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kia sportage 2000 service repair manual free downloadPlease try again.Please try again.Please try again. These differences are important when considering the diagnosis and treatment of patients with major depression in the primary-care setting. Then you can start reading Kindle books on your smartphone, tablet, or computer - no Kindle device required. Register a free business account To calculate the overall star rating and percentage breakdown by star, we don’t use a simple average. Instead, our system considers things like how recent a review is and if the reviewer bought the item on Amazon. It also analyzes reviews to verify trustworthiness. Abstract Depression is one of the most common mental health problems encountered in primary care and a leading cause of disability worldwide. In many cases, depression is a chronic or recurring disease, and as such, it is best managed like a chronic illness. Moreover, medically ill patients with depressive disorder are at greater risk for a chronic course of depression or less complete recovery. Antidepressant medications and psychotherapies can help many if not most depressed individuals, but millions of primary care patients do not receive effective treatment. Programs in which primary care providers and mental health specialists collaborate effectively using principles of measurement-based stepped care and treatment to target can substantially improve patients’ health and functioning while reducing overall health care costs. Introduction Depression is one of the most common and disabling chronic health problems encountered in the primary care setting. In this article, opportunities and strategies to improve care for depression in primary care practice are reviewed and collaborative care, an evidence-based approach to chronic disease management for depression is introduced. In this approach, primary care providers (PCPs) and care managers look after a caseload of depressed patients with systematic support from mental health experts.
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Lessons from implementing evidence-based collaborative care programs in diverse primary care practice settings are summarized to convey relatively simple changes that can improve patient outcomes in primary care practices. The clinical epidemiology of depression in primary care Behavioral health problems such as depression, anxiety, alcohol or substance abuse are among the most common and disabling health conditions worldwide 1 and common in primary care settings 2 - 9. A recent national survey 26 concluded that two thirds of primary care providers reported that they could not get effective mental health services for their patients. Barriers to mental health care access included shortage of mental health care providers, and lack of insurance coverage. Interaction of depression with other chronic illnesses Successful management of depression in primary care settings is particularly important considering complex interactions between mental and physical health 27. Major depression is associated with high numbers of medically unexplained symptoms 28 - 30, such as pain and fatigue, and poor general health outcomes 1, 31. Untreated depression is independently associated with morbidity 31 - 34, delayed recovery and negative prognosis among those with medical illness, elevated premature mortality associated with comorbid medical illness 35 and increased health care costs 36 - 38. Depression also increases functional impairment 39 - 44 and decreases work productivity 45. Depression significantly decreases quality of life for patients and their family members 46, 47. In a study of 2,558 elderly primary care patients, participants with depression had greater losses in quality adjusted life years (QALYs) than those with emphysema, cancer, chronic foot problems, or hypertension 47. Depression can also be a barrier to positive and productive relationships between patients and providers 48, 49. PCPs tend to rate patients with depression as more difficult to evaluate and treat compare to those without depression 48 and depressed patients have been shown to be less satisfied with their PCPs 49. Older adults, men, patients with medical comorbidities, and patients from ethnic minority groups are at particularly high risk of not being recognized as depressed or treated effectively. 50 - 54 The U.S. Preventive Services Task Force (USPSTF) issued recommendations, encouraging primary care physicians to routinely screen their adult patients for depression in clinical settings that have systems in place to assure effective treatment and follow up 55. Brief screening tools for depression are available. Positive response to these questionnaires should alert the primary care provider to further evaluate the patient for depression. Not all depressed patients will answer positively to these questionnaires. Treatment of depression Over 25 medications have been approved by the FDA for the treatment of major depression and there is strong and increasing evidence about the effectiveness of psychotherapies that can be delivered in primary care or specialty mental health care settings 58 - 60. A number of guidelines have been developed to guide the effective management of depression in primary care 61 and in specialty mental health settings. 62 These guidelines succinctly summarize the evidence-base for pharmacological and nonpharmacological treatment options. If nonpharmacologic treatments are available, PCPs should ask patients who are initiating depression treatment about preferences for medications or psychotherapy because the ability to address a patient's treatment preference has been shown to be related to the likelihood of entering depression treatment 63 and better treatment outcomes 64.http://dev.pb-adcon.de/node/19647 Patients’ clinical outcomes should be tracked with structured depression rating scales, such as the 9-item Patient Health Questionnaire (PHQ-9), similar to the way primary care providers follow clinical outcomes of other treatments such as blood pressures or blood lipids. The flowchart in Figure 1 summarizes a comprehensive guideline for the treatment of major depression in primary care developed by the Institute of Clinical Systems Improvement (ICSI). 