom MA, Soumerai SB, Kulldorff M. Near real-time surveillance for consequences of health policies using sequential analysis. Med Care. 2018 May;56(5):365-372.Lu, CY, Simon, G, Soumerai, SB, Kulldorff, M. Early warning systems are imperfect, but essential. Med Care. 2018 May;56(5):382-383.Lu, CY, Simon, G, Soumerai, SB. Staying honest when policy changes backfire. Med Care. 2018 May;56(5):384-390. |
| Resources:N/A |
| Lessons Learned: Completeness of e-codes varies significantly over time, across treatment settings and across study sites. Improvements in e-coding in commercial health plan datasets are critical for injury research. In the meantime, poisoning by psychotropic drugs appears to be a useful proxy for identifying suicide attempts leading to emergency room visits and hospitalizations. There were substantial reductions in antidepressant use among all age groups and simultaneous, small increases in psychotropic drug poisonings, a validated measure of suicide attempts, among adolescents and young adults following the FDA warnings. These results were consistent across 11 geographically diverse U.S. study sites. Media exaggeration about FDA reports of drug risks may reduce appropriate drug use and increase adverse outcomes. We did not detect changes in completed suicides after the warnings, which is an extremely rare outcome. |
| What’s Next? The Virtual Data Warehouse (VDW) provides a rich resource for multi-site research. The longitudinal nature of the VDW enables longitudinal analyses that are necessarily part of the interrupted time series method, a strong quasi-experimental study design for studying impacts of health policies. MHRN hosts a health policy special interest group for discussing these research ideas. |
Next Generation Assessment Using Mobile Devices
| Project Name: Mobile Assessment Pilot: Next Generation Assessment Using Mobile Devices |
| Principal Investigator: Gregory Clarke, PhD |
| Principal Investigator Contact Information: Greg.Clarke@kpchr.org |
| Principal Investigator institution: Kaiser Permanente Northwest |
| Funder: NIMH |
| Funding Period: 08/2014 – 07/2017 |
| Abstract: The constructs of cognitive control, emotional processing, attentional and negativity bias, physical and social engagement are specific and measurable characteristics that may aid in the selection of optional acute treatment for depression and anxiety. Methods to assess these constructs either passively or with very low burden/cost have advanced significantly, such that they are now readily available through mobile devices such as smart phones, tablets and wearable sensors. Given that over 120 million people in the US own a mobile device, the practical utility of these assessment tools for compiling important clinical information is high, and the potential for data from these devised to inform clinical practice especially compelling. |
| Grant Number: U19MH092201 |
| Participating Sites: Kaiser Permanente Northwest, Portland, OR (Lead Site) University of Washington, Seattle, WA Kaiser Permanente Georgia, Atlanta, GA |
| Investigators: Gregory Clarke, PhD Patricia Arean, PhD Ashli Owen-Smith, PhD |
| Major Goals: The purpose of this pilot project is to assess consumer engagement, predictive utility, and clinical applicability of mobile, IT-enabled assessment of cognitive, physical and social activity in patients seeking treatment for depression and anxiety. |
| Description of study sample: We will recruit 75 members per performance site, for a total of 150 members. Members will be 18 and older, English-speaking, own a smart device (iOS operating system). We will recruit members who have had a recent dispense of an anti-depressant medication. |
| Current Status: Enrollment is currently closed, and data collection is complete. We are currently summarizing data collected from qualitative interviews with providers and members to include in our analyses. We are also conducting quantitative analyses on the predictive utility of these mobile health apps. We are writing manuscripts for both sets of results. |
| Study Registration: N/A |
| Publications: N/A |
| Resources N/A |
| Lessons Learned: Recruitment was much more difficult than initially expected. We had an overall enrollment rate of approximately 3% between the two sites. Likewise, we had somewhat low engagement with participant usage of the study apps. We believe this is mostly due to the design of the study, where all recruitment and study activities are completed remotely and there is no direct contact with participants. |
| What’s next? We have finished conducting quantitative analyses on the predictive utility of these mobile health apps and summarize the responses from the qualitative interview data. We are now writing a manuscript with the results from these analyses and from the quantitative data collected as part of the study. |
Pathways from Chronic Prescription Opioid Use to New Onset Mood Disorder
Grant Details
Funder: NIH, NIDA
Grant Number: R01ActDA043811
Grant Period: 4/1/2019 – 3/31/2023
Narrative: Research on the association between psychopathology and prescription opioid analgesic use (OAU) has established that mental illness influences risk of chronic OAU (i.e. >90-days), high dose OAU and misuse. We explored the reverse direction of association and found longer OAU and higher opioid doses are associated with increased risk of new onset depression (NOD), independent of pain. Using Veterans Health Affairs (VA) patient data revealed >90-day OAU was associated with a 35% (in VA patients) to 105% (in private sector patients) increased risk of NOD compared to patients with 1-30 day OAU. Our additional studies revealed that OAU is associated with depression recurrence and treatment resistant depression. If these results are confirmed in the present proposal, results have potential to greatly inform interventions to reduce chronic OAU (e.g. treating depression), elucidate pathways to OAU misuse, and generate a body of evidence that informs safe opioid prescribing. To reveal pathways from OAU to NOD and related depression phenotypes (i.e. dysthymia, bipolar, anhedonia, vital exhaustion) we must measure the patients’ pre-existing risk factors and post-OAU events. We will obtain diagnoses and symptom level data and covariates that are not available in the medical record data used in our R21 and strengthen the temporal relationships between OAU and NOD. The central hypothesis driving this research is that pre-OAU risk factors such as a history of depression and post-OAU events such as onset of opioid misuse contribute to NOD.
