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. Author manuscript; available in PMC: 2023 Mar 1.
Published in final edited form as: Fam Syst Health. 2021 Nov 4;40(1):35–45. doi: 10.1037/fsh0000637

Depression complexity prevalence and outcomes among Veterans Affairs patients in integrated primary care

Duncan G Campbell 1, Anayansi Lombardero 2, Ivie English 1, Thomas J Waltz 3, Katherine J Hoggatt 4, Barbara F Simon 4, Andrew B Lanto 4, Alissa Simon 4, Lisa V Rubenstein 4,5,6, Edmund F Chaney 7
PMCID: PMC8940635  NIHMSID: NIHMS1729357  PMID: 34735212

Abstract

Introduction:

The Veterans Health Administration (VA) Primary Care-Mental Health Integration (PC-MHI) initiative targets depression (MDD), anxiety/PTSD, and alcohol misuse (AM) for care improvement. In primary care, case finding often relies on depression screening. Whereas clinical practice guidelines solely inform management of depression, minimal information exists to guide treatment when psychiatric symptom clusters coexist. We provide descriptive clinical information for care planners about VA PC patients with depression alone, depression plus alcohol misuse, and depression with complex psychiatric comorbidities (PTSD and/or probable bipolar disorder).

Methods:

We examined data from a VA study that used a visit-based sampling procedure to screen 10,929 VA PC patients for depression; 761 patients with probable major depression completed baseline measures of health and care engagement. Follow-up assessments were completed at seven months.

Results:

At baseline, 53% of patients evidenced mental health conditions in addition to depression; 10% had concurrent AM, and 43% had psychiatrically complex depression (either with or without AM). Compared to patients with depression alone or depression with AM, those with psychiatrically complex depression evinced longer standing and more severe mood disturbance, higher likelihood of suicidal ideation, higher unemployment, and higher levels of polypharmacy. Baseline depression complexity predicted worse mental health status and functioning at follow-up.

Discussion:

A substantial proportion of VA primary care patients with depression presented with high medical multimorbidity and elevated safety concerns. Psychiatrically complex depression predicted lower treatment effectiveness, suggesting that PC-MHI interventions should coordinate and individualize care for these patients.

Keywords: Depression Complexity, Primary Care, Integrated Behavioral Health, Collaborative Care

Introduction

Depression is common and debilitating. Twelve-month prevalence estimates approach 7% of the US general population, and nearly 17% of persons will experience a major depressive episode in their lifetimes (Center for Behavioral Health Statistics and Quality, 2016; Kessler et al., 2003). Despite its prevalence and functional impact, depression remains undertreated (Hockenberry, Joski, Yarbrough & Druss, 2019). Approximately 33% of people with depression receive no care at all (CBHSQ, 2016), and estimates of mental health care adequacy are even lower (Kessler et al., 2003, Wang et al., 2005). Indeed, most mental health treatment is provided in primary care (PC), a setting in which inadequate mental health care is common (Castro-Rodriguez et al., 2015; Duhoux, Fournier & Menear, 2011).

In 2007, VA implemented a system-wide effort to improve Veterans’ health (Post et al., 2010). The Primary Care-Mental Health Integration (PC-MHI) initiative mandated specific mental health management strategies, including depression collaborative care management (CCM) (e.g., Rubenstein et al., 2010; Tew, Klaus & Oslin, 2010), an approach that outperforms PC-based depression treatment-as-usual (Chaney et al., 2011; Gilbody et al., 2006; Simon, 2009). VA PC patients often present with high psychiatric burden and relatively high rates of posttraumatic stress disorder (9.3%), substance use disorder (8.3%), and anxiety (4.8%), conditions that co-occur frequently (Trivedi et al., 2015).

