Researchers Pinpoint Key Component of Collaborative Care Model for Depression

Manualized psychotherapy and caregiver involvement in the patients’ treatment may be the secret sauce for treating depression with collaborative care, suggests a meta-analysis issued today by JAMA Psychiatry.

“Collaborative care has been shown to be significantly more effective for depression than usual care” in primary care settings, wrote Hannah Schillok, MSc, of Ludwig Maximilian University Hospital in Munich, Germany, and colleagues. “However, its implementation remains rare, primarily due to limited resources and unclear understanding of its components.”

Collaborative care interventions use a multiprofessional approach in which a primary care physician works alongside one or more other health professionals—such as a psychiatrist care manager, a nurse, a psychologist, and/or a social worker—to provide the patient with an evidence-based, structured treatment plan, symptom monitoring, and scheduled follow-ups.

The meta-analysis included data from 35 studies involving 20,046 adults who had depression, mixed anxiety/mood disorder, or symptoms thereof; all were treated in a primary care setting, receiving either a collaborative care approach or usual care. Studies used depression scores from validated inventories as an outcome, from which Schillok and colleagues collected participants’ scores at four to six months.

The researchers then calculated the intensity of each collaborative care model used among four broad components:

• Patient-centered care that respects patient preferences, needs, and values
• Measurement-based care using data-driven decisions for patient management
• Integrated mental health care in the primary setting
• A therapeutic treatment strategy that employs structured treatment strategies such as manual-based psychotherapy, routine follow-ups, and involving friends and family.

Their analysis found that, based on the levels of patient improvement in different models, the most influential component of collaborative care for reducing depression severity was therapeutic treatment strategy, especially the subcomponents of manual-based psychotherapy and involvement of family or friends. The other three components also contributed to a lesser degree.

“Practitioners and policymakers should ensure this key component is consistently included in future intervention designs to optimize effectiveness,” the researchers wrote. “Additionally, these findings offer an initial basis for engaging health insurers to evaluate coverage decisions. Funding critical components may enhance the impact of collaborative care on depression outcomes and support sustainable implementation in routine practice.”

For related information, see the Psychiatric News article “Three Health Systems Find Success With Collaborative Care.”

(Image: Getty Images/iStock/shapecharge)

---

Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.

Follow Psychiatric News on X!

Follow Psychiatric News on LinkedIn!

Low-Resource Patients With OUD Engaged With Collaborative Care Intervention

Patients with co-occurring mental illness and opioid use disorders in a low-resource community engaged with a collaborative care treatment program and stuck with it, according to a study in JAMA Network Open today.

“Opioid use disorders (OUDs) remain undertreated, particularly when co-occurring with mental illness,” wrote Katherine E. Watkins, M.D., M.S.H.S., with the RAND Corporation in Santa Monica, California, and colleagues. “The collaborative care model (CoCM), an evidence-based approach for integrating behavioral health treatment in primary care, offers a potential solution, but the extent to which the CoCM can engage high-risk populations with fidelity in community settings is poorly understood.”

Watkins and colleagues tapped into data from a randomized clinical trial in 14 low-resourced primary care clinics in New Mexico involving adults with probable OUD and co-occurring mental illness who were assigned to a six-month CoCM program between 2021 and 2023. About one-quarter of the adults had used fentanyl or heroin in the 30 days prior to enrollment, and three-quarters were prescribed medications for OUD.

The CoCM deployed addiction-certified psychiatric consultants, primary care clinicians, and community health workers as care managers, supported by a caseload tracking tool. Engagement was defined as participating in an intake interview, while fidelity was defined as having at least two care manager encounters, at least two assessments of OUD and mental health symptom severity, and a treatment plan review by a psychiatric consultant.

Of the 369 adults assigned to the CoCM, 297 participants (81%) engaged with it. Of those who engaged, 206 (69%) stuck with the CoCM, with a median of nine care encounters. Rates varied by substance used: Just 54% of individuals with stimulant co-use participated with fidelity, whereas 81% of those who misused only prescription pain medication did so.

Further work is needed to determine whether fidelity to the CoCM is associated with positive patient outcomes, the authors wrote. Limitations included the study’s use of observational data from one arm of a clinical trial in just one state with high OUD rates.

“Our results indicate that the CoCM may offer a solution to the undertreatment of OUD for patients with complex conditions,” researchers wrote. “When community health workers are used, the CoCM may be an efficient approach to address behavioral health professional shortages.”

For related information, see the Psychiatric News article “Three Health Systems Find Success With Collaborative Care.”

