Development and Implementation of an Ambulatory Integrated Care Pathway for Major Depressive Disorder and Alcohol Dependence

An ICP has been defined as a “multidisciplinary outline of anticipated care, placed in an appropriate time frame to help patients move progressively through a clinical experience to positive outcomes” (1). Thus ICP is a vehicle for interdisciplinary teams to deliver evidence-based practices. Although extensively used in other areas of medicine (for example, Cancer Care Ontario [www.cancercare.on.ca]), ICPs are still rare in mental health and addictions treatment. The ICP methodology includes evidence reviews, knowledge translation, process reengineering, and change management. An ICP specifically details what to do, when to do it, and who will do it. CAMH ICPs have four key components: psychopharmacological intervention, nonpharmacological interventions, interdisciplinary collaboration, and a project management approach to implement and sustain the ICP. The outpatient ICP for major depressive disorder and alcohol dependence was designed by a group of pharmacists, nurses, physicians, psychologists, administrators, and researchers, with a process expert to coordinate the project. Best practices, both local and in the literature, were reviewed for each diagnosis, and consensus was obtained on the design elements. A patient focus group was conducted, resulting in a clear end-user-informed goal for the implementation.

There is extensive evidence of the frequent co-occurrence of major depressive disorder and alcohol dependence. A total of 2.7 million U.S. adults (1.2% of those ages 18 and older) had these co-occurring disorders in the past year (2). Despite their frequent co-occurrence, the disorders have traditionally been treated separately, and there is little evidence to guide best practice for their integrated treatment (3). Consequently, people with co-occurring disorders have poor access to specialized psychiatric treatment. Although 48.9% of those with major depressive disorder and alcohol dependence reported past-year treatment for depression, only 8.8% received specialized treatment for both disorders (3).

The need for an ICP for these co-occurring disorders arises because current guidelines provide no direction. Commonly used guidelines typically present a variety of treatment options for specific conditions. For example, major depressive disorder guidelines recommend several first-line pharmacological options, providing no guidance on how to decide among them (4). Furthermore, such guidelines do not indicate how interdisciplinary teams should coordinate treatment delivery when more than one intervention is required. The ICP provides a practical tool to deliver integrated care based on evidence and consensus.

The pilot program, which began in December 2013, was evaluated. Results of the evaluation suggest that ICP has enhanced access to evidence-based integrated care for patients with concurrent major depressive disorder and alcohol dependence. There is preliminary evidence that the ICP has improved treatment retention, which we have defined as the proportion of patients completing the 16-week pathway divided by the total number admitted to the ICP. A preliminary comparison of retention rates for the pathway (N=28) and for treatment as usual (N=92) conducted in August 2014 showed significantly lower dropout in the ICP cohort (46% versus 78%, p<.05). ICP’s short wait from referral to treatment (<14 days) may have contributed, because long waits may diminish motivation and lead to disengagement.

Patient satisfaction with the ICP has been high: all patients endorsed being satisfied or very satisfied with the overall care. Preliminary results also show a clinically meaningful reduction of symptoms for both depression and alcohol dependence. ICP patients experienced a significant reduction in depressive symptom severity on the basis of QIDS and Beck Depression Inventory and a reduction in the percentage of heavy drinking days (from 42% to 23%, p<.04). No significant changes in severity of cravings, number of drinking days per week, and drinks per drinking day were observed between the start and end of treatment [see online supplement].

Results suggest that the ICP is a feasible and potentially effective approach to treat concurrent major depressive disorder and alcohol dependence at an academic tertiary care hospital. On the basis of the pilot findings, the clinical team and hospital management are developing a strategy for increasing treatment capacity within the ICP. The growth strategy will include incorporating a group CBT option, building treatment capacity by recruiting additional clinical staff and training nonpsychologists to deliver the CBT protocol, growing the ICP through other clinical programs in the hospital, and beginning to accept external referrals. Further research, including implementation in a variety of settings, is required to establish expanded applicability and effectiveness.