While some work suggests that CCM effectiveness is greater among patients with more severe illness (Miller et al., 2013), mounting evidence highlights the need for CCM to attend to multiple health conditions concurrently (Lin et al., 2014). At present, it is unclear how to optimize CCM across diverse groups of patients who present with different clinical problems. Some CCM patients remain symptomatic or respond partially, and CCM effect sizes vary across treatment settings (Thota, et al., 2012). These circumstances may be due, in part, to patient heterogeneity, high psychiatric burden or chronicity, and/or complexity (Woltmann, Grogran-Kaylor, Perron, Georges, Kilbourne & Bauer, 2012). The Vector Model of complexity asserts that patients vary along multiple interacting dimensions of experience (Safford, Allison & Kiefe, 2007), including multimorbidity, ethnic minority status, psychosocial circumstances, environmental considerations, and socioeconomic status. Patients with more active and intersecting vectors have higher complexity and may necessitate different treatment approaches (Baker, Grant & Gopalan, 2018; Safford et al., 2007).

The existing knowledge base provides minimal guidance for CCM adaptations to account for patient heterogeneity and psychiatric complexity. VA patients with depression are often more severely ill and have more co-occurring psychiatric concerns compared to CCM populations studied outside the VA (e.g., Jakupcak et al., 2010; Stecker, Fortney, Owen, McGovern, & Williams, 2010). Because VA PC settings identify patients for CCM through routine depression screening, accurate complexity prevalence estimates and information about outcomes associated with it are essential.

The present study has three aims. First, we estimate the prevalence of depression complexity within a representative sample of VA PC patients. Second, we provide descriptive information about clinical and care engagement differences for depressed patients with additional psychiatric symptoms versus those without them. Finally, we test whether depression complexity at baseline predicts patients’ engagement with specialty mental health care and their functional mental health status over time. We hypothesized that our representative sample of VA PC patients with depression would include many patients with complicated presentations and that psychiatric complexity would predict worse functional status longitudinally, even after accounting for specialty mental health care engagement.

To achieve these aims, we present secondary analyses of data from the Well-being Among Veterans Enhancement Study (WAVES), a group randomized-controlled trial of VA depression CCM. Our work builds on an earlier baseline analysis of the prevalence of Depression-PTSD comorbidity among WAVES participants (Campbell et al., 2007). We advance existing work by conceptualizing depression complexity, and by examining its correlates and predictive relationships with seven month clinical outcomes. Additionally, patients with probable bipolar disorder, excluded from earlier analyses, were included in the present analysis as part of the psychiatrically complex depression group.

Methods

WAVES participants included 761 clinically representative PC patients with major depressive symptomatology from ten VA PC clinics across five geographically diverse states (Florida, Ohio, South Dakota, Texas, and Wisconsin). Seven sites were community-based outpatient clinics, and three were in medical centers. Two medical centers and one community clinic were in rural settings; the remaining sites were in metropolitan areas. The sites included teaching and non-teaching clinics. They employed 4–13 PC providers, and served 3,900–13,000 patients (Chaney et al., 2011; Fickel et al., 2009). The present sample included all WAVES participants, collapsed across the original study’s intervention (CCM) and usual care arms. Institutional Review Boards at participating VA clinics, VA Greater Los Angeles, and the University of Washington approved all study procedures.

Participants

WAVES recruited participants using visit-based sampling, minimal exclusion criteria (see Chaney et al., 2011), and commonly used depression screening measures (Patient Health Questionnaire-2 and −9 [PHQ-2/PHQ-9]: Kroenke, Spitzer & Williams, 2001). Using administrative databases, project personnel first identified patients with a previous year PC visit to a study clinic and a scheduled upcoming visit. In 2003 and 2004, highly trained contracted data collection personnel telephoned potential participants, obtained oral informed consent, and initiated depression screening. Of the 10,929 contacted patients, 2,195 (20%) screened positive on the PHQ-2, and 2,122 agreed to complete the full PHQ-9. Using an established cut-off score, 1,313 patients (12% of those contacted) met the WAVES inclusion criterion for probable major depression. Ultimately, 58.0% of these eligible patients completed the baseline assessment, a 50-minute computer-assisted telephone interview about health status, psychiatric experiences, medication use, health care engagement, and related issues. Consistent with the study’s safety management plan, patient reports of potential harm to self or others initiated structured risk evaluation by data collection personnel (see Campbell et al., 2011). Patients with active harm ideation were evaluated immediately by study clinicians and referred to local VA care resources when necessary. For safety reasons, approximately 4% of the eligible patients were excluded from study participation at baseline due to acute suicidal intent (Campbell et al., 2011; Chaney et al., 2011). Five-hundred and forty-six (72% of baseline) patients provided seven month follow-up data in 2004 and 2005.