If NOD is explained by OAU alone and not by pre-existing risk factors, then the opioid epidemic is generating new cases of depression in a large population of middle-aged adults, otherwise not at risk for NOD. Findings will disentangle consequences or correlates of chronic pain per se from those of chronic, high dose OAU. We test whether the OAU-NOD association is moderated by pre-existing depression, substance use disorder (SUD), including opioid use disorder and trauma exposure. We next propose that post-OAU opioid misuse, SUD, poor functioning, low social support and poor sleep quality promote NOD. Using 12 monthly brief assessments, we will determine if change in OAU, independent of change in pain influences, depression trajectories and determine if there is a reciprocal relationship among these variables over time. We will determine if OAU is associated with different depression phenotypes and last determine which subtypes of depression contribute to incident opioid use disorder.
Lead Site: St. Louis University (PI Jeffrey Scherrer)
Participating Sites: HFHS (Site PI Brian Ahmedani)
Current Status:
Summary of Findings:
Publications:
Practice Variation in High- and Low-value Care for Mood Disorders
| Project Name: Practice Variation in High- and Low-Value Care for Mood Disorders |
| Principal Investigator: Gregory Simon MD MPH |
| Principal Investigator Contact Information: simon.g@ghc.org |
| Principal Investigator institution: Group Health Research Institute |
| Funder NIMH |
| Funding Period: 09/2010 – 06/2015 |
| Abstract: This multi-site observational study examined patient, provider, and health system influences on process of depression care in primary care and mental health specialty settings. Comprehensive records data from five MHRN sites (Group Health Cooperative, HealthPartners, Kaiser Permanente Colorado, Kaiser Permanente Hawaii, and Kaiser Permanente Southern California) were used to identify three patient cohorts: Primary care patients receiving a new diagnosis of depression with no recent history of depression treatment. Primary care and mental health specialty patients initiating a new episode of antidepressant treatment with a diagnosis of depression. Mental health specialty patients initiating a new episode of psychotherapy with a diagnosis of depression |
| Grant Number: U19 MH092201 (Mental Health Research Network Cooperative Agreement) |
| Participating Sites: Group Health Cooperative HealthPartners Institute Kaiser Permanente Colorado Kaiser Permanente Hawaii Kaiser Permanente Southern California |
| Investigators: Gregory Simon MD MPH Robert Penfold PhD Susan Shortreed, PhD Rebecca Rossom MD Arne Beck PhD Beth Waitzfelder PhD Karen Coleman PhD |
| Major Goals: To examine patient and provider contributions to variation in care (medication and psychotherapy) for depression. |
| Description of study sample: The sample includes new diagnoses and new treatment episodes between 1/1/2010 and 12/31/2012. These data are being used to address the following specific questions: Among primary care patients receiving a new diagnosis of depression, how do specific patient characteristics (age, sex, race/ethnicity, severity of depression) influence both the likelihood of initiating any treatment for depression and the choice between treatments (medication or psychotherapy)Among patients initiating medication treatment for depression, how are medication selection, early medication adherence, and acute-phase treatment response related to specific patient characteristics (age, sex, race/ethnicity, severity of depression)? How do these treatment processes vary among providers? Among patients initiating psychotherapy for depression, how are early treatment adherence and acute-phase treatment response related to specific patient characteristics (age, sex, race/ethnicity, severity of depression)? How do these treatment processes vary among providers? |
| Current Status: All analyses are complete. |
| Study Registration: N/A |
| Publications: Simon GE, Coleman KJ, Waitzfelder BE, Beck A, Rossom RC, Stewart C, Penfold RB. Adjusting Antidepressant Quality Measures for Race and Ethnicity. JAMA Psychiatry. 2015 Oct;72(10):1055-6. doi: 10.1001/jamapsychiatry.2015.1437. No abstract available. PMID:26352783Simon GE, Rossom RC, Beck A, Waitzfelder BE, Coleman KJ, Stewart C, Operskalski B, Penfold RB, Shortreed SM.J. Antidepressants are not overprescribed for mild depression. Clin Psychiatry. 2015 Dec;76(12):1627-32. doi: 10.4088/JCP.14m09162.PMID:26580702Simon GE, Johnson E, Stewart C, Rossom RC, Beck A, Coleman KJ, Waitzfelder B, Penfold R, Operskalski BH, Shortreed SM. Does patient adherence to antidepressant medication actually vary between physicians? J Clin Psychiatry. 2017 Oct 24 (epub ahead of print) |
| Resources: None |
| Lessons Learned: In MHRN health systems, we see little evidence for over-prescribing of antidepressants for mild depression. Likelihood of prematurely discontinuing antidepressant medication is much higher in minority racial and ethnic groups than in non-Hispanic Whites, and these racial and ethnic differences are far larger than differences related to other demographic or clinical characteristics. Likelihood of prematurely discontinuing psychotherapy for depression is modestly higher in minority racial and ethnic groups – but racial/ethnic disparities in psychotherapy adherence are smaller than disparities in antidepressant medication adherence. Among primary care patients receiving a new diagnosis of depression, likelihood of initiating any specific treatment (medication or psychotherapy) is lower among minority racial or ethnic groups. Patients from minority racial and ethnic groups are more likely to start psychotherapy than medication. Failure to adjust antidepressant treatment quality measures for race and ethnicity will significantly disadvantage health systems serving members from traditionally under-served racial and ethnic groups. After accounting for random variation, likelihood of prematurely discontinuing antidepressant medication varies only minimally across physicians. |
| What’s next? A follow-up study (funded during the second cycle of MHRN funding) will further explore racial and ethnic disparities in care identified in this project. |