Worldwide5%-10% of population 121 million affected½ depressed adults get treatment

WHO, 2009

NationallyLife-time prevalence 15.3% -

16.9%

University Student Higher prevalence 8.7% - 43.4%

Andrade et al., 2003; CDC, n.d.; Kessler, 2003; Ohayon, 2007; ACHA, 2009; Steptoe, Tsuda, Tanaka, & Wardle, 2007; Wardle et al., 2004; Vasquez & Blanco, 2008; Wong, Cheung, Chan, Ma & Tang, 2006; Stecker, 2004; Dahlin, Joneborg & Runeson, 2005, WHO, 2009

ACHA NCHA II22.7% felt very sad in the past 12 months

20% felt hopeless in the past 12 months

13.7% felt so depressed it was difficult to function

ACHA NCHA II11.1% of students felt depression affected their academic performance

9.2% of students were diagnosed or treated by a professional for depression

3.8% seriously considered suicide0.8% attempted suicide

SuicideReduced quality of lifeReduced social functioningRole impairmentExcess disability

WHO, 2009; CDC, n.d.; Kessler, 2003; Kessler & Walters, 2003

Occurs with anxietyMore likely to have CVD, DM, asthma, and obesity

More likely to smoke, be physically inactive, and drink alcohol

Andrade et al., 2003; CDC, n.d., Kessler, 2003; Ohayon, 2007

Insufficient30% properly diagnosed and treated

Chizobam et al., 2009; WHO, 2009; Wittchen, 2009

USPSTF (2002) recommends screening for depression in clinical practices that have systems in place that assure accurate diagnosis, effective treatment, and adequate follow-up

Healthy Campus 2010 goal: “improve mental health and ensure access to appropriate, quality mental health services”

ACHA, 2002 p. 66

Unipolar depression:◦Major depressive disorder (MDD)◦Dysthymic disorder◦Depressive disorder not otherwise specified (NOS)

APA, 1994

1. Depressed mood 2. Diminished interest (anhedonia)

APA, 1994

1. Significant weight loss or gain or decreased or increase in appetite

2. Insomnia or hypersomnia 3. Psychomotor agitation or retardation4. Fatigue or loss of energy 5. Feelings of worthlessness or excessive or

inappropriate guilt6. Diminished ability to think or concentrate or

indecisiveness7. Recurrent thoughts of death, recurrent suicidal

ideation without a specified plan or a suicide attempt, or a specific plan for committing suicide

A depressive disorder that is characterized by at least two years of depressed mood for more days than not

Accompanied by two of the following:1. Poor appetite or overeating2. Insomnia or hypersomnia3. Low energy or fatigue4. Low self-esteem5. Poor concentration or difficulty making

decisions6. Feelings of hopelessness

Included for diagnostic coding of depression that has features that do not meet criteria for the other depressive disorder

Improve depression careSample of 50 students18% were diagnosed with depression

24% had a history of depression

What are the effects of using the Chronic Care Model (CCM) on depression outcomes with a group of students compared with a group using current practice at a Midwestern university health and wellness center?

Outcomes measured• Detection of depression• Depression improvement• Patient compliance with medication

• Patient satisfaction

Databases Searched ◦Cochrane◦Academic Search Premier ◦CINAHL◦Health Source: Nursing/Academic◦MEDLINE◦PsycArticles◦ERIC

Key Terms Used◦Depression and multifaceted interventions

◦Depression and collaborative care◦Depression and chronic care model◦Depression and disease management

Inclusion CriteriaInclusion Criteria◦ January 1, 1999 to January, 31

2010◦ English◦ Age 18 to 64◦ More than one intervention ◦ Primary care

Exclusion CriteriaExclusion Criteria◦Patients with pre- or postnatal depression

◦Care specific to one gender

  Abstracts identified using search terms

N = 939

Articles met criteria for review

N = 38

ExcludedN = 901

Articles met criteria for review

from hand searchesN = 63

Articles met inclusion criteriaN = 14

Articles valid and reliable

N = 9

ExcludedN = 87

 

Author/Year Level of Evidence Research Design Quality Assessment

Badamgarav et al. (2003)

I Systematic reviewMeta-analysis

+++

Bower et al. (2003) I Systematic reviewMeta-analysis

+++

Christensen et al. (2008)

V Systematic reviewDescriptive analysis

++

Gilbody et al. (2003)

V Systematic review Narrative summary

+

Gilbody et al. (2006)

I Systematic review Meta-analysis

+++

Neumeyer-Gromen et al. (2004)

I Systematic review Meta-analysis

+++

Tsai et al. (2005) I Systematic review Meta-analysis

++

Vergouwen et al. (2003)

V Systematic review Qualitative review

+

Williams et al. (2007)

V Systematic reviewDescriptive analysis

+

• Sample sizes: 10 – 55 articles• Patients described as depressed• 5-18 multifaceted interventions

used

Models that guided the literature search and interventions:

Chronic Care Model (3 reviews) Collaborative Care (3 reviews) Disease Management Program (2

reviews) 1 looked at multifaceted

interventions

Interventions:1.Delivery system design:

◦ Case management◦ Regular follow-up◦ Culturally appropriate care ◦ Defining each provider’s roles and

tasks

ICSI, 2009; Wagner et al., 1999

2. Self-Management Support: Educating patients about their disease

Providing emotional support Helping set priorities and goal setting Developing strategies for living withchronic illness