Measures

Demographic Characteristics.

Demographic information included gender, age, race/ethnicity, relationship status, education, and employment status.

Clinical Characteristics.

General health.

Patients responded to a general health question (Kazis et al., 1999: “In general, would you describe your health as…?”) with five options ranging from “poor” to “excellent.” Responses were dichotomized to “good” or better versus “fair” or worse.

Chronic illness.

Patients reported past/current diagnoses of seven health conditions (e.g., cancer, diabetes, congestive heart failure) from the Seattle Index of Comorbidity, a case-mix measure (Fan et al., 2002).

Depression and depression qualifiers.

The PHQ–9 assessed the two-week frequency of nine major depressive episode (MDE) symptoms (Kroenke et al., 2001). The PHQ-9 sum score reflected depressive severity at baseline. The last PHQ-9 item assessed frequency of thoughts about suicide/self-harm. Any response to this item other than “not at all” indicated the presence of suicidal ideation (SI). Two questions from a previous depression care quality improvement study (Rubenstein et al., 2002) assessed depression chronicity. Patients screened positive for chronic depressed mood if they reported persistent depression/sadness on most days for at least two years without remission of two months or more.

General anxiety and panic.

Patients indicated general anxiety with a ‘yes’ response to a question about whether they felt anxious most of the time during the previous six months. Presence of panic required a report of a past month panic attack plus panic-related anticipatory anxiety.

Mental health functional status.

The Mental Health Inventory-5 (MHI-5; Ware, Snow & Kosinski, 2000) provided an indicator of mental health status at seven months. It included five questions about the frequency of feelings of happiness, calm and peacefulness, depression and nervousness over the previous month. Responses were standardized, with a possible range from 0 to 100 (poorest to best mental health) (Ware et al., 2000).

Psychiatric comorbidity.

Posttraumatic Stress Disorder (PTSD).

The Primary Care-PTSD Screen (PC-PTSD: Prins et al., 2003) assessed the prior month presence of four PTSD symptoms. Each present symptom added a point to the PC-PTSD sum score; consistent with previous sensitivity and specificity analyses, scores of three and greater identified PTSD (Prins et al., 2003).

Alcohol misuse (AM).

The Alcohol Use Disorders Identification Test–Consumption questions (AUDIT-C: Bush et al., 1998; Bradley et al., 2007) assessed frequency of alcohol consumption, the number of drinks typically consumed, and the frequency of over-consumption. Possible AUDIT-C scores ranged from 0–12. Because scores ≥ 5 initiate brief intervention for AM in VA PC (Lapham et al., 2012), we used this threshold to identify AM in the present study.

Probable Bipolar Disorder.

Probable bipolar disorder was identified when patients indicated that a doctor had previously said that they had a “…bipolar or manic-depressive illness” and when they reported that they had previously “…taken the medications lithium, Depakote or Tegretol for a depressive illness.”

Complex Depression.

Combinations of the PTSD, AM, and probable bipolar indicators composed a three-level depression complexity variable. Patients with ‘depression only’ screened positive only for probable major depression at baseline. Patients in the ‘depression and AM’ group had major depression and met the screening threshold for AM, but did not have PTSD and/or probable bipolar disorder. Irrespective of AM, which could be present or absent, patients with ‘psychiatrically complex depression’ had depression plus PTSD and/or bipolar disorder.

Health Care Engagement and Care Quality.

Mental health service use.

Patients provided self-reports of in-person or phone visits in the previous six months with a mental health specialist (i.e., psychiatrist, psychologist, social worker, or mental health nurse).

Medication use.

Patients described their past six month general medication use and medication use “…specifically for mental or emotional problems, such as depression, manic-depression, anxiety, nerves, alcohol or drug abuse.” Survey administrators asked for specific names of all medications and encouraged patients to read this information from the medications’ containers (80% of patients did so). A double-boarded psychiatrist and internal medicine specialist coded each medication by class.

