1. Effectiveness & Cost-Effectiveness of Collaborative Care Depression Treatment in Veterans who screen positive for PTSD Domin Chan, MHS, PhC Northwest HSRD Center of Excellence VA Puget Sound Healthcare System, University of Washington, Seattle, Washington, USA Funded by VA HSR&D

2. Objective To evaluate the effect of Collaborative Care on depression severity & functional status (Hedrick et al.) To evaluate the cost-effectiveness of Collaborative Care (Liu et al.) Among depressed VA primary care patients who screen positive for post-traumatic stress disorder (PTSD)

3. Background Depression & PTSD are: Highly prevalent illnesses in Veterans –36-51% depressed veterans have PTSD Underdiagnosed and undertreated Depression & comorbid PTSD are associated with: Greater functional impairment Higher risk of suicidal behavior

4. Study Design Design: Group-Randomized Trial (by provider group) Setting: General Internal Medicine clinic, Seattle VA Medical Center Telephone interviews at 3 and 9 months to assess clinical outcomes (87-88% retained at 9 months) Inclusion: major depression or dysthymia Exclusion: acute suicidality, psychosis, bipolar disorder or primary diagnosis of PTSD

5. PTSD Classification Experienced at least one trauma and 2 out of 3 PTSD symptoms: –Re-experiencing trauma –Increased arousal –Detachment or avoidance Sample: 54% depressed Veterans screened PTSD positive

6. Study Sample 338 Depressed Patients Collaborative Care n=175 PTSD + n=87 PTSD - n=73 Usual Care n=163 PTSD + n=96 PTSD - n=82 ® Patients were randomized by provider group R

7. Treatment for Depression Collaborative Care –Mental health team provides patient assessment & treatment plan to providers –Patient education materials sent to patients –Cognitive Behavioral Therapy (Group) –Social worker phoned patients to encourage adherence on a regular schedule Usual Care –Provider notification of depressed patients –Patient education materials available –PCP consults or refers to mental health specialist –Mental health available in primary care

8. Depression Symptoms: Hopkins Symptom Checklist (SCL-20) Depression-Free Days Social/Role Functioning: Sheehan disability scale Outcome Measures

9. Outpatient Services –Depression Treatment Antidepressant prescriptions Primary care visit with depression diagnosis Mental health specialty care Collaborative care intervention costs –Other outpatient services Inpatient Care Total Health Services Cost Measures

10. Analysis Mixed Effects Regression –Provider group random effects –Independent variables fixed effects Adjusted for provider clustering ICER = Δ costs Δ effectiveness Cost per additional depression-free day Logistic regression for probability of depression-free day Gamma GLM regression for costs Bootstrap standard errors (1000 reps) EffectivenessCost-effectiveness

11. Mean PTSD + (n=158) PTSD - (n=139) P- value Age5562<.001 Chronic disease (CDS)3.184.040.017 Depression (SCL-20)2.101.60<.001 SF-36 Physical (PCS)3334N.S. SF-36 Mental (MCS)3238<.001 Sheehan Disability 5.90 5.020.002 Baseline Patient Characteristics Note: CDS, SCL & Sheehan – higher scores are sicker PCS & MCS – lower scores are sicker

12. Adjusted Clinical Outcomes SCL Depression ScoreCollaborative Care Effect P-value 3 months-0.22N.S. 9 months-0.270.02 Sheehan Disability Score 3 months-0.63N.S. 9 months-0.920.03 Adjusted for: age, sex, race, education, marital status, living alone, baseline chronic disease, baseline SCL & previous years antidepressant use

13. Adjusted Incremental Cost & Cost-Effectiveness Cost TypeIncremental Cost ($) Cost per additional depression- free day ($) Mean95% CIMean95% CI Depression Treatment Costs 323128-57922.84-103 Total Outpatient Costs 383N.S.38.2N.S. Total Costs -80N.S.147N.S. Collaborative care: 17.5 more depression-free days

14. Conclusions For depressed Veterans who screen positive for PTSD: –Collaborative care treatment is effective in reducing depression symptoms by 9 months, but not at 3 months, compared to enhanced usual care –Collaborative care improves social functioning at 9 months, but not at 3 months –Collaborative care impact takes longer

15. Conclusions For depressed Veterans who screen positive for PTSD: –Collaborative care results in moderate increase in costs in order to achieve improved outcomes

16. Policy Implications For treatment of depressed Veterans with PTSD symptoms: –Integration of primary care providers and mental health specialists, supportive patient care management may be effective in reducing depression symptoms at a moderate cost

17. Acknowledgements Co-Authors: –Chuan-Fen Liu, PhD –Ed Chaney, PhD –Gayle Reiber, PhD –Lori Zoellner, PhD –Susan Hedrick, PhD