Elsevier

General Hospital Psychiatry

Volume 28, Issue 1, January–February 2006, Pages 18-26
General Hospital Psychiatry

Psychiatry and Primary Care
Design and implementation of the Telemedicine-Enhanced Antidepressant Management Study

https://doi.org/10.1016/j.genhosppsych.2005.07.001Get rights and content

Abstract

Objective

Evidence-based practices designed for large urban clinics are not necessarily transportable into small rural practices. Implementing collaborative care for depression in small rural primary care clinics presents unique challenges because it is typically not feasible to employ on-site mental health specialists. The purpose of the Telemedicine-Enhanced Antidepressant Management (TEAM) study was to evaluate a collaborative care model adapted for small rural clinics using telemedicine technologies. The purpose of this paper is to describe the TEAM study design.

Method

The TEAM study was conducted in small rural Veterans Administration community-based outpatient clinics with interactive video equipment available for mental health, but no on-site psychiatrists/psychologists. The study attempted to enroll all patients whose depression could be appropriately treated in primary care.

Results

The clinical characteristics of the 395 study participants differed significantly from most previous trials of collaborative care. At baseline, 41% were already receiving primary care depression treatment. Study participants averaged 5.5 chronic physical health illnesses and 56.5% had a comorbid anxiety disorder. Over half (57.2%) reported that pain impaired their functioning extremely or quite a bit.

Conclusions

Despite small patient populations in rural clinics, enough patients with depression can be successfully enrolled to evaluate telemedicine-based collaborative care.

Introduction

Intervention studies have demonstrated the effectiveness of collaborative care models designed to improve depression outcomes in primary care settings [1], [2], [3], [4], [5], [6], [7], [8], [9]. Collaborative care involves primary care providers (PCPs) working in conjunction with a depression care team comprising nonphysicians (e.g., nurses, pharmacists) and mental health specialists (e.g., psychologists, psychiatrists). The demonstrated cost-effectiveness of collaborative care has led to implementation efforts to promote adoption in routine practice [10], [11], [12].

Interventions designed and tested in large urban clinics are not necessarily applicable in small rural practices [13]. Implementing collaborative care in small rural primary care practices presents unique challenges because it is typically not feasible to employ mental health specialists on site. In fact, only 25% of primary care practices nationwide have on-site mental health specialists [14]. Although 21% of the U.S. population lives in rural areas according to the 2000 Census, only one previous study of collaborative care (QuEST) recruited a substantial number of rural primary care practices as study sites [4]. In the QuEST study, on-site primary care nurses were trained to provide depression care management, and psychiatrists were available for telephone consults [4]. The QuEST collaborative care model design has the advantage that nurse care managers have established therapeutic relationships with their patients, have access to on-site paper medical records and have open communication channels with PCPs. However, the QuEST design has the potential disadvantage that nurse care managers cannot specialize in depression treatment, lack meaningful access to mental health supervision/consultation and must incorporate care management activities into busy routines with competing demands.

The purpose of the Telemedicine-Enhanced Antidepressant Management (TEAM) study was to adapt the collaborative care model for small rural primary care practices using telemedicine technologies without altering the nature/content of the collaborative care model itself. Telemedicine (e.g., telephone, interactive video, electronic medical records, and internet) facilitates communication between a centrally located depression care team and PCPs practicing in geographically diverse clinic locations. We chose to conduct this first telemedicine-based collaborative care trial in rural areas served by the Veterans Administration (VA) healthcare system. The VA is a particularly suitable setting for telemedicine-based interventions because of the widespread standardized use of interactive video technology and electronic medical records [e.g., Computerized Patient Record System (CPRS)].

The objectives of the TEAM study are to compare processes and outcomes among patients with depression treated at intervention and matched control sites, and to determine whether the intervention was cost-effective in routine practice. The purpose of this paper is to describe the design of the TEAM study, including (1) methods used to enroll study participants, (2) usual depression care in the VA, (3) the TEAM intervention and (4) methods for evaluating the effectiveness/cost-effectiveness of the intervention. In addition, we describe the socioeconomic and clinical characteristics of the study participants and discuss our rational for the study design and the resulting strengths and weaknesses.

Section snippets

Study sites

Veterans Administration is organized into 21 Veterans Integrated Service Networks (VISNs). TEAM was conducted in VISN 16, one of the largest and most rural of the networks. The study was conducted in community-based outpatient clinics (CBOCs), of which there are 674 currently in operation across the nation and 34 in VISN 16. Community-based outpatient clinics are satellite facilities, usually located a long distance from their “parent” VA Medical Centers (VAMC) that maintain administrative

Results

The socioeconomic and clinical characteristics of the study participants are provided in Table 3. Eighty-two percent met criteria for major depressive disorder. Of particular note is the extremely high level of disease burden. Virtually, all (99.2%) of the study participants reported having at least one serious chronic health condition, and the average number was 5.5 [e.g., diabetes (32.9%), heart disease (32.2%), lung disease (20.3%), stroke (18.2%) and cancer (12.7%)]. SF12V physical health

Conclusions

The strengths and weaknesses of the TEAM study design were impacted by many decisions and tradeoffs. The first decision concerned the unit of randomization. We chose not to randomize at the patient level because of potential contamination among providers treating both intervention and usual care patients. We chose not to randomize at the provider level because of potential turnover and contamination across providers. By randomizing matched clinics, we avoid potential contamination problems. The

Acknowledgments

This research was supported by VA IIR 00-078-3 grant to Dr. Fortney, VA NPI-01-006-1 grant to Dr. Pyne, the VA HSR&D Center for Mental Health and Outcomes Research and the VA South Central Mental Illness Research Education and Clinical Center. Drs. Pyne and Edlund were supported by VA HSR&D Research Career Awards. Dr. Mittal was supported by VISN 16 South Central Network Research Career Development Grant Program. The authors would like to thank Dr. Kathryn Rost, Dr. Lisa Rubenstein, Dr. Greg

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