65 Open in a separate window Figure 1 ICSI Guideline for Major Depression in Adults in Primary Care Effective management of depression in primary care requires a number of steps: detection and diagnosis, patient education and engagement in treatment, initiation of evidence-based pharmacotherapy or psychotherapy, close follow-up focusing on treatment adherence, treatment effectiveness, and treatment side effects. Consistent follow up is crucial as treatment adherence is a major problem in primary care. Clinicians should follow existing guidelines and take into account patient's treatment preferences when selecting initial treatments. Quality of care for depression There is a large gap between the efficacy of treatments for depression under research conditions and the effectiveness of treatments as they occur in the “real world” primary care settings 71. Although a number of effective pharmacological and nonpharmacological treatments exist for depression, studies in the United States and Canada have consistently demonstrated that few patients receive adequate doses or courses of such treatments. 50, 72 - 74 Almost 30 million Americans receive prescriptions for antidepressants each year, which are most often prescribed by primary care providers. Unfortunately many patients stop medication early because of side effects or other concerns and do not follow up with their primary care provider to change treatments. Few patients have access to or use evidence-based psychotherapies in primary care settings. Others continue on ineffective doses and medications due to clinical inertia 75 and a lack of appropriate treatment intensification in patients who are not improving with initial treatments. Patients referred to psychotherapy often receive inadequate trials of such treatments and treatment response rates can be as low as 20 . 79 Barriers include limited availability of evidence-psychotherapy and costs. Generalist physicians also have limited training in the diagnosis and treatment of depression and other mental illnesses. Patients may feel reluctance to discuss their emotional distress, family problems, or behavioral problems with primary care providers because of the stigma associated with mental disorders and concerns that the PCP might not take their other health problems seriously. Strategies to improve the management of depression in primary care Efforts to improve the management of depression and other common mental disorders in primary care have focused on screening, education of primary care providers, development of treatment guidelines, and referral to mental health specialty care. Although well intended, these efforts have by and large not been effective in reducing the substantial burden of depression and other common mental disorders in primary care. 81 Another approach to improve care for patients with depression is to co-locate mental health specialists into primary care clinics. More recent studies have documented the effectiveness of such collaborative approaches for anxiety disorders 86 and for depression and comorbid medical disorders such as diabetes and heart disease 87. In such programs, primary care providers are part of a collaborative care team that a depression care manager (usually a nurse or clinical social worker and in some cases a trained medical assistant under supervision from a mental health provider) and a designated psychiatric consultant to augment the management of depression in the primary care setting. The depression care manager supports medication management prescribed by PCPs through patient education, close and pro-active follow-up, and brief, evidence-based psychosocial treatments such as behavioral activation or problem solving treatment in primary care. The care manager may also facilitate referrals to additional services as needed. A designated psychiatric consultant regularly (usually weekly) reviews all patients in the care manager's caseload who are not improving as expected and provides focused treatment recommendations to the patient's PCP. The psychiatric consultant is also available to the care manager and the PCP for questions about patients. 83, 88 - 90 Stepped care approaches can enhance the cost-effectiveness of depression care by focusing the use of limited resources such as care management and specialist consultation on those patients who cannot be effectively managed by the primary care provider alone. Patients initiating care are educated on this systematic approach to treatment and provided tools such as a 9-item Patient Health Questionnaire (PHQ-9) 92, 93 that help them track symptoms of depression over time. They are also encouraged and empowered to request changes in treatment if treatments are not effective or cause significant side effects. Patients who continue to have depressive symptoms after initial treatment trials with medication or psychotherapy are systematically reviewed with a psychiatric consultant and considered for additional treatments as summarized in table 2. Table 2 Stepped-care Activities for Depression in Evidence-based Collaborative Care Programs Stepped Care Activity Depression Local Considerations Screening for bipolar disorder and substance use. Support of medical management. Behavioral activation strategies used at each contact. Anxiolytics and Hypnotics as clinically indicated. Open in a separate window From Advancing Integrated Mental Health Solutions (AIMS) Center Website, with permission Because of the high risk of depression relapse 94, patients who have responded to treatment receive relapse prevention plans that help them maintain treatment gains made. Such relapse prevention plans include advice on the continuation of maintenance medications as clinically indicated, personal warning signs if depression should recur, strategies to maintain clinical gains made (e.g., continued systematic scheduling of pleasant events), and advice on what to do if depression symptoms should recur. IMPACT participants were more than twice as likely as those in usual care to experience a substantial improvement (a 50 or greater improvement in the depression severity score of the Hopkins Symptom Checklist (SCL-20) over 12 months. 