Appropriate depression care.

Following previous research (Wells et al., 2000), we defined minimally appropriate depression care as four or more visits with a mental health specialist in the previous six months and/or adherence to an antidepressant prescription for at least 25 days in the previous month. The appropriate depression care variable was dichotomized.

Analyses

We incorporated patient-level weights to adjust for survey non-response and to generate estimates representative of the sampling frame. At baseline, we used ANOVA to test for cross-sectional group differences for continuous measures, and chi-square statistics to test differences for categorical variables. Prospective analyses of treatment and mental health status at seven months employed logistic and linear regression, respectively. The statistical significance threshold was p=0.05.

Results

Table 1 presents demographic, clinical and care engagement characteristics for the sample overall and for groups of patients with depression only, depression and AM, and complex depression. Overall, the sample mostly comprised White men who averaged 60 years old (SD=12). About half reported some education beyond high school, and 60% were married or living as married. Only 20% reported ‘good’ or better general health. Likewise, chronic health conditions were prevalent; 15% of participants reported a past stroke, and 37% described having chronic lung disease. Furthermore, 36% reported a history of pneumonia, 35% reported diabetes, and 28% reported a prior heart attack. Psychiatric burden was similarly high. Nearly one third of all participants reported suicidal ideation, 27% described chronic depression, 16% screened positive for panic, and 64% described high general anxiety.

Table 1.

Illness complexity and care characteristics by psychiatric comorbidity: Comparisons of patients with depression only, depression with alcohol misuse, and complex depression.

Diagnostic Grouping
Characteristic* All (N=761) Depression only (358: 47.0%) Depression and alcohol misuse (78: 10.3%) Complex Depression (325: 42.7%) p-value
Demographic characteristics at baseline
 Age (SD)** 60.3 (11.9) 64.9a (12.3) 57.5b (9.5) 56.0b (10.0) <.001
 Gender (% male) 94.0 94.4 97.4 92.6 .244
 Race/ethnicity (% minority) 16.8 12.1 20.5 21.0 .005
 Education (% some college/more) 50.6 45.3 47.4 57.2 .006
 Employment (% employed) 17.0 16.5 23.1 16.1 <.001
 Relationship (% married/living as married) 60.1 64.8 50.0 57.2 .021
Clinical characteristics at baseline
 Health (% good or better) 19.6 19.0 26.9 18.5 .226
 Chronic illnesses (% yes)
  Cancer 17.7 19.3 15.4 16.4 .531
  Pneumonia 36.3 36.1 31.2 37.7 .566
  Chronic Lung Disease 36.9 34.8 39.7 38.5 .531
  Diabetes 34.7 37.4 25.6 33.8 .127
  Stroke 15.3 16.5 15.6 14.0 .653
  Heart Attack 28.2 32.7 32.1 22.5 .009
  Congestive Heart Failure 18.1 22.3 16.0 13.9 .016
 Depression severity (PHQ-9 M, SD)** 15.8 (4.3) 14.7a (3.8) 15.0a (3.7) 17.3b (4.4) <.001
 Suicidality (% yes) 31.7 22.4 23.1 44.3 <.001
 Chronic depression/Dysthymia (% yes) 27.2 14.0 30.8 40.8 <.001
 Panic screener: n (% yes) 16.3 4.5 6.4 31.7 <.001
 Anxious much of the time: n (% yes) 64.0 49.4 62.8 80.3 <.001
Diagnostic Grouping
Characteristic* All (N=761) Depression only (n=358) Depression and alcohol misuse (n=78) Complex Depression (n=325) p-value
Care at Baseline
 Medication use:
  Number, all meds (Ms, SDs) 6.9 (5.5) 7.1 (5.9) 5.6 (4.3) 6.9 (5.3) .070
  Use for mood/emotion (% yes) 55.3 41.9 35.9 74.7 <.001
  Number, meds for mood/emotion (Mean, sd)**† 2.0 (1.2) 1.6 (1.1)a 1.8 (0.9)ab 2.3 (1.3) b <.001
  Use by class†† (% yes)
   Antidepressant 43.0 32.1 28.6 58.7 <.001
   Anxiolytic (Buspirone/Hydroxyzine) 5.4 3.3 2.6 8.5 .007
   Benzodiazepine 16.6 11.9 14.3 22.3 .002
   Hypnotic (Zolpidem/trazodone) 9.5 3.9 7.8 16.1 <.001
   Mood Stabilizer (Li/anticonvulsant) 7.7 2.4 0.0 15.4 <.001
   Antipsychotic 9.3 2.1 5.2 18.4 <.001
 MH Specialist visit, prior 6 mos††† (% yes) 45.1 27.0 28.6 69.0 <.001
Prospective analyses
 7-month follow-up N=546 N=261 n=53 n=232
  Appropriate depression care (% yes) 49.5 37.2 34.0 66.8 <.001
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Note: Complex depression comprises Depression plus PTSD (n=202, 26.5%), Depression plus PTSD and Alcohol Misuse (n=46, 6.0%), Probable Bipolar Disorder (n=25, 3.3%), Probable Bipolar Disorder plus PTSD (n=38, 5.0%), Probable Bipolar Disorder plus PTSD and Alcohol Misuse (n=8, 1.1%), and Probable Bipolar Disorder plus Alcohol Misuse (n=6, 0.8%)

