Virtual Collaborative Care Versus Specialty Psychiatry Treatment for Depression or Anxiety

Kathryn K. Ridout, MD, PhD ; Mubarika Alavi, MS ; Catherine Lee, PhD ; Lisa Fazzolari, DO ; Samuel J. Ridout, MD, PhD ; Maria T. Koshy, MD ; Brooke Harris, PhD ; Sameer Awsare, MD ; Constance M. Weisner, DrPH ; Esti Iturralde, PhD

J Clin Psychiatry 2024;85(3):24m15332

Abstract

Objective: While collaborative care is known to improve depressive and anxiety symptoms in primary care, comparative effectiveness studies of virtual collaborative care versus virtual specialty psychiatry treatment in real world settings are lacking. This study examined patient depressive and anxiety symptoms over 6 months in collaborative care versus specialty psychiatry.

Methods: This was an observational study with target trial emulation in a large, community-based, integrated health care system. Participants were ≥18 years old with mild-moderate depressive or anxiety symptoms measured by the Patient Health Questionnaire-9 or Generalized Anxiety Disorder-7 Scale. Exclusion criteria included acute suicide risk. Patients were assigned to collaborative care or specialty psychiatry, and symptoms were measured 6 months after treatment initiation using linear mixed-effects regression with inverse probability of treatment weighting.

Results: There were N = 10,380 patients (n = 1,607 in collaborative care; n = 8,773 in specialty psychiatry) with depressive disorders and N = 2,935 (n = 570 in collaborative care; n = 2,365 in specialty psychiatry) with anxiety disorders. Model effects at 6 months showed significant symptom improvement for patients in collaborative care (adjusted mean difference [AMD] = −9.0, 95% CI, −9.7, −8.4 for depression; −5.4, 95% CI, −6.2, −4.7 for anxiety) and in specialty psychiatry (AMD = −5.0, 95% CI, −5.6, −4.5 for depression; −2.8, 95% CI, −3.6, −2.1 for anxiety), with patients in collaborative care showing significantly greater improvement compared to those in specialty psychiatry (AMD = −4.0, 95% CI, −4.7, −3.3, P < .0001 for depression; AMD = −2.6, 95% CI, −3.4, −1.8, P < .0001 for anxiety).

Conclusions: Virtual collaborative care was at least as effective as specialty psychiatry for depression and anxiety. Collaborative care implementation can support national guidelines regarding depression and anxiety screening and treatment.

J Clin Psychiatry 2024;85(3):24m15332

Author affiliations are listed at the end of this article.

Continue Reading...

Members enjoy unlimited free PDF downloads as part of their subscription! Subscribe today for instant access to this article and our entire library in your preferred format. Alternatively, you can purchase the PDF of this article individually.

Subscribe Now

Already a member? Login

Buy PDF for $40

Please sign in or purchase this PDF for $40.

References (57)

