Elsevier

Journal of Affective Disorders

Volume 184, 15 September 2015, Pages 269-276
Journal of Affective Disorders

Research report
Effectiveness of a stepped care intervention for anxiety and depression in people with diabetes, asthma or COPD in primary care: A randomized controlled trial

https://doi.org/10.1016/j.jad.2015.05.063Get rights and content

Highlights

  • Depression and anxiety are common comorbidities in people with a chronic disease.

  • Guidelines recommend using stepped care although the effectiveness is not yet known.

  • We tested the effectiveness of stepped care plus monitoring.

  • This model was effective in reducing symptoms of anxiety and depression.

Abstract

Background

Depression and anxiety are common in people with a chronic somatic disease. Although guidelines recommend stepped care, the effectiveness of this approach has not been evaluated in people with diabetes, asthma, or COPD in primary care.

Methods

3559 People were sent screening questionnaires (41% response). Of 286 persons with anxiety and/or depression (Generalized Anxiety Disorder questionnaire, GAD-7, cut-off ≥8 and/or Patient Health Questionnaire, PHQ-9, cut-off ≥7), 46 were randomized into the intervention (stepped care and monitoring of symptoms; n=23) or control (usual care) group (n=23). Main outcomes were symptoms of anxiety and depression after the 12-months intervention and six months post intervention. Analysis of covariance was first adjusted for condition and baseline GAD-7/PHQ-9 scores and additionally for age, sex and education.

Results

The intervention group had a significantly lower level of anxiety symptoms at the end of the program (GAD-7 6±6 vs. 9±6; Cohen's d=0.61). This effect was still present six months post intervention. The effect on depression was statistically significant in the first model (PHQ-9 6±4 vs. 9±6; p=0.035), but not in the fully adjusted model (p=0.099), despite a large effect size (d=0.63). At six months post intervention there was no statistically significant difference in symptoms of depression between the two groups although the difference in symptoms was still clinically significant (Cohen's d=0.61).

Limitations

Many people were screened, but relatively few participated in the randomized controlled trial.

Conclusions

Stepped care with monitoring resulted in a lower level of symptoms of anxiety and depression in people with a chronic condition.

Introduction

Symptoms of depression and anxiety are common in people with a chronic disease such as asthma, chronic obstructive pulmonary disease (COPD) or diabetes (Ali et al., 2006, Katon et al., 2007, Smith et al., 2013, Yohannes et al., 2010). Besides their negative impact on quality of life and disease burden (Katon et al., 2007, Lavoie et al., 2006), these symptoms are also related to the development of complications and higher mortality rates (Lavoie et al., 2006, Lin et al., 2010, Van Dooren et al., 2013, Xu et al., 2008, Yohannes et al., 2010).

Previous studies have concluded that depression and anxiety are not recognized by primary health care providers or diabetes nurses in up to 75% of the cases (Barbui and Tansella, 2006, Pouwer et al., 2006, Tylee and Walters, 2007). However, more recent studies showed that general practitioners are aware of depression in most patients, but diagnoses are not always recorded in the medical file using the official coding (Joling et al., 2011). Another recent study showed that general practitioners did less often recognize people without a comorbid anxiety disorder, who did not consult their GP for mental problems, with fewer depression symptoms or with increased appetite (Piek et al., 2012). Therefore, there is still room for improvement (Piek et al., 2012).

Not surprisingly, international guidelines have recommended heightened awareness of psychosocial problems in people with a chronic disease (American Diabetes Association, 2010, IDF Clinical Guidelines Task Force, 2005, National Collaborating Centre for Mental Health, 2010a; Perk et al., 2012; Vestbo et al., 2013). For example, several diabetes guidelines and guidelines for cardiovascular disease prevention advocate standard screening and monitoring of psychosocial wellbeing/distress (American Diabetes Association, 2010, IDF Clinical Guidelines Task Force, 2005; Perk et al., 2012). While screening may facilitate recognition, higher recognition rates do not necessarily lead to increased treatment initiation and improved patient outcomes (Baas et al., 2009, Pouwer et al., 2011). Hence, it has been advocated that screening should be embedded into comprehensive care for mental health problems such as anxiety and depression (Gilbody et al., 2008).