*

Tests of significance include X2 statistics for categorical data and ANOVAs with Scheffe’s method for continuous data

**

Means that do not share a superscript differ (p<.05) on post hoc testing

†

383 participants reported use of medications for mood or emotional problems

††

Due to missing data percentages reflect total of 719 participants

†††

Due to missing data percentages reflect total of 756 participants

Participants reported taking seven medications on average and two specifically for mood/emotion. More than half of participants endorsed medication use for mood/emotions. Antidepressants were the most common psychiatric medication (43%); 17% of the sample reported benzodiazepine use. Nearly half of the sample (45%) reported mental health (MH) specialty visits within the last six months.

Psychiatric comorbidity was prevalent at baseline. Ten percent reported depression and AM. Forty-three percent of participants had complex depression, including patients with depression plus PTSD (n = 202, 27%), depression plus PTSD and AM (n = 46, 6%), probable bipolar disorder (n = 25, 3%), probable bipolar disorder plus PTSD (n = 38, 5%), probable bipolar disorder plus PTSD and AM (n = 8, 1%), and probable bipolar disorder plus AM (n = 6, 1%). Depression was more severe, and suicidal ideation was more likely among the patients with complex depression. These patients were also more likely to report depression chronicity, anxiety, and panic than those with depression only or depression and AM. Additionally, relative to those with depression only, patients with psychiatrically complex depression were younger, less likely to be employed, and more likely to report use of multiple psychiatric medications, including benzodiazepines, mood stabilizers, antipsychotics and sleep medications.

Table 1 describes patients’ engagement with MH specialists, as well as minimally appropriate depression care at 7-months. About half of all participants received at least minimally appropriate depression care at follow-up. This differed significantly among groups, as 67% of those with complex depression reported appropriate depression care (versus 37% of depression only and 34% of depression + AM; p < .001). Approximately 25% of all patients at 7-months (data not shown) reported suicidal ideation that warranted structured suicide risk management assessment, urgent intervention, and/or referral to local care providers (Campbell et al., 2011).

The logistic regression in Table 2 predicts minimally appropriate care at the 7-month follow-up as a function of baseline depression complexity and controlling for general health status and demographics. Relative to patients with depression only, patients with psychiatrically complex depression at baseline were two and half times more likely to report minimally appropriate care 7 months later. Finally, Table 3 presents a linear regression that predicted functional mental health status at the 7-month follow-up. Controlling for receipt of minimally appropriate depression care, recent specialty mental health provider engagement, and baseline differences among the diagnostic groups, patients with complex depression evidenced significantly worse mental health status (MHI-5) over time than patients with depression alone.

Table 2.

Predictors of minimally appropriate care at seven month follow-up (n=543).