Kessler RC, Berglund P, Demler O, et al. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2005;62(6):593–602. PubMed CrossRef
Hasin DS, Sarvet AL, Meyers JL, et al. Epidemiology of adult DSM-5 major depressive disorder and its specifiers in the United States. JAMA Psychiatry. 2018;75(4):336–346. PubMed
Pan American Health Organization. The Burden of Mental Disorders in the Region of the Americas, 2018. Pan American Health Organization; 2018.
Greenberg PE, Fournier AA, Sisitsky T, et al. The economic burden of adults with major depressive disorder in the United States (2005 and 2010). J Clin Psychiatry. 2015;76(2):155–162. PubMed CrossRef
Bukh JD, Bock C, Vinberg M, et al. The effect of prolonged duration of untreated depression on antidepressant treatment outcome. J Affect Disord. 2013;145(1):42–48. PubMed CrossRef
Bachmann S. Epidemiology of suicide and the psychiatric perspective. Int J Environ Res Public Health. 2018;15(7):1425. PubMed
Bradvik L. Suicide risk and mental disorders. Int J Environ Res Public Health. 2018;15(9):2028. PubMed
National Institute of Mental Health. Suicide. National Institute of Mental Health. Accessed September 28, 2023. https://www.nimh.nih.gov/health/statistics/suicide
Harvard Medical School. National Comorbidity Survey; 2017. Accessed June 22, 2023. https://www.hcp.med.harvard.edu/ncs/index.php
Kalin NH. The critical relationship between anxiety and depression. Am J Psychiatry. 2020;177(5):365–367. PubMed CrossRef
Cuijpers P, Sijbrandij M, Koole SL, et al. The efficacy of psychotherapy and pharmacotherapy in treating depressive and anxiety disorders: a meta-analysis of direct comparisons. World Psychiatry. 2013;12(2):137–148. PubMed CrossRef
Goncalves DC, Byrne GJ. Interventions for generalized anxiety disorder in older adults: systematic review and meta-analysis. J Anxiety Disord. 2012;26(1):1–11. PubMed CrossRef
Schoenbaum M, Unützer J, McCaffrey D, et al. The effects of primary care depression treatment on patients’ clinical status and employment. Health Serv Res. 2002;37(5):1145–1158. PubMed CrossRef
Puyat JH, Kazanjian A, Goldner EM, et al. How often do individuals with major depression receive minimally adequate treatment? A population-based, data linkage study. Can J Psychiatry. 2016;61(7):394–404.
Gilbody S, Bower P, Fletcher J, et al. Collaborative care for depression: a cumulative meta-analysis and review of longer-term outcomes. Arch Intern Med. 2006;166(21):2314–2321. PubMed CrossRef
Grochtdreis T, Brettschneider C, Wegener A, et al. Cost-effectiveness of collaborative care for the treatment of depressive disorders in primary care: a systematic review. PLoS One. 2015;10(5):e0123078. PubMed CrossRef
AIMs Center. Patient-Centered Integrated Behavioral Health Care Principles & Tasks Checklist. University of Washington; 2014. Accessed December 3, 2023. https://aims.uw.edu/sites/default/files/CollaborativeCarePrinciplesAndComponents_2014-12-23.pdf
Archer J, Bower P, Gilbody S, et al. Collaborative care for depression and anxiety problems. Cochrane Database Syst Rev. 2012;10:CD006525. PubMed CrossRef
Fortney JC, Pyne JM, Edlund MJ, et al. A randomized trial of telemedicine-based collaborative care for depression. J Gen Intern Med. 2007;22(8):1086–1093. PubMed CrossRef
Huffman JC, Niazi SK, Rundell JR, et al. Essential articles on collaborative care models for the treatment of psychiatric disorders in medical settings: a publication by the academy of psychosomatic medicine research and evidence-based practice committee. Psychosomatics. 2014;55(2):109–122. PubMed CrossRef
Thota AB, Sipe TA, Byard GJ, et al. Collaborative care to improve the management of depressive disorders: a community guide systematic review and meta-analysis. Am J Prev Med. 2012;42(5):525–538. PubMed CrossRef
Katon W, Unützer J, Wells K, et al. Collaborative depression care: history, evolution and ways to enhance dissemination and sustainability. Gen Hosp Psychiatry. 2010;32(5):456–464. PubMed CrossRef
Colorafi K, Vanselow J, Nelson T. Treating anxiety and depression in primary care: reducing barriers to access. Fam Pract Manag. 2017;24(4):11–16. PubMed
The National Council. The Comprehensive Healthcare Integration Framework; 2024. Accessed August 21, 2024. https://www.thenationalcouncil.org/resources/the-comprehensive-healthcare-integration-framework/
Pincus HA, Hough L, Houtsinger JK, et al. Emerging models of depression care: multi-level (‘6 P’) strategies. Int J Methods Psychiatr Res. 2003;12(1):54–63. PubMed CrossRef
Katon WJ, Lin E, Russo J, et al. Increased medical costs of a population-based sample of depressed elderly patients. Arch Gen Psychiatry. 2003;60(9):897–903. PubMed CrossRef
Callahan CM, Hui SL, Nienaber NA, et al. Longitudinal study of depression and health services use among elderly primary care patients. J Am Geriatr Soc. 1994;42(8):833–838. PubMed CrossRef
Unützer J, Patrick DL, Simon G, et al. Depressive symptoms and the cost of health services in HMO patients aged 65 years and older. A 4-year prospective study. JAMA. 1997;277(20):1618–1623. PubMed
Luber MP, Meyers BS, Williams-Russo PG, et al. Depression and service utilization in elderly primary care patients. Am J Geriatr Psychiatry. 2001;9(2):169–176. PubMed
Solberg LI, Crain AL, Jaeckels N, et al. The DIAMOND initiative: implementing collaborative care for depression in 75 primary care clinics. Implement Sci. 2013;8:135. PubMed CrossRef
