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      A population-based approach to the management of depression in a patient-centered medical home

      Family Medicine and Community Health
      Family Medicine and Community Health & American Chinese Medical Education Association
      patient-centered medical home, population health, Depression

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          Abstract

          Objective: This article describes the implementation of a population-based strategy to manage depression in a patient-centered medical home. Methods: Review of English language articles; description of specific protocols utilized in one medical home. Results: Depression is a global concern estimated to affect 350 million people worldwide. Rates for depression vary between the United States and the Peoples’ Republic of China, possibly due to significant factors in under diagnosis of this often hidden burden. Given the comorbidity of depression with other health factors and the need for ongoing monitoring and care of this chronic illness, primary care has become a significant part of treatment interventions. Utilizing electronic health records (EHR), our strategy included the creation of a patient registry; selection of evidence-based treatment guidelines and protocols for point of care procedures; patient outreach and screening. Conclusion: The population-based program we outline is highly dependent on the EHR and the flexibility of roles and responsibilities of clinical staff. Further investigation is warranted into improved patient outcomes.

          Most cited references28

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          What did STAR*D teach us? Results from a large-scale, practical, clinical trial for patients with depression.

          The authors provide an overview of the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) study (www.star-d.org), a large-scale practical clinical trial to determine which of several treatments are the most effective "next-steps" for patients with major depressive disorder whose symptoms do not remit or who cannot tolerate an initial treatment and, if needed, ensuing treatments. Entry criteria were broadly defined and inclusive, and patients were enrolled from psychiatric and primary care clinics. All participants began on citalopram and were managed by clinic physicians, who followed an algorithm-guided acute-phase treatment through five visits over 12 weeks. At the end of each sequence, patients whose depression had not fully remitted were eligible for subsequent randomized trials in a sequence of up to three clinical trials. In general, remission rates in the study clinics were lower than expected, suggesting the need for several steps to achieve remission for most patients. There was no clear medication "winner" for patients whose depression did not remit after one or more aggressive medication trials. Both switching and augmenting appeared to be reasonable options when an initial antidepressant treatment failed, although these two strategies could not be directly compared. Further, the likelihood of remission after two vigorous medication trials substantially decreased, and remission would likely require more complicated medication regimens for which the existing evidence base is quite thin. STAR*D demonstrated that inclusion of more real-world patients in clinical trials is both feasible and informative. Policy implications of the findings, as well as the study's limitations, are discussed.
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            Diabetes and depression.

            Diabetes and depression occur together approximately twice as frequently as would be predicted by chance alone. Comorbid diabetes and depression are a major clinical challenge as the outcomes of both conditions are worsened by the other. Although the psychological burden of diabetes may contribute to depression, this explanation does not fully explain the relationship between these 2 conditions. Both conditions may be driven by shared underlying biological and behavioral mechanisms, such as hypothalamic-pituitary-adrenal axis activation, inflammation, sleep disturbance, inactive lifestyle, poor dietary habits, and environmental and cultural risk factors. Depression is frequently missed in people with diabetes despite effective screening tools being available. Both psychological interventions and antidepressants are effective in treating depressive symptoms in people with diabetes but have mixed effects on glycemic control. Clear care pathways involving a multidisciplinary team are needed to obtain optimal medical and psychiatric outcomes for people with comorbid diabetes and depression.
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              Epidemiology of Major Depressive Disorder in Mainland China: A Systematic Review

              Background Major depressive disorder (MDD) is one of the important causes of disease burden in the general population. Given the experiencing rapid economic and social changes since the early 1990s and the internationally recognized diagnostic criteria and interview instruments across the surveys during 2001–2010 in china, the epidemiological studies on MDD got varied results. We performed this meta-analysis to investigate current, 12-month and lifetime prevalence rates of MDD in mainland China. Methods PubMed, Embase, Chinese Biological Medical Literature database (CBM), Chinese National Knowledge Infrastructure database (CNKI), and the Chinese Wanfang and Chongqing VIP database were searched for associated studies. We estimated the overall prevalence of MDD using meta-analysis. Conclusions Seventeen eligible studies were included. Our study showed that the overall estimation of current, 12-month and lifetime prevalence of MDD was 1.6, 2.3, 3.3%, respectively. The current prevalence was 2.0 and 1.7% in rural and urban areas, respectively; between female and male, it was 2.1 and 1.3%, respectively. In addition, the current prevalence of MDD diagnosed with SCID (Structured Clinical Interview for DSM-IV) was 1.8% and that diagnosed with CIDI (Composite International Diagnostic Interview) was 1.1%. In conclusion, our study revealed a relatively high prevalence rate in the lifetime prevalence of MDD. For current prevalence, MDD diagnosed with SCID had a higher prevalence rate than with CIDI; males showed a lower rate than females, rural residents seemed to have a greater risk of MDD than urban residents.
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                Author and article information

                Journal
                10.15212/FMCH.2015.0102
                https://creativecommons.org/licenses/by-nc/4.0/

                General medicine,Medicine,Geriatric medicine,Occupational & Environmental medicine,Internal medicine,Health & Social care
                patient-centered medical home,population health,Depression

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