March 03, 2020
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Telemedicine intervention plus integrated care improves outcomes of veterans with depression

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A telephonic work-focused counseling program added to integrated care improved veterans’ psychiatric and occupational outcomes, which reduced obstacles in civilian life, according to findings of a randomized clinical trial published in JAMA Network Open.

“Facilitating reentry and reintegration into civilian life are high-priority goals within the Department of Veterans Affairs, and many employers want to hire veterans and be assured that they will function effectively in the workplace,” Debra Lerner, MSc, PhD, senior scientist at Tufts Medical Center Institute for Clinical Research and Health Policy Studies in Boston, and colleagues wrote. “Depression and difficulty functioning in occupational roles and settings pose significant barriers to achieving success. Building telephonic work-focused care into [integrated care] offers a holistic, accessible and economical solution.”

The Veterans Health Administration (VHA) is responsible for the largest health care system in the U.S., in which approximately 7% of patients meet criteria for major depressive disorder. Of patients visiting VHA primary care clinics, 13.5% have depressive symptoms. Research has shown that veterans with depression have increased rates of unemployment and more functional deficits and work absences compared with veterans without depression.

Lerner and colleagues tested whether integrated telephonic work-focused counseling, known as Be Well at Work (BWAW), combined with the VHA integrated care program is superior to integrated care alone for improving depression and occupational functioning. Specifically, they sought to determine whether these effects persist 4 months later and whether the return on investment is positive. To do so, they screened patients undergoing integrated care at VHA facilities for eligibility and randomly assigned them to integrated care alone or integrated care plus BWAW. Before the intervention and 4 and 8 months after its completion, blinded interviewers administered the Work Limitations Questionnaire and the Patient Health Questionnaire, which included nine items assessing symptom severity. Participants were aged 18 years or older, worked at least 15 hours per week in a job they had held for at least 6 months, experienced work limitations and had current MDD or persistent depressive disorder. The researchers excluded individuals who could not read or speak English, had planned maternity leave or had a history of bipolar disorder or psychosis.

The study included 253 veterans (mean age, 45.7 years; 86.2% men; 53.4% white) randomly assigned to integrated care (n = 114; 45.1%) or integrated care plus BWAW (n = 139; 54.9%). Veterans who received integrated care plus BWAW experienced greater reductions in at-work productivity loss (adjusted effect = 1.7; 95% CI, 3.1 to 0.4) and depression symptom severity (adjusted effect = 2.1; 95% CI, 3.5 to 0.7) at the 4-month follow up. Improvements from the combined intervention persisted 4 months after completion (at-work productivity loss mean difference = 0.5; 95% CI, 1.9 to 0.9; depression symptom severity mean difference = 0.6; 95% CI, 0.9 to 2.1). The return on investment for BWAW was 160%, with the cost per patient totaling $690.98.

“As the VHA invests in telemedicine to address access barriers, BWAW’s telephone-based counseling provides a further opportunity to make higher-quality care more accessible to veterans,” the researchers wrote. – by Joe Gramigna

Disclosures: Lerner reports being a co-developer of BWAW and being employed by Health and Productivity Sciences, which may eventually distribute the intervention, as well as owning stock in Mylan. Please see the study for all other authors’ relevant financial disclosures.