Depression complexity and psychiatric comorbidity: Implications for Primary Care-Mental Health Integration efforts
In order to better address mental health illness burden, Veterans Affairs’ (VA) Primary Care-Mental Health Integration (PC-MHI) initiative has targeted depression (MDD), anxiety/PTSD, and alcohol misuse (AUD) for care improvement within primary care (PC). We provide descriptive clinical information for care planners about VA PC patients with MDD alone and in combination with PTSD and/or AUD.
We examined data from a VA depression quality improvement study. Study personnel contacted 10,929 VA PC patients by telephone between 2003-2004. These patients were screened for depression; patients with positive screens completed a depression severity/case-finding measure. 761 reported major depressive symptomatology and consented to study participation. Participants completed baseline measures of PTSD, AUD, physical and mental health, and care engagement.
Comorbid/complex psychiatric conditions were common. A high proportion (40%) of the patients with depression also had PTSD; 24% reported AUD, and 10% had all three conditions. Chronic illnesses were common as well, with 35% of patients reporting diabetes, and 28% noting that they had suffered a heart attack. When PTSD was present--with and without AUD--depression was more chronic, more severe, and more likely to include suicidal ideation. Moreover, 22% of those with MDD-PTSD-AUD reported benzodiazepine use, which is particularly concerning because half of these patients reported suicidal ideation. Patients with the highest psychiatric comorbidity at baseline knew the least about how to manage their health 18 months later.
No definitive evidence base exists to guide systems-level protocols for PC-management of problems like major depression in patients with psychiatric comorbidity. Successful implementation of PC-MHI requires detailed information about targeted patients’ clinical status. The present results suggest that PC-MHI interventions need to be designed for patients with complex presentations who may require more highly coordinated care.
Learning Areas:Chronic disease management and prevention
Provision of health care to the public
Social and behavioral sciences
Describe the prevalence and nature of psychiatric comorbidity among patients with depression in VA primary care. Discuss some implications of psychiatric comorbidity and illness complexity for Primary Care-Mental Health Integration efforts.
Keyword(s): Depression, Primary Care
Qualified on the content I am responsible for because: I am an Associate Professor of Psychology at the University of Montana. I have researched primary care-mental health integration efforts within VA for over a decade. My research team has published several peer-reviewed articles regarding depression treatment in primary care.
Any relevant financial relationships? No
I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.