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Published Online: 1 April 2013

Practice-Based Versus Telemedicine-Based Collaborative Care for Depression in Rural Federally Qualified Health Centers: A Pragmatic Randomized Comparative Effectiveness Trial

Abstract

Using telemedicine technologies, off-site mental health specialists collaborating with on-site primary care physicians yielded better depression outcomes than practice-based care with staff available on-site. In this study of mostly rural, unemployed, and uninsured patients with treatment-resistant depression and numerous comorbidities, those patients assigned to a telemedicine-based group had significantly and substantially greater treatment response rates, remission rates, reductions in depression severity, and increases in mental health status and quality of life than patients assigned to the practice-based care group.

Abstract

Objective

Practice-based collaborative care is a complex evidence-based practice that is difficult to implement in smaller primary care practices that lack on-site mental health staff. Telemedicine-based collaborative care virtually co-locates and integrates mental health providers into primary care settings. The objective of this multisite randomized pragmatic comparative effectiveness trial was to compare the outcomes of patients assigned to practice-based and telemedicine-based collaborative care.

Method

From 2007 to 2009, patients at federally qualified health centers serving medically underserved populations were screened for depression, and 364 patients who screened positive were enrolled and followed for 18 months. Those assigned to practice-based collaborative care received evidence-based care from an on-site primary care provider and a nurse care manager. Those assigned to telemedicine-based collaborative care received evidence-based care from an on-site primary care provider and an off-site team: a nurse care manager and a pharmacist by telephone, and a psychologist and a psychiatrist via videoconferencing. The primary clinical outcome measures were treatment response, remission, and change in depression severity.

Results

Significant group main effects were observed for both response (odds ratio=7.74, 95% CI=3.94–15.20) and remission (odds ratio=12.69, 95% CI=4.81–33.46), and a significant overall group-by-time interaction effect was observed for depression severity on the Hopkins Symptom Checklist, with greater reductions in severity over time for patients in the telemedicine-based group. Improvements in outcomes appeared to be attributable to higher fidelity to the collaborative care evidence base in the telemedicine-based group.

Conclusions

Contracting with an off-site telemedicine-based collaborative care team can yield better outcomes than implementing practice-based collaborative care with locally available staff.

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Information & Authors

Information

Published In

Go to American Journal of Psychiatry
Go to American Journal of Psychiatry
American Journal of Psychiatry
Pages: 414 - 425
PubMed: 23429924

History

Received: 28 May 2012
Revision received: 17 September 2012
Accepted: 12 October 2012
Published online: 1 April 2013
Published in print: April 2013

Authors

Details

John C. Fortney, Ph.D.
From the Division of Health Services Research, Department of Psychiatry, College of Medicine, the Department of Biostatistics, College of Public Health, and the Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock; Health Services Research and Development and the South Central Mental Illness Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock; Community Health Centers of Arkansas, North Little Rock; United Family Services, Little Rock; and the Department of Mental Health Law and Policy, College of Behavioral and Community Sciences, University of South Florida, Tampa.
Jeffrey M. Pyne, M.D.
From the Division of Health Services Research, Department of Psychiatry, College of Medicine, the Department of Biostatistics, College of Public Health, and the Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock; Health Services Research and Development and the South Central Mental Illness Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock; Community Health Centers of Arkansas, North Little Rock; United Family Services, Little Rock; and the Department of Mental Health Law and Policy, College of Behavioral and Community Sciences, University of South Florida, Tampa.
Sip B. Mouden, M.S., C.R.C.
From the Division of Health Services Research, Department of Psychiatry, College of Medicine, the Department of Biostatistics, College of Public Health, and the Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock; Health Services Research and Development and the South Central Mental Illness Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock; Community Health Centers of Arkansas, North Little Rock; United Family Services, Little Rock; and the Department of Mental Health Law and Policy, College of Behavioral and Community Sciences, University of South Florida, Tampa.
Dinesh Mittal, M.D.
From the Division of Health Services Research, Department of Psychiatry, College of Medicine, the Department of Biostatistics, College of Public Health, and the Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock; Health Services Research and Development and the South Central Mental Illness Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock; Community Health Centers of Arkansas, North Little Rock; United Family Services, Little Rock; and the Department of Mental Health Law and Policy, College of Behavioral and Community Sciences, University of South Florida, Tampa.
Teresa J. Hudson, Pharm.D.
From the Division of Health Services Research, Department of Psychiatry, College of Medicine, the Department of Biostatistics, College of Public Health, and the Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock; Health Services Research and Development and the South Central Mental Illness Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock; Community Health Centers of Arkansas, North Little Rock; United Family Services, Little Rock; and the Department of Mental Health Law and Policy, College of Behavioral and Community Sciences, University of South Florida, Tampa.
Gary W. Schroeder, Ph.D.
From the Division of Health Services Research, Department of Psychiatry, College of Medicine, the Department of Biostatistics, College of Public Health, and the Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock; Health Services Research and Development and the South Central Mental Illness Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock; Community Health Centers of Arkansas, North Little Rock; United Family Services, Little Rock; and the Department of Mental Health Law and Policy, College of Behavioral and Community Sciences, University of South Florida, Tampa.
David K. Williams, Ph.D.
From the Division of Health Services Research, Department of Psychiatry, College of Medicine, the Department of Biostatistics, College of Public Health, and the Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock; Health Services Research and Development and the South Central Mental Illness Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock; Community Health Centers of Arkansas, North Little Rock; United Family Services, Little Rock; and the Department of Mental Health Law and Policy, College of Behavioral and Community Sciences, University of South Florida, Tampa.
Carol A. Bynum, Ph.D.
From the Division of Health Services Research, Department of Psychiatry, College of Medicine, the Department of Biostatistics, College of Public Health, and the Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock; Health Services Research and Development and the South Central Mental Illness Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock; Community Health Centers of Arkansas, North Little Rock; United Family Services, Little Rock; and the Department of Mental Health Law and Policy, College of Behavioral and Community Sciences, University of South Florida, Tampa.
Rhonda Mattox, M.D.
From the Division of Health Services Research, Department of Psychiatry, College of Medicine, the Department of Biostatistics, College of Public Health, and the Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock; Health Services Research and Development and the South Central Mental Illness Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock; Community Health Centers of Arkansas, North Little Rock; United Family Services, Little Rock; and the Department of Mental Health Law and Policy, College of Behavioral and Community Sciences, University of South Florida, Tampa.
Kathryn M. Rost, Ph.D.
From the Division of Health Services Research, Department of Psychiatry, College of Medicine, the Department of Biostatistics, College of Public Health, and the Center for Distance Health, University of Arkansas for Medical Sciences, Little Rock; Health Services Research and Development and the South Central Mental Illness Education and Clinical Center, Central Arkansas Veterans Healthcare System, North Little Rock; Community Health Centers of Arkansas, North Little Rock; United Family Services, Little Rock; and the Department of Mental Health Law and Policy, College of Behavioral and Community Sciences, University of South Florida, Tampa.

Notes

Address correspondence to Dr. Fortney ([email protected]).

Funding Information

The authors report no financial relationships with commercial interests.
Supplementary Material
Supported by NIMH grant R01 MH076908/MH076908-04S1 to Dr. Fortney.

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