Collaborative Depression Care in OB-GYN Benefits Disadvantaged Patients

Collaborative depression care adapted to an obstetrics-gynecology (OB-GYN) setting appears to have a greater impact on depression outcomes for socially disadvantaged women with no insurance or with public coverage than for women with commercial insurance, according to a report published online in AJP in Advance August 26.

The study extends the evidence of the benefits of collaborative care beyond the insured populations in which it has largely been tested to uninsured and publicly insured patients with multiple medical, psychiatric, and social problems.

Wayne Katon, M.D.

“It’s a really important finding,” said lead author Wayne Katon, M.D., of the University of Washington. “Many of the original collaborative care studies have been done in HMO settings with insured patients. Some people have thought that although the model worked in those settings, it won’t help disadvantaged patients because they have too many other challenges—housing, transportation, domestic violence, or other social adversities. But the fact is that it appears from this study that it does help and works even better. More vulnerable populations need even more support to really help them with their illnesses,” Katon said.

In the study, 205 women who screened positive for depression with a score of at least 10 on the Patient Health Questionnaire–9 and met criteria for major depression or dysthymia were randomized to a 12-month intervention program or to usual care, with blinded assessments at six, 12, and 18 months. Of these patients, 120 had no insurance or relied on public coverage, and the rest had commercial insurance.

The collaborative care model designed for the OB-GYN population included an initial engagement session with the care manager, choice of initial treatment (psychotherapy or medication), proactive outreach for patients who did not follow through with appointments, help for uninsured patients with charity care for medications, choice of in-person or telephone visits, and use of social workers as care managers to help alleviate barriers to care. Two depression care managers provided training on issues related to women’s mental health, such as domestic violence and sexual assault.

The care managers followed patients in-person and by telephone every one to two weeks for up to 12 months.

Patients assigned to usual care were informed of their depression diagnosis by the research assistant and received an educational depression pamphlet. All patients had an opportunity for referral to social work and psychiatric consultations.

Katon and colleagues found that the treatment effect was significantly associated with insurance status: patients with no insurance or with public coverage had greater recovery from depressive symptoms than patients with commercial insurance over the 18-month follow-up period with the intervention than with usual care.

Women with commercial insurance tended to improve sooner (at the six-month follow-up) with the intervention than with usual care compared with women with no insurance or with public coverage. However, patients with no insurance or with public coverage tended to have greater improvements with the intervention than with usual care at 12 and 18 months on these measures (see chart on page 29).

For patients in both insurance categories, the intervention was associated with a higher percentage of patients receiving four or more mental health visits, compared with usual care. Similarly, for both insurance groups, patients receiving the intervention were more satisfied with the quality of depression care than were usual-care patients.

Katon said the study is one of the first to look at collaborative care in an OB-GYN setting. That’s important, he said, because a third of women identify their OB-GYN as their primary care physician. “For many economically and socially disadvantaged women who are publicly insured or uninsured, the only time they may have contact with a health care provider is around having a baby,” he said. ■