Solberg LI, Crain AL, Maciosek MV, et al. A stepped-wedge evaluation of an initiative to spread the collaborative care model for depression in primary care. Ann Fam Med. 2015;13(5):412–420. PubMed CrossRef
Coleman KJ, Dreskin M, Hackett DL, et al. A roadmap for institutionalizing collaborative care for depression in a large integrated healthcare system. J Gen Intern Med. 2020;35(suppl 2):839–848. PubMed CrossRef
Unützer J, Carlo AC, Arao R, et al. Variation in the effectiveness of collaborative care for depression: does it matter where you get your care? Health Aff (Millwood). 2020;39(11):1943–1950. PubMed
Bauer AM, Azzone V, Goldman HH, et al. Implementation of collaborative depression management at community-based primary care clinics: an evaluation. Psychiatr Serv. 2011;62(9):1047–1053. PubMed CrossRef
Blackmore MA, Patel UB, Stein D, et al. Collaborative care for low-income patients from racial-ethnic minority groups in primary care: engagement and clinical outcomes. Psychiatr Serv. 2022;73(8):842–848. PubMed CrossRef
Carlo AD, Jeng PJ, Bao Y, et al. The learning curve after implementation of collaborative care in a state mental health integration program. Psychiatr Serv. 2019;70(2):139–142. PubMed
Fortney JC, Bauer AM, Cerimele JM, et al. Comparison of teleintegrated care and telereferral care for treating complex psychiatric disorders in primary care: a pragmatic randomized comparative effectiveness trial. JAMA Psychiatry. 2021;78(11):1189–1199. PubMed CrossRef
Sanchez K. Collaborative care in real-world settings: barriers and opportunities for sustainability. Patient Prefer Adherence. 2017;11:71–74. PubMed CrossRef
Hernan MA, Robins JM. Using big data to emulate a target trial when a randomized trial is not available. Am J Epidemiol. 2016;183(8):758–764. PubMed
Hansford HJ, Cashin AG, Jones MD, et al. Development of the TrAnsparent ReportinG of observational studies emulating a target trial (TARGET) guideline. BMJ Open. 2023;13(9):e074626. PubMed CrossRef
Gordon N, Lin T. The Kaiser Permanente northern California adult member health survey. Perm J. 2016;20(4):15–225.
Hedegaard H, Schoenbaum M, Claassen C, et al. Issues in developing a surveillance case definition for nonfatal suicide attempt and intentional self-harm using international classification of diseases, tenth revision, clinical modification (ICD-10-CM) coded data. Natl Health Stat Rep. 2018;(108):1–19.
Ridout KK, Ridout SJ, Alavi M, et al. Evaluating implementation and outcomes of the achieving depression and anxiety patient-centered treatment collaborative care program in a large, integrated health care system: a mixed methods observational study protocol. Perm J. 2022;26(4):39–48. PubMed CrossRef
Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001;16(9):606–613. PubMed CrossRef
Spitzer RL, Kroenke K, Williams JBW, et al. A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006;166(10):1092–1097. PubMed CrossRef
AHRQ. Depression screening and follow-up for adolescents and adults. Accessed March 31, 2023. https://www.ahrq.gov/sites/default/files/wysiwyg/pqmp/measures/chronic/chipra-0245-technical-specifications.pdf
Coventry PA, Hudson JL, Kontopantelis E, et al. Characteristics of effective collaborative care for treatment of depression: a systematic review and meta regression of 74 randomised controlled trials. PLoS One. 2014;9(9):e108114. PubMed CrossRef
Muntingh AD, van der Feltz-Cornelis CM, van Marwijk HW, et al. Collaborative care for anxiety disorders in primary care: a systematic review and meta-analysis. BMC Fam Pract. 2016;17:62. PubMed CrossRef
Perugi G, Calò P, De Filippis S, et al. Clinical features and outcomes of 124 Italian patients with treatment resistant depression: a real-world, prospective study. Front Psychiatry. 2021;12:769693. PubMed CrossRef
Weinberger MI, Sirey JA, Bruce ML, et al. Predictors of major depression six months after admission for outpatient treatment. Psychiatr Serv. 2008;59(10):1211–1215. PubMed CrossRef
Kautzky A, Dold M, Bartova L, et al. Clinical factors predicting treatment resistant depression: affirmative results from the European multicenter study. Acta Psychiatr Scand. 2019;139(1):78–88. PubMed CrossRef
Buckman JEJ, Saunders R, Stott J, et al. Socioeconomic indicators of treatment prognosis for adults with depression: a systematic review and individual patient data meta-analysis. JAMA Psychiatry. 2022;79(5):406–416. PubMed
Liu X, Mukai Y, Furtek CI, et al. Epidemiology of treatment-resistant depression in the United States. J Clin Psychiatry. 2021;83(1):21m13964. PubMed CrossRef
Probst G, Vîslă A, Flückiger C. Patients’ symptoms and strengths as predictors of long-term outcomes of CBT for generalized anxiety disorder – a three-level, multi predictor analysis. J Anxiety Disord. 2022;92:102635. PubMed CrossRef
Murphy JM, Olivier DC, Monson RR, et al. Depression and anxiety in relation to social status. A prospective epidemiologic study. Arch Gen Psychiatry. 1991;48(3):223–229. PubMed CrossRef
Corey-Lisle PK, Nash R, Stang P, et al. Response, partial response, and nonresponse in primary care treatment of depression. Arch Intern Med. 2004;164(11):1197–1204. PubMed CrossRef
National Committee for Quality Assurance. HEDIS depression measures specified for electronic clinical data systems. National Committee for Quality Assurance; 2024. Accessed January 13, 2024. https://www.ncqa.org/hedis/thefuture-of-hedis/hedis-depression-measures-specified-for-electronic-clinicaldata/