The American healthcare system, particularly the managed

REPORTS Collaborative Care and Motivational Interviewing: Improving Depression Outcomes Through Patient Empowerment Interventions Bill Anderson, PharmD The American healthcare system, particularly the managed care model, is sometimes ill-suited for caring for persons with chronic conditions, more specifically chronic behavioral health related conditions such as depression. Recently, various patient empowerment techniques have been employed to encourage patients to take an active role in their therapy as a means of improving outcomes. Two of the more promising patient empowerment techniques include collaborative care and motivational interviewing. Collaborative care is a system of coordinated interventions incorporating the efforts of several different providers in managed care and employing patient education, regular monitoring of outcomes, and thorough patient follow-up. Collaborative care interventions are supported by extensive clinical data, and have demonstrated recent promise in depression treatment in new regional programs, such as Project ImPACT: Depression (Improving Persistence and Compliance with Therapy), modeled after the Asheville Project and Project ImPACT: Hyperlipidemia. Although not supported by a wealth of data similar to that which backs collaborative care interventions, motivational interviewing is another technique demonstrating value in empowering patients in influencing the outcome of their own treatment. Motivational interviewing involves a series of carefully modeled questions administered by a healthcare professional designed to promote patient interest and involvement in the course of their treatment. Ascend Media Collaborative Care The most widely tested approach for improving care in the treatment of chronic mental illness is the use of collaborative care initiatives. Collaborative care involves the coordination of efforts between various different levels of providers in managed care and captures a range of patient support interventions of varying intensity, from simple telephone support to encourage medication adherence to more complex efforts that involve intensive follow-up and incorporate a form of structured psychosocial intervention. 1 These initiatives employ multidisciplinary teams to follow patients over time, actively engaging them Abstract Patient empowerment interventions have demonstrated significant success in the treatment of several chronic conditions. Recently, 2 such interventions, collaborative care and motivational interviewing, have been employed in the treatment of depression with promise in the managed care setting. Collaborative care initiatives feature a multidisciplinary team of providers to deliver such services as patient education, thorough follow-up, and case management. Motivational interviewing employs specifically tailored dialogue to encourage patients to take an active role in their therapy. Through increased treatment adherence and improved outcomes, these interventions have the potential to decrease the significant overall healthcare costs associated with depression. (Am J Manag Care. 2007;13:S103-S106) Address correspondence to: Bill Anderson, PharmD, Health First Health Plans, 6450 US Highway 1, Rockledge, FL 32955. E-mail: Bill.Anderson@health-first.org. VOL. 13, NO. 4 THE AMERICAN JOURNAL OF MANAGED CARE S103

Reports Figure 1. Benefit of Collaborative Care Over Usual Care in Clinical Outcomes at Different Follow-up Intervals Clinical Outcome Improvement (%) 35 30 25 20 15 10 5 0 25% 31% 25% 6 Months 12 Months 18 Months 24 Months 60 Months Gilbody S, et al. Arch Intern Med. 2006;166:2314-2321. 15% 15% in managing their illnesses and ensuring that they follow up with treatment regimens. The multidisciplinary teams featured in collaborative care interventions are comprised of primary care physicians, consulting psychiatrists, nurse case managers, clinical educators, and pharmacists. Collectively, these caregivers provide such services as patient education, nurse case management, and telephone medication counseling by nurses or trained counselors. 2 The aforementioned collaborative care model has demonstrated effectiveness in improving care for a range of chronic illnesses, and it also has the potential to reduce costs of care. 3,4 More than a dozen studies have shown that the collaborative care approach can improve care for major depression in primary care settings. A review of the literature found that whereas simple guidelines and educational programs generally were inadequate, complex programs that also included nurse case management and better integration between mental health and primary care led to substantial improvements in depression care. 2 A meta-analysis of this literature indicated that such programs resulted in improved detection and treatment of depression. 5 Furthermore, a more recent meta-analysis of 37 randomized trials (N >12 000) reported that 6-month, 12-month, 18-month, 24-month, and 60-month clinical outcomes (25%, 31%, 25%, 15%, and 15%, respectively) improved with collaborative care interventions over usual care (Figure 1). 1 In terms of medication adherence alone, Katon et al observed that patients receiving treatment via a collaborative care intervention were nearly twice as likely to refill antidepressant medication prescriptions than usual care patients during 1 year of follow-up (adjusted odds ratio, 1.91; 95% confidence interval, 1.37-2.65; P <.001). 6 One recent collaborative care initiative, the Asheville Project, has enrolled more than 1000 patients from 5 employers for diabetes, asthma, hypertension, and lipid therapy management. 7 This successful program was designed in conjunction with the American Pharmacists Association (APhA) and focuses on pharmacy-related patient-focused interventions to improve medication adherence and ultimately outcomes. 7 Patients enrolled in the program continue to have improved outcomes and increased medication adherence, including a 50% reduction in sick days, no workers compensation claims in the diabetes group over 6 years, and an average net savings of $1600 to $3200 per person with diabetes each year from year 2 on. 7 Modeled after the Asheville Project and Project ImPACT: Hyperlipidemia and designed in conjunction with the APhA, Project ImPACT: Depression employs a community pharmacy based healthcare service delivery model to intervene with patients who are being treated with depression therapy and are not currently being monitored in a pharmacy setting. 8 Project ImPACT: Depression employs requests that employers waive copays for antidepressant therapies and provide compensation for pharmacists who provide patient care services related to improving persistence and compliance with treatment regimens. 7 This latter feature of the project encompasses interventions incorporated in both collaborative care and pay-for-performance initiatives. Project ImPACT: Depression attempts to consistently produce an environment that results in a high level of collaboration between healthcare providers. 8 This collaboration is accomplished through regular communications between and among all involved parties, referral of patients by pharmacists to physicians and psychiatrists, and referral of patients to pharmacists by physicians and psychiatrists. 8 The program also seeks to increase availability and use of objective clinical measures and encourage the sharing of treatment data and pertinent lifestyle and clinical information between patients and physicians. 8 Furthermore, periodic evaluation of progress toward remission and timely adjustments in treatment plans improve the likelihood that patients are receiving optimal care at all times. 8 Motivational Interviewing Another patient empowerment technique, S104 www.ajmc.com NOVEMBER 2007