(Image: Getty Images/iStock/SDI Productions)

---

Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.

Follow Psychiatric News on X!

Follow Psychiatric News on LinkedIn!

APA Applauds Mental Health Provisions in Federal End-of-Year Spending Package

APA today responded to the Congressional passage of the fiscal year 2023 Omnibus Appropriations bill (HR 2617 – Consolidated Appropriations Act, 2023). The bill includes funding for workforce equity, collaborative care, telehealth, and other measures that APA supports.

“As families around the nation continue to contend with the adverse impacts of the pandemic, a crisis in child and adolescent mental health, a high rate of suicide, and the opioid epidemic, it is heartening to see Congress forge a bipartisan agreement and invest in policies that that are proven to help,” APA said in a statement.

The fiscal year 2023 Omnibus Appropriations bill includes funding to support following:

Workforce Equity: The bill invests in 100 new graduate medical education slots specifically for psychiatry or psychiatry subspecialties.

Collaborative Care Model: The bill provides grants and technical assistance to primary care practices to implement the evidence-based Collaborative Care Model into their practices for prevention of mental health and substance use disorders (SUD) and early intervention for treatment.

Telehealth: The bill extends certain emergency measures related to Medicare telehealth payments for mental health services. It also delays implementation of the in-person requirement for such services until December 31, 2024.

Health Equity: The bill provides increased authorization and funding for programs to improve maternal health and for the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Minority Fellowship Program. APA participates in this program.

Mental Health/SUD Funding: The bill significantly increases funding for critical mental health and SUD programs under SAMHSA, the Centers for Disease Control and Prevention, and the National Institutes of Health, including the National Institute on Minority Health and Health Disparities.

Parity Compliance: The bill eliminates the ability of non-federal governmental health plans to opt out of parity and provides funding for state insurance departments to enforce and ensure compliance with mental health parity requirements.

APA also expressed concern that Congress had only adjusted and not completely eliminated a cut in Medicare payments to physicians. The cut, which will go into effect on January 1, was originally slated to be 4.5% but will now be 2%.

“This runs counter to the need to improve access to care for patients, and we urge Congress to revisit this continuing challenge as soon as possible in the new year,” APA said in the statement.

---

Don't miss out! To learn about newly posted articles in Psychiatric News, please sign up here.

Follow Psychiatric News on Twitter!

Medicare Final Rule Increases Payment for Psychiatric Consultation in Collaborative Care

The Centers for Medicare and Medicaid Services (CMS) last night released a final rule on the 2017 Medicare Fee Schedule including the 2017 fee for Psychiatric Collaborative Care Management Services, with improved payment amounts over those included in the proposed rule issued in August.

The coding for these services will support payments to psychiatrists for consultative services they provide to primary care physicians in the collaborative care model. The model was developed by the late Wayne Katon, M.D., and Jürgen Unützer, M.D., M.P.H., at the AIMS Center of the University of Washington. It is the only evidence-based model of its kind and has been proven effective in more than 80 randomized, controlled trials. The AIMS Center has been an invaluable ally to APA in advocating for reimbursement coding for collaborative care.

In a weblog post, CMS Acting Administrator Andy Slavitt wrote that “these changes will result in an estimated $140 million in additional funding in 2017 to physicians and practitioners providing these services.”

Initial analysis of the rule by APA staff indicates that the Obama Administration heeded several points that APA made earlier this year in its response to the proposed rule, which led to the higher payment in the final rule. “We are grateful to the administration for acting on recommendations we provided to address what we believe was a significant undervaluing in the proposed rule of the work a psychiatrist performs in the collaborative care model,” said APA CEO and Medical Director Saul Levin, M.D., M.P.A.

In comments submitted to CMS in August, Levin noted that the CMS proposal to crosswalk the work of the psychiatric consultant to CPT code 90836 (Psychotherapy, 45 minutes with patient and/or family member when performed with an evaluation and management service) was not appropriate and resulted in a work value that Levin said was not sustainable.

The new work value is based on a crosswalk to a level three evaluation and management service. APA staff say that while this work value is an improvement, it is difficult to know whether it will be sufficient over the long term. 

“Establishing a sustainable payment for psychiatric participation in collaborative care is vital to making this important new model of care successful,” Levin told Psychiatric News. “We look forward to continuing to work with  Congress and the administration around this important issue.”

The new code and work value should help underscore the importance of the CMS Transforming Clinical Practice Initiative (TCPI). APA is a Support and Alignment Network within this initiative and to date has trained over 800 psychiatrists in the collaborative care model. APA will begin to train primary care practitioners later this year. 