76 They also had less physical pain, better social and physical functioning, and better overall quality of life than patients in care as usual 97. Similar cost savings have been identified in other collaborative care trials in patients with depression and diabetes 103 and other chronic medical conditions, and in patients with severe anxiety (panic disorder) 106. Large scale implementations outside of research trials in several large health care systems such as Kaiser Permanente 107 and Intermountain Healthcare 108 also point to savings in overall health care costs when collaborative care is effectively implemented. Collaborative care interventions also generate important social benefits in terms of quality adjusted life years. 109 Finally, and perhaps most importantly, collaborative care has been shown to improve both patient 76 and provider 98 satisfaction with care. On the PHQ9, a drop in 5 points has been identified as a clinically meaningful reduction in symptoms but the ultimate treatment target is remission, which is captured by a PHQ-9 score less than 5. 116 Psychiatric consultation, a limited resource in most settings can then be focused on patients who are not improving as expected. Several health care organizations have undertaken large-scale implementations of evidence-based collaborative care programs for depression. These include national health plans such as Kaiser Permanente, the Depression Improvement Across Minnesota, Offering a New Direction (DIAMOND) program in Minnesota in which the Institute for Clinical Systems Improvement (ICSI) has worked with 8 commercial health plans, 25 medical groups, and over 80 primary care clinics to implement collaborative care for depression 117, 118. In the State of Washington, the Mental Health Integration Program (MHIP) sponsored by the Community Health Plan of Washington and Seattle King County Public Health 120 includes more than 100 community health centers and over 30 community mental health centers that work together to provide integrated care for poor, underserved, uninsured or underinsured clients with medical and behavioral health needs. Other large-scale implementations include the Army's Re-Engineering Systems of Primary Care Treatment in the Military (RESPECT-MIL) program 121, implemented in Army primary care clinics in the US and abroad; and the Department of Veterans Affairs’ Veterans Health Administration 122, which has implemented Collaborative Care in hundreds of primary care clinics across the US. Implementing Effective Collaborative Care Programs Over the past 10 years, the Advancing Integrated Mental Health Solutions (AIMS) Center at the University of Washington 97 has provided technical assistance and training to more than 5,000 clinicians in over 600 primary care practices to implement effective collaborative care. Below are some key lessons from the implementation of such programs in diverse practice settings.Simply co-locating a mental health provider into a primary care setting may improve access to behavioral health care but it does not guarantee improved health outcomes for the large population of primary care patients with mental health needs. This can be accomplished using the registry functions of electronic health record systems or a freestanding registry tool 124 Initial treatments (be they pharmacologic or psychosocial) are rarely sufficient to achieve desired health outcomes. Systematic outcome tracking, treatment adjustment, and consultation for patients who are not improving can help achieve the desired health outcomes. This requires systematic caseload review by the treating providers and psychiatric consultation, focusing on patients who are not improving as expected. For mental health providers, effective collaboration in primary care requires clinical flexibility in both mental health specialist as well as primary care providers mental health providers to be flexible, regular and effective communication with patients’ PCPs, the willingness to be interrupted during therapy sessions, the use of the telephone to reach patients who cannot make clinic appointments and the use of brief, evidence-based therapies such as motivational interviewing, behavioral activation, problem solving, or brief cognitive behavioral therapy that can be provided in the context of a busy primary care practice. Training mental health specialists and primary care in integrated care are important but not sufficient. Effective implementation requires ongoing support from clinical champions in primary care and behavioral health, financial support, operational support, and a clear set of shared and measureable goals and objectives. As with all efforts to improve chronic illness care, such support may be easier to obtain in large delivery systems and under managed care arrangements than in small fee-for-service medical practices. There are many ways to implement effective integrated care for behavioral health problems in primary care. Such changes includeIncorporation of evidence-based motivational interviewing strategies into patient encounters to help engage patients engage in and adhere to effective treatment for behavioral health problems. Both physicians and other office staff can be trained in these techniques. Training office-based personnel to help perform core support functions of behavioral health care managers such as proactive outreach and tracking of treatment adherence, medication side effects, referrals (if appropriate), and treatment effectiveness. These strategies are highly compatible with approaches to improve patient care and outcomes through patient centered medical homes. 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