In anxiety and depression guidelines, the use of a stepped care intervention model is recommended (National Collaborating Centre for Mental Health, 2010b, National Collaborating Centre for Mental Health, 2011, Spijker et al., 2013, Van Balkom et al., 2013). The rationale behind the stepped care model is that (a) treatment is started with a low-intensity, cheap though effective intervention (e.g. psycho-education) and (b) via systematic reassessments it is evaluated whether the treatment goal is met or the following step needs to be initiated comprising a more intensive treatment (Bower and Gilbody, 2005). Hence it is assumed that this intervention model provides adequate cost-effective care (Bower and Gilbody, 2005).

The guideline on treatment and management of depression in adults with a chronic physical health problem developed by the National Institute for Health and Clinical Excellence (NICE) also recommends using a basic stepped care model despite the fact that this model has rarely been evaluated in this group (National Collaborating Centre for Mental Health, 2010a). They argue that “the stepped-care model remains the best developed system for ensuring access to cost-effective interventions for a wide range of people with depression and a chronic physical health problem, particularly if supported by systems for routine outcome monitoring” (National Collaborating Centre for Mental Health, 2010a). Several studies, mainly conducted in the USA primary care setting, found that the extended collaborative stepped care model was effective in treating symptoms of depression or anxiety in people with a chronic disease (Ell et al., 2011, Fortney et al., 2007, Katon et al., 2010, Katon et al., 2004, Morgan et al., 2013, Rollman et al., 2009). In addition to stepped care treatment, the collaborative care treatment incorporates a multidisciplinary team across care settings (e.g. including a psychiatrist) and a care manager (Katon and Unutzer, 2006). However, the effectiveness of a basic stepped care model for treating symptoms of anxiety and/or depression in people with a chronic disease in primary care has not been evaluated (National Collaborating Centre for Mental Health, 2010 a).

Therefore, the aim of the current study was to evaluate the effectiveness of a stepped care model in reducing symptoms of anxiety and/or depression in people with a chronic disease (type 2 diabetes, asthma and/or COPD) and co-morbid emotional distress in primary care.

Section snippets

Participants and procedure of inclusion

Twenty-four primary care practices took part in the current study. All participating general practices were allied to the large primary care organization PoZoB, located in the South of the Netherlands, and employed a practice nurse for mental health. People who were treated within the framework of the somatic managed care programs for type 2 diabetes (DIAZOB) or asthma and COPD (ASCOZOB) were considered for participation (Pommer et al., 2012, Stoop et al., 2011). The general practitioner

Results

The 24 participating practices had 4094 people in the chronic disease care management programs of whom 3559 individuals were eligible and therefore invited to complete the screening questionnaire (Fig. 2). The response to the screening was 41% (n=1465), with 1336 people completing the PHQ and GAD-7. Of these 1336 individuals, 286 (21%) had an elevated score on the depression or anxiety questionnaire, of whom 215 consented to be invited for an interview. However, only 122 individuals attended

Discussion

The results of present study suggest that a stepped care treatment with additional monitoring after remission is effective in reducing symptoms of anxiety and depression in people with a chronic disease treated in a primary care setting. The effect sizes were moderate to large for both anxiety and depression immediately after the 12-month disease management program and also at 6 months follow up. After adjustment for age, sex, educational level, stratum and baseline scores, the intervention

Contributors

FP, VP, CS and AP designed the study. CS and AP collected the data. CS wrote the first draft of the manuscript and analyzed the data. All authors drafted the manuscript, interpreted the data, reviewed and revised the manuscript critically and approved the final version of the manuscript.

Role of funding source

Study sponsors had no further role in study design; in the collection, analyses and interpretation of data; in the writing of the report; and in the decision to submit the paper for publication.

Conflict of interest

None.

Acknowledgments

This study has been funded by ZonMw the Netherlands Organization for Health Research and Development, the Hague, the Netherlands, grant number 300020015 and CoRPS, Tilburg University.

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