Look for more information about the fee schedule in an upcoming edition of Psychiatric News. More information about the TCPI and APA's collaborative care training for psychiatrists is posted at www.psych.org/SAN.

Early Follow Up Found to Be Key to Patient Success in Collaborative Care of Depression

Patients with depression who were contacted by a care manager at least once within four weeks of their initial visit were more likely to achieve improvements in symptoms and had a shorter time to improvement than those who were not contacted early on, according to a study of a collaborative care model (CCM) published today in Psychiatric Services in Advance. For patients who did not achieve improvements by week 8, consultation about the case between the primary care provider and the team psychiatrist by week 12 predicted improvement within six months.

According to the study authors, who were led by Jürgen Unützer, M.D., M.P.H. (pictured left), of the University of Washington, the findings of the study highlight the importance of patient engagement in the early phase of treatment and timely psychiatric consultation when patients do not experience improvement in the early phases of the collaborative care model.

The researchers analyzed outcomes for over 5,400 adult psychiatric patients who had initiated care in clinics that were part of the Mental Health Integration Program (MHIP), a publicly funded implementation of the CCM in a network of more than 100 community health centers in the state of Washington. The group examined whether care manager follow-up and psychiatric consultation were associated with clinically significant improvements in depression (defined as having at least one follow-up PHQ-9 score of less than 10 or achieving a 50% or more reduction in the PHQ-9 score within 24 weeks of initial contact).

Four-week follow-up was associated with a greater likelihood of achieving improvement in depression and a shorter time to improvement. Psychiatric consultation was also associated with a greater likelihood of improvement but not with a shorter time to improvement.

“Our findings support efforts to improve fidelity to these two process-of-care tasks and to include these two tasks among quality measures for CCM implementation,” the study authors wrote. “Future studies should seek to assess the relative importance of other key tasks of CCM and test implementation strategies (for example, pay for performance) to encourage and enable high fidelity to tasks found to contribute to good patient outcomes,” the study authors commented.

To read about some of APA’s efforts to facilitate broader use of collaborative care models, see the Psychiatric News article “APA Urges Creation of Payment Codes Specific to Collaborative Care Model.”

Bipolar Disorder Patients in Integrated Primary Care May Need More-Intensive Services, Study Shows

Primary care patients with bipolar disorder enrolled in an integrated care system in Washington state may require more intensive services than currently provided in a collaborative care model, according to a study, “Bipolar Disorder in Primary Care: Clinical Characteristics of 740 Primary Care Patients With Bipolar Disorder,” which is published online today in Psychiatric Services.

Researchers from the University of Washington identified 740 primary care patients with bipolar disorder in the statewide mental health integration program (MHIP) between January 2008 and December 2011 using the Composite International Diagnostic Interview and clinician diagnosis. The MHIP uses collaborative care based on the IMPACT model (Improving Mood–Promoting Access to Collaborative Treatment) to improve recognition and systematic treatment of patients with psychiatric disorders in primary care settings.

Primary care patients with bipolar disorder had high symptom severity on both depression and anxiety measures using the Patient Health Questionnaire and the Generalized Anxiety Disorder scale. Psychosocial problems were common, with approximately 53% reporting concerns about housing, 15% reporting homelessness, and 22% reporting lack of a support person. Yet only 26% of patients were referred to specialty mental health treatment.

Study co-author Wayne Katon, M.D. (photo above), vice chair of the Department of Psychiatry at the University of Washington, said that the study indicates that these patients may need more-intensive care than is currently provided in a collaborative care model, in which a care manager, supervised by a psychiatrist, provides the direct patient care. “The importance of this article is that the U.S. federally qualified primary care clinics, as well as many primary care clinics that treat both uninsured and Medicaid patients, are likely to have a significant percentage of patients with bipolar illness, especially bipolar 2 illness,” Katon told Psychiatric News. “This article emphasizes that despite the fact that only about one-third improve with treatment in these clinics, few are being referred to community mental health clinics or actually attend when referred. These clinics already had integrated collaborative care—that is, the use of a care manager supervised by a psychiatrist—so the inference is that these patients may need more-intensive psychiatric treatment, which could occur if psychiatrists are integrated into the clinics either in person or via telemedicine. Alternatively, the clinics need to establish better links with community mental health.”

To read more about integrated and collaborative care, see the Psychiatric News article by Katon, "Three Decades of Working in Integrated Care."