Criterion = Appropriate depression care at seven month follow-up
Predictor Variables Odds Ratio 95 % CI P-value
 Age (in years) 0.95 0.94–0.97 <.001
 Ethnicity (nonminority=0 v. minority=1) 0.62 0.37–1.06 .079
 Employment (not employed=0 v. employed=1) 0.96 0.59–1.57 .873
 Relationship status (not partnered=0 v. partnered=1) 1.56 1.06–2.30 .024
 Education (high school/less=0 v. some college/more=1) 1.28 0.88–1.85 .196
 General health (poor/fair=0 v. good or better=1) 0.93 0.58–1.49 .764
 Diagnostic status at baseline:
  Depression Only REF
  Depression + Alcohol Misuse 0.71 0.37–1.36 .300
  Complex Depression 2.53 1.69–3.80 <.001
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Notes: χ2=84.5, df=8, p<.001

Table 3.

Predictors of mental health status at seven month follow-up (n=540).

Criterion = Mental Health Inventory – 5 (MHI-5)
Predictor Variables B SE B P-value
Step 1*: Covariates
 Age (in years) 0.50 0.09 <.001
 Ethnicity (nonminority=0 v. minority=1) 2.26 2.66 .397
 Employment (not employed=0 v. employed=1) 1.75 2.54 .492
 Relationship status (not partnered=0 v. partnered=1) 1.41 1.97 .473
 Education (high school/less=0 v. some college/more=1) 3.44 1.91 .072
 General health (poor/fair=0 v. good or better=1) 3.46 2.36 .143
Step 2**
 Age (in years) 0.18 0.09 .038
 Ethnicity 2.05 2.49 .412
 Employment −0.35 2.37 .883
 Relationship status 1.99 1.83 .278
 Education 5.75 1.79 .001
 General health 4.71 2.20 .033
 Appropriate depression care between baseline and 7-month follow-up (no = 0 v. yes = 1) −2.87 2.05 .161
 Mental Health Specialist engagement between baseline and 7-month follow-up (no = 0 v. yes = 1) −4.96 2.18 .024
 Diagnostic status at baseline:
  Depression Only REF
  Depression + Alcohol Misuse −3.17 3.08 .303
  Complex Depression −14.70 2.10 <.001
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Notes:

*

R2 = .07, F(6, 533) = 6.66, p <.001

**

ΔR2 = .14, F(10, 529) = 13.77, p < .001.

Discussion

We recruited the present sample with minimal exclusion criteria in order to maximize its clinical representativeness and ecological validity. Thus, we think our findings are relevant to clinical care planners working with VA PC patients with depression. Our findings may also be relevant for other health care systems as they serve an expanding population of complex patients (Moffat & Mercer, 2015; Ornstein et al., 2013).

As anticipated, complexity was prevalent. Psychiatric comorbidities were quite common among our sample of typical VA PC patients with depression. As hypothesized, there were important clinical and care differences for patients across complexity groups. In patients with complex depression, mood disturbance was more chronic, more severe, and considerably more likely to include suicidal ideation; anxiety and panic were also more common. Nearly three quarters of patients with psychiatrically complex depression reported medication use for mood or emotion regulation. Relative to patients with depression only, they reported greater use of antidepressants, hypnotics, mood stabilizers, and antipsychotic medications. Over one-fifth of patients with depression and alcohol misuse and a quarter of patients with complex depression reported taking benzodiazepines, drugs that are contraindicated among older adults (American Geriatrics Society, 2015) and can increase risk of serious outcomes (hospitalization and/or death) when combined with alcohol use (Day, 2014). Finally, almost half of patients with complex depression reported recent or current thoughts about suicide at baseline.

Our findings also supported the hypothesis that psychiatrically complex depression among VA PC patients would predict worse outcomes over time, even after controlling for care engagement. On one hand, it appears that the VA PC system responds to patients with particularly difficult presentations and connects many with MH specialists. It remains concerning, however, that many patients do not receive targeted care and that many patients with complex depression remain less well-off over time, even when this care is provided. Finally, even though participants with psychiatrically complex depression were more likely to receive treatment that met our definition of minimally appropriate depression care (Wells et al., 2000), this does not necessarily mean that this care was adequate.