Figure 2. Impact of Motivational Interviewing on Mental Health Status Collaborative Care and Motivational Interviewing Motivational interviewing (n = 145) Control (n = 131) Mental Composite Score on SF-12 52 51 50 49 48 47 46 45 44 Baseline * Postintervention Mental Health Composite score derived from responses to questions in each of the following domains: Physical function Role limitations due to physical function General health perception Bodily pain Social functioning Energy/vitality Role limitations due to emotional functioning Mental health status *P =.03 vs control. SF-12 indicates Short Form-12. Butterworth S, et al. J Occup Health Psychol. 2006;11:358-365. motivational interviewing, has demonstrated promise in the treatment of depression but is relatively untested compared with well-established collaborative care interventions. This technique was originally designed for addiction counseling but has proven applications in the treatment of other chronic conditions. 9 Motivational interviewing differs from traditional health coaching approaches in that it is not based on the information model, does not use scare tactics, and is not confrontational, forceful, guilt-ridden, or authoritarian; instead, the technique is shaped by an understanding of what triggers change. 10 In motivational interviewing, the practitioner or coach emphasizes the 3 underlying assumptions of chronic disease collaboration, evocation, and autonomy to establish rapport, reduce resistance, and elicit change talk (ie, one s own reasons and arguments for change). 10 In the motivational interviewing process, the provider expresses empathy through reflection by responding to the patient with direct feedback on their comments. 11 The provider also works through dialogue to develop discrepancies between his or her present maladaptive behaviors because of depression and the patient s values and goals. 11 For example, the provider may say something like, While it seems important to you to be a good father to your son, your depression often makes you unavailable to him when he needs you. Furthermore, a provider applying motivational interviewing techniques accepts the patient s resistance, seeing it as information about perceived pros and cons of change to be respected and worked with, not an obstacle to overcome. 11 In patients with depression, the negative characteristics of change may be the secondary gains that are perceived by patients to come from their current mood, such as the manner in which the disease may allow patients to avoid difficult situations or decisions. 11 For example, the provider may say something like, Although your depression may have temporarily allowed you to avoid making a decision on your college major, it is interfering with your studies and your grades are suffering. Finally, providers should support the patients beliefs that they can help themselves, by inquiring about activities that may help improve the patients mood or about past successful attempts at change in other areas. 11 Motivational interviewing has demonstrated worth in a variety of chronic conditions, including hypertension, hypercholesterolemia, obesity, and diabetes. 10 In a study of 276 employees at a medical center self-selected to participate in either a 3- month intervention or control group, patients receiving the motivational interviewing intervention demonstrated significant improvement over those who received standard care. 10 Interviewing was conducted by health promotion specialists with training in motivational interviewing and included 1 initial session and 2 follow-up contacts over 3 VOL. 13, NO. 4 THE AMERICAN JOURNAL OF MANAGED CARE S105

