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Original Investigation | Meta-analysis

Association Between Chronic Physical Conditions and the Effectiveness of Collaborative Care for Depression An Individual Participant Data Meta-analysis

Maria Panagioti, PhD1; Peter Bower, PhD1; Evangelos Kontopantelis, PhD1; Karina Lovell, PhD2; Simon Gilbody, DPhil3; Waquas Waheed, MD1; Chris Dickens, PhD4,5; Janine Archer, PhD2; Gregory Simon, MD6; Kathleen Ell, PhD7; Jeff C. Huffman, MD8; David A. Richards, PhD4; Christina van der Feltz-Cornelis, MD9; David A. Adler, MD10; Martha Bruce, PhD11; Marta Buszewicz, MD12; Martin G. Cole, MD13; Karina W. Davidson, PhD14; Peter de Jonge, PhD15; Jochen Gensichen, MD16; Klaas Huijbregts, PhD17; Marco Menchetti, MD18; Vikram Patel, PhD19; Bruce Rollman, PhD20; Jonathan Shaffer, PhD21; Moniek C. Zijlstra-Vlasveld, PhD17; Peter A. Coventry, PhD22,23
[+] Author Affiliations
1National Institute of Health Research School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, England
2School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, England
3Mental Health and Addiction Research Group, Department of Health Sciences, Hull York Medical School, University of York, York, England
4Institute of Health Research, University of Exeter Medical School, Exeter, England
5National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula, University of Exeter, Exeter, England
6Group Health Research Institute, Seattle, Washington
7Ethnicity and Poverty, School of Social Work, University of Southern California, Los Angeles
8Harvard Medical School, General Hospital/Blake 11, Boston, Massachusetts
9Department of Psychiatry and Behavioral Sciences, Faculty of Social and Behavioral Sciences, Tilburg University, the Netherlands
10Department of Psychiatry, Tufts Medical Center, Boston, Massachusetts
11Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
12Institute of Epidemiology and Health, Faculty of Population and Health Sciences, University College London, London, England
13Department of Psychiatry, St. Mary's Hospital Center, McGill University, Montreal, Quebec, Canada
14Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University, New York, New York
15Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, Groningen, the Netherlands
16Institute of General Practice, Friedrich-Schiller-University, School of Medicine, University Hospital, Jena, Germany
17Netherlands Institute of Mental Health and Addiction, Trimbos Institute, Utrecht, the Netherlands
18Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
19Public Health Foundation of India, Gurgaon, India
20Psychiatry, Biomedical Informatics, and Clinical and Translational Science, Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania
21Department of Psychology, University of Colorado, Denver
22Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, England
23Centre for Reviews and Dissemination, University of York, York, England
JAMA Psychiatry. 2016;73(9):978-989. doi:10.1001/jamapsychiatry.2016.1794.
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Importance  Collaborative care is an intensive care model involving several health care professionals working together, typically a physician, a case manager, and a mental health professional. Meta-analyses of aggregate data have shown that collaborative care is particularly effective in people with depression and comorbid chronic physical conditions. However, only participant-level analyses can rigorously test whether the treatment effect is influenced by participant characteristics, such as chronic physical conditions.

Objective  To assess whether the effectiveness of collaborative care for depression is moderated by the presence, type, and number of chronic physical conditions.

Data Sources  Data were obtained from MEDLINE, EMBASE, PubMed, PsycINFO, CINAHL Complete, and Cochrane Central Register of Controlled Trials, and references from relevant systematic reviews. The search and collection of eligible studies was ongoing until May 22, 2015.

Study Selection  This was an update to a previous meta-analysis. Two independent reviewers were involved in the study selection process. Randomized clinical trials that compared the effectiveness of collaborative care with usual care in adults with depression and reported measured changes in depression severity symptoms at 4 to 6 months after randomization were included in the analysis. Key search terms included depression, dysthymia, anxiety, panic, phobia, obsession, compulsion, posttraumatic, care management, case management, collaborative care, enhanced care, and managed care.

Data Extraction and Synthesis  Individual participant data on baseline demographics and chronic physical conditions as well as baseline and follow-up depression severity symptoms were requested from authors of the eligible studies. One-step meta-analysis of individual participant data using appropriate mixed-effects models was performed.

Main Outcomes and Measures  Continuous outcomes of depression severity symptoms measured using self-reported or observer-rated measures.

Results  Data sets from 31 randomized clinical trials including 36 independent comparisons (N = 10 962 participants) were analyzed. Individual participant data analyses found no significant interaction effects, indicating that the presence (interaction coefficient, 0.02 [95% CI, −0.10 to 0.13]), numbers (interaction coefficient, 0.01 [95% CI, −0.01 to 0.02]), and types of chronic physical conditions do not influence the treatment effect.

Conclusions and Relevance  There is evidence that collaborative care is effective for people with depression alone and also for people with depression and chronic physical conditions. Existing guidance that recommends limiting collaborative care to people with depression and physical comorbidities is not supported by this individual participant data meta-analysis.

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Figure 1.
PRISMA Flowchart

Flowchart of the inclusion of studies in the review. IPD indicates individual participant data.

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Figure 2.
Study-Level Analysis Examining the Effect of the Presence Chronic Physical Conditions on the Effectiveness of Collaborative Care

Study-level data and pooled effects across 36 comparisons. A, Studies that did not explicitly recruit patients with chronic physical conditions. B, Studies that explicitly recruited patients with chronic physical conditions; mixed-effects model used. Weights are from random-effects analysis. ML indicates maximum likelihood.

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Figure 3.
Individual Participant–Level Analysis Examining the Effect of the Presence of Chronic Physical Conditions on the Effectiveness of Collaborative Care

Individual participant data and pooled effects across 30 comparisons. A, Studies in which participants did not have a chronic physical condition. B, Studies in which participants had a chronic physical condition. Mixed-effects model used. Weights are from random-effects analysis. REML indicates restricted maximum likelihood.

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Figure 4.
Individual Participant–Level Analysis Examining the Effect of the Number of Chronic Physical Conditions on the Effectiveness of Collaborative Care

Individual participant data and pooled effects across 30 comparisons. A, Main effect of the individual participant data analysis. B, Interaction effect of the study group and the number of physical chronic conditions. Mixed-effects model used. Weights are from random-effects analysis. REML indicates restricted maximum likelihood.

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