Whereas current VA initiatives target depression, anxiety/PTSD, and AM for care improvement within PC, depression clinical practice guidelines and CCM protocols do not provide explicit guidance for complicated depression presentations. Based on our findings, we suggest that standard PC-based approaches to care for VA patients with complex depression may require augmentation, enhanced PC-MH collaboration, and/or additional patient-specific problem-solving. For example, we found that employment among patients with complex depression was quite low, even though these patients were pre-retirement age on average. Because employment and depressive mood vary over time in a bidirectional manner (Zivin et al., 2012), including employment support within depression CCM may help patients with complex depression achieve better outcomes. For example, care managers could assess patients’ employment status and satisfaction with work. Care managers could then help unemployed or underemployed patients connect with employment support resources (e.g., vocational rehabilitation; social work service) within the health care system or with similar resources in the community. Consistent with recommendations reported elsewhere (e.g., Czypionka et al., 2020), care managers could also expand their focus in other relevant areas for psychiatrically complex patients. Social isolation may be higher among patients with depression and concurrent PTSD, for example, and care managers can help patients reestablish important social connections and identities, with potential to benefit mood (Russell & Russell, 2018). Additionally, care managers can communicate with patients about their preferences for involving family members and/or partners in care (Bolkan et al., 2013)

In addition to expanding care managers’ focus, we suggest revisiting what care coordination looks like for psychiatrically complex patients. We believe care managers can reinforce treatment occurring in MH specialty settings. Consider a patient taking an antidepressant who is working concurrently on behavioral activation in psychotherapy. With knowledge of the MH treatment plan and regular collaborative communication with the psychotherapist, care managers could help patients achieve the benefit of concurrent somatic and psychotherapeutic treatments. Consistent with recommendations made elsewhere (Campbell et al., 2018), this would require MH specialists to prioritize connections with care managers, share MH treatment plans, and provide regular progress updates.

Our work among VA PC patients mirrors findings from non-VA PC settings that document the prevalence and impact of multimorbidity among older patients (Gallo et al., 2015). VA researchers and others should continue to study the benefits of PC-based intensive care coordination for complex patients, with the goal of maintaining many of them in primary care. This suggestion is consistent with existing research that highlights the positive impact on depression treatment adequacy of teamwork with PC-based providers who focus specifically on MH concerns (Menear et al., 2015) and calls for multifaceted treatment plans that target multimorbidity explicitly (Funderburk et al., 2018).

Questions about how to maximize outcomes for complex patients in CCM and other models of PC-MHI should be pursued in future research. This work needs to examine factors of patient complexity beyond our psychiatric symptom definition and should also attend to some of the issues (employment, social support, closer collaboration) we mentioned above. Future research will improve our understanding of the effects of various combinations of psychiatric circumstances, chronic disease, and psychosocial factors on patients and their treatment outcomes.

Limitations

The present study has limitations. First, the data were collected during 2003–2005, using a resource intensive visit-based sampling method designed for high ecological validity. VA PC patient population characteristics change over time (Eibner et al., 2015). Generalization of our findings to present patient populations and health care systems outside VA should be done with caution. Second, our operational definitions of depression complexity were established with screening measures that are used commonly in clinical practice. The possibility exists that some patients with ‘screening diagnoses’ were misidentified and would not meet full diagnostic criteria in a formal clinical evaluation. Finally, as noted previously, ‘patient complexity’ comprises many factors, such as chronic illness multimorbidity, psychosocial circumstances, and psychiatric burden. For this study, we restricted our analysis to psychiatric complexity within individuals with depression.

Acknowledgments

This work was supported by funding from the Department of Veterans Affairs Health Services Research and Development Service (HSR&D) and the VA Quality Enhancement Research Initiative (QUERI) (Project nos. MHI 99-375, MNT 01-027, MHQ 10-06, RRP 12-175). The views we express are our own and do not necessarily represent the position or policy of the Department of Veterans Affairs, the United States Government, or the authors’ respective institutions.

Footnotes

We have no known conflicts of interest to disclose.

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