Implementation of Evidence-Based Practices for Complex Mood Disorders in Primary Care Safety Net Clinics

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Abstract

Introduction: Use quality improvement methods to implement evidence-based practices for bipolar depression and treatment-resistant depression in 6 Federally Qualified Health Centers. Method: Following qualitative needs assessments, implementation teams comprised of front-line providers, patients, and content experts identified, adapted, and adopted evidence-based practices. With external facilitation, onsite clinical champions led the deployment of the evidence-based practices. Evaluation data were collected from 104 patients with probable bipolar disorder or treatment-resistant depression via chart review and an interactive voice response telephone system. Results: Five practices were implemented: (a) screening for bipolar disorder, (b) telepsychiatric consultation, (c) prescribing guidelines, (d) online cognitive−behavioral therapy, and (e) online peer support. Implementation outcomes were as follows: (a) 15% of eligible patients were screened for bipolar disorder (interclinic range = 3%−70%), (b) few engaged in online psychotherapy or peer support, (c) 38% received telepsychiatric consultation (interclinic range = 0%−83%), and (d) 64% of patients with a consult were prescribed the recommended medication. Clinical outcomes were as follows: Of those screening at high risk or very high risk, 67% and 69%, respectively, were diagnosed with bipolar disorder. A third (32%) of patients were prescribed a new mood stabilizer, and 28% were prescribed a new antidepressant. Clinical response (50% reduction in depression symptoms), was observed in 21% of patients at 3-month follow-up. Discussion: Quality improvement processes resulted in the implementation and evaluation of 5 detection and treatment processes. Though varying by site, screening improved detection and a substantial number of patients received consultations and medication adjustments; however, symptom improvement was modest.

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