ICSI, 2009; Wagner et al., 1999

3. Clinical Information Systems Electronic health records Paper registry systems

ICSI, 2009; Wagner et al., 1999

4. Decision Support Provider education to stay up to date Evidence based guidelines in daily

practice Sharing of evidence based guidelines

and information with patients to encourage their participation

ICSI, 2009; Wagner et al., 1999

5. Community Resources Encouraging patients to participate in

effective community programs Forming partnerships with community

organizations to support patient interventions

Advocating for policies to improve patient care

ICSI, 2009; Wagner et al., 1999

6. Health System Leadership that visibly supports

improvements at all levels Leadership that provides incentives based

on quality of care Leadership that encourages open and

systematic handling of quality problems to improve care

ICSI, 2009; Wagner et al., 1999

Outcomes from implementing multifaceted interventions caused improvement in:1. Depression (all 9 articles)2. Medication adherence (6 out of 6

articles)3. Patient satisfaction (2 out of 2

articles)4. Depression detection through

screening (1 out of 1 article)

• Less likely to cause depression improvement: Provider education and feedback

• More likely to cause depression improvement: Case management and patient preference

• Systematic reviews• Provider preference• CCM• PHQ-9 depression screening tool• Institute for Clinical Systems

Improvement (ICSI; 2009) practice guideline

RN Discuss the Project with Patient

2 simple questions

PHQ-9 screening tool

Randomly draw envelope

DeclinesUsual Care

UnexposedUsual Care

No Usual Care

Score 0-4Usual Care

PHQ-9 screening tool

InterviewAssess

comorbiditesTreat

Assess response

Good: Continuation or Maintenance

Phase

No: Reevaluate

• Ace Star Model• Quasi experimental design• Convenience sample • University students • Age 18 and older • Midwestern university health and

wellness center • Randomly assigned • Consented

Interventions based on the CCM:

1. Delivery system2. Patient self-management3. Clinical information system4. Decision support5. Community resources6. Health care system

Sample Size91 (65%) agreed to participate and 49 (35%) declined

Eight patients withdrew (8.8%) Total of 83 patients, 47 (57%) exposed, 36 (43%) unexposed

Sample Characteristics for Entire Group

22 males (26.5%) and 61 females (73.5%)

Age range between 19-53 years, mean age 27

15 patients diagnosed with depression (18%)

Demographic Data for Entire Patient Population in Study

 Demographi

csExposed Unexposed Test

Resultp

Female % (n=83)

70 (n=47) 78 (n=36) X²(1) = .599 0.439

Age, mean (sd) (n=81)

28.70 (8.87)(n=46)

25.89 (7.19)(n=35)

t(79) = 1.53 0.130

Demographic Data for Depressed Population

Demographics

Exposed (n = 10)

Unexposed (n = 5)

Test Result

p

Female % 55.6 44.4 X²(1) =1.25 0.264

Age, mean (sd)

31.50 (12.42) 22.40 (1.14) t(9.30) = 2.30 0.046

Demographic Information for Depressed Patients (n = 10)

(n = 10)

10% declined medication/counseling 70% used antidepressant medication 90% used on-campus counseling 30% referred to psychiatrist

21.3% detected in the exposed 13.9% detected in the unexposed

X²(df) = .751(1) p = .386

No statistically significant difference

N Initial Mean PHQ-9 Score (sd)

Final Mean PHQ-9 Score

(sd)

t test

6 16.67 (7.12) 9.00 (5.37) t(5) = 2.15,p > .05

10 17.80 (6.01) 9.20 (4.26) t(9) = 3.63 p = .005

Outcome 2: Changes in PHQ-9 Scores

Outcome n Exposed (%) Unexposed (%)

X²(df) p

Improved depression

13 75 (n = 9) 25 (n = 3) 4.88(2) 0.087

Medication compliance

14 83.3 (n = 10) 16.7 (n = 2) 3.97(2) 0.141

Outcome 3 and 4:

Patient Satisfaction with the Care Received◦ Of the questionnaires sent out◦ 4 (11%) completed with 2 (50%) in the exposed

and 2 (50%) in the unexposed group

◦ 5 (14%) returned with no forwarding address◦ 6 (16%) completed without a name

Patient Satisfaction (continued)◦ Mean PHQ-9 score: 91.75◦ No significant difference between the 2 groups

Patient Group

N Mean Score

Minimum

Score

Maximum

Score

sd

Total 4 91.75 81 99 7.63

Exposed 2 90.00 81 99 12.73

Unexposed

2 93.50 93 94 0.70

Strengths of the project◦PHQ-9 scores improved◦Current staff ◦No increase in budget◦NP feedback positive◦PHQ-9 screening tool improved

communication

Recommendations about implementation◦Increase sample size◦Implement multi-center design◦Utilize different patient satisfaction survey◦Change the location of the educational

brochures◦Ensure consistency in demographic data

collection and PHQ-9 screening◦Longer than 12 weeks

Implications for nursing◦Multidisciplinary approach◦Campus resources linked◦APN education of chronic illness

Implications for nursing◦Further research needs to be completed Larger sample size NP vs. MD Interventions with the greatest impact Use with other chronic conditions

“Depression is the inability to construct a future.”Rollo May