Reports months. Sessions were limited to 30 minutes each. Mental health status was measured using the Mental Composite Score and the Physical Composite Score of the Short Form-12 version 2 (SF-12) health survey. 10 At study s end, the treatment group showed significant improvement in both SF-12 physical (P <.035) and mental (P <.0001) health status compared with controls (Figure 2). 10 Motivational interviewing presents promise in the treatment of depression because it is helpful in increasing a patient s intrinsic motivation to achieve a goal and highly effective in diseases with a large behavioral component. 12 In addition, this novel patient empowerment intervention is effective in helping increase treatment adherence. 12 This increased adherence is significant in the treatment of depression, for which medication adherence is a concern. From a health plan perspective, motivational interviewing is ideal in that it is compatible with a variety of traditional approaches and is effective across various patient demographics, including sex, ethnicity, age, socioeconomic status, and culture. 10,13 Furthermore, motivational interviewing may not be as costly as other, more timeconsuming interventions, because it has proven efficacy with as few as three 30-minute sessions and can be administered by trained healthcare extenders who are not physicians. 10,13 Conclusion Encouraging patients to take an active role in their therapy has the potential to improve outcomes in the treatment of chronic diseases in which traditional care is often insufficient. Furthermore, for particularly burdensome behavioral health related conditions, such as depression, patient empowerment interventions may provide additional advantages over traditional hands-off care. Collaborative care is one such intervention that relies on a multidisciplinary effort among physicians, psychiatrists, nurse case managers, and pharmacists to carefully monitor and educate patients throughout the course of treatment. A wealth of data has demonstrated this intervention to be effective over traditional care in the treatment of depression, and numerous programs of this type are being implemented across the country, including Project ImPACT: Depression. Although not supported by the same abundance of data as collaborative care, motivational interviewing is another intervention for empowering patients that presents promise in the treatment of depression. This technique employs a series of questions carefully designed to encourage patients to actively participate in the course of their own treatment. Considering this technique demonstrates particular promise in diseases with a large mental health component and has the potential to improve treatment adherence, the implications in the treatment of depression are significant. In fact, the capacity for combining both of these patient empowerment interventions to improve treatment adherence and outcomes makes them valuable in their potential to decrease overall healthcare costs. REFERENCES 1. Gilbody S, Bower P, Fletcher J, Richards D, Sutton AJ. Collaborative care for depression: a cumulative metaanalysis and review of longer-term outcomes. Arch Intern Med. 2006;166:2314-2321. 2. Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organizational interventions to improve the management of depression in primary care: a systematic review. JAMA. 2003;289:3145-3151. 3. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness. JAMA. 2002;288:1775-1779. 4. Bodenheimer T, Wagner EH, Grumbach K. Improving primary care for patients with chronic illness: the chronic care model, part 2. JAMA. 2002;288:1909-1914. 5. Badamgarav E, Weingarten SR, Henning JM, Knight K, Hasselblad V, Gano A Jr. Effectiveness of disease management programs in depression: a systematic review. Am J Psychiatry. 2003;160:2080-2090. 6. Katon W, Rutter C, Ludman EJ, Von Korff M, Lin E, Simon G. A randomized trial of relapse prevention of depression in primary care. Arch Gen Psychiatry. 2001; 58:241-247. 7. American Pharmacists Association Foundation. Asheville Project. Available at: http://www.aphafoundation.org/ programs/asheville_project/. Accessed October 15, 2007. 8. American Pharmacists Association Foundation. Project ImPACT. Available at: http://www.aphafoundation.org/ programs/project_impact/362.cfm. Accessed October 15, 2007. 9. Miller WR. Motivational interviewing with problem drinkers. Behav Psychother. 1983;11:147-172. 10. Butterworth S, Linden A, McClay W, Leo MC. Effect of motivational interviewing-based health coaching on employees physical and mental health status. J Occup Health Psychol. 2006;11:358-365. 11. Arkowitz H, Westra H. Integrating motivational interviewing and cognitive behavioural therapy in the treatment of depression and anxiety. J Cognitive Psychother. 2004;18:337-350. 12. Rubak S, Sandbæk A, Lauritzen T, Christensen B. Motivational interviewing: a systematic review and meta-analysis. Br J Gen Pract. 2005;55:305-312. 13. Hettema J, Steele J, Miller WR. Motivational interviewing. Annu Rev Clin Psychol. 2005;1:91-111. S106 www.ajmc.com NOVEMBER 2007

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