Development and Implementation of an Ambulatory Integrated Care Pathway for Major Depressive Disorder and Alcohol Dependence

In 2013, the Centre for Addiction and Mental Health (CAMH), an academic tertiary care hospital, in Toronto, Canada, embarked on an initiative to establish integrated care pathways (ICPs) for mental health and addictions treatment in a variety of clinical settings. Preliminary work included a literature review of existing published care pathways, international standards, and practice guidelines. The goal was to develop a method for ICP development that could be replicated and feasibly implemented to ensure sustainability. The ICP was implemented as a pilot with the capacity to treat up to 20 patients at the same time.

The Rationale for Integrated Care

An ICP has been defined as a “multidisciplinary outline of anticipated care, placed in an appropriate time frame to help patients move progressively through a clinical experience to positive outcomes” (1). Thus ICP is a vehicle for interdisciplinary teams to deliver evidence-based practices. Although extensively used in other areas of medicine (for example, Cancer Care Ontario [www.cancercare.on.ca]), ICPs are still rare in mental health and addictions treatment. The ICP methodology includes evidence reviews, knowledge translation, process reengineering, and change management. An ICP specifically details what to do, when to do it, and who will do it. CAMH ICPs have four key components: psychopharmacological intervention, nonpharmacological interventions, interdisciplinary collaboration, and a project management approach to implement and sustain the ICP. The outpatient ICP for major depressive disorder and alcohol dependence was designed by a group of pharmacists, nurses, physicians, psychologists, administrators, and researchers, with a process expert to coordinate the project. Best practices, both local and in the literature, were reviewed for each diagnosis, and consensus was obtained on the design elements. A patient focus group was conducted, resulting in a clear end-user-informed goal for the implementation.

There is extensive evidence of the frequent co-occurrence of major depressive disorder and alcohol dependence. A total of 2.7 million U.S. adults (1.2% of those ages 18 and older) had these co-occurring disorders in the past year (2). Despite their frequent co-occurrence, the disorders have traditionally been treated separately, and there is little evidence to guide best practice for their integrated treatment (3). Consequently, people with co-occurring disorders have poor access to specialized psychiatric treatment. Although 48.9% of those with major depressive disorder and alcohol dependence reported past-year treatment for depression, only 8.8% received specialized treatment for both disorders (3).

The need for an ICP for these co-occurring disorders arises because current guidelines provide no direction. Commonly used guidelines typically present a variety of treatment options for specific conditions. For example, major depressive disorder guidelines recommend several first-line pharmacological options, providing no guidance on how to decide among them (4). Furthermore, such guidelines do not indicate how interdisciplinary teams should coordinate treatment delivery when more than one intervention is required. The ICP provides a practical tool to deliver integrated care based on evidence and consensus.

ICP Components

Psychopharmacological Intervention

The evidence-based psychopharmacological protocol includes a limited number of choices and a titration schedule based on standardized assessments. Medication treatment begins after a phase of detoxification. For major depression pharmacotherapy, priority is given to antidepressants that have demonstrated efficacy in alcohol dependence (5) and can be safely prescribed with anticraving medications. The Texas Medication Algorithm is used to guide titration and switching of antidepressants on the basis of the Quick Inventory for Depressive Symptoms (QIDS) scores (6). The first-line antidepressant in the protocol is sertraline, given evidence of beneficial effect on alcohol consumption in combination with naltrexone (7). This option is followed by fluoxetine, venlafaxine, and mirtazapine—in that order. Pharmacotherapy options for alcohol dependence are naltrexone (first line) and acamprosate (second). Use of both is empirically supported (8). A third-line option is topiramate, an anticonvulsant medication that appears promising, although it is currently used off label for alcohol dependence (9).

Medication selection is expected to account for previous medication response and tolerance, contraindications, and side-effect profile. The protocol calls for switching in cases of intolerable side effects or absence of clinical response. Patients entering the ICP who take medications deemed effective by the treating physician are maintained on them. The pharmacist assumes the role of medication review with patients, which includes evaluation of medication history, facilitation of patient access to medications, and patient education regarding clinical expectations and potential side effects. Patients are routinely asked to describe their medication experience, including how they administer their medications. Adherence is monitored and encouraged at every visit by each team member. [Further details about the medication intervention and the ICP are provided in an online supplement to this column.]

Nonpharmacological Interventions

The ICP’s weekly individual therapy component combines empirically supported treatments for both major depressive disorder and alcohol dependence (10): motivational interviewing (11), cognitive-behavioral therapy (CBT) for acute depression (12), and a CBT-informed relapse prevention intervention for both disorders (13). Optional services include individual sessions focused on emotion regulation skills and crisis management and assistance with accessing and navigating community resources. Relapse prevention and crisis management planning are a significant component of the CBT protocol given the chronicity and high relapse rates of both conditions. Other key components, including management of cravings and identification of depressogenic cognitive styles, are emphasized as needed for each patient.

ICP Implementation in Usual Care

The final design is a 12- to 16-week algorithm that includes assessment, treatment interventions, education regarding medication adherence, and transition planning. The maximum duration of the treatment protocol is based on the length of the CBT treatment module. ICP patients have weekly individual visits with a psychologist and biweekly visits with a nurse, pharmacist, and physician. A standardized approach for regular symptom assessments with the QIDS and Penn Alcohol Craving Scale (PACS) was implemented to guide clinical decision making and provide measurement-based care. Patients with psychosis or suicidality or whose level of acuity necessitates a higher level of care are not eligible for the ICP. Potential ICP patients who are using additional substances requiring a higher level of care (for example, inpatient care or medical withdrawal management) are provided with needed treatment and reassessed for ICP reentry. Discharge planning includes transition of care to the patient’s primary care physician or referral to other outpatient services, such as an extended relapse prevention group.

Setting the Stage for Interdisciplinary Collaboration

To enhance interdisciplinary collaboration, a weekly clinical team huddle brought the team together to discuss new referrals, current patients, clinical decision making, treatment plans, concerns, and transition planning for patients ready to exit the ICP. Inclusion and engagement of frontline clinicians from the start helped the clinical team “own’” the processes they developed and created accountability for results and sustainability. This bottom-up approach has led to successful change management. Specific tools and templates, such as process maps and medication algorithm charts, were developed to encourage team adherence to the ICP. After implementation, the clinical team met monthly to discuss what was and was not working, which led to continuous improvement in ICP uptake and promoted discussions about changes to ICP processes on the basis of practical results and patient feedback.

Addressing Implementation Challenges

Building Clinical Expertise

We identified a need for nonpsychiatrist physicians specialized in addictions to develop expertise in the assessment and treatment of major depressive disorder. To meet this need, we developed a note template for the initial evaluation, which included diagnostic guidelines for the disorder and a process for conducting QIDS assessments. For highly complex cases, addiction specialists partner with the team psychiatrist for one-on-one consultation.

Referral Management and Patient Engagement

An early finding after ICP implementation was the need to clearly communicate the treatment niche for the ICP to referring parties and to ensure that potential patients understand their role and responsibilities (attendance, medication adherence, and CBT home practice). To simplify the referral process, we decided to accept only internal referrals from the hospital. This allowed us to refine referral and intake processes and develop targeted materials and disseminate them to referring parties through presentations and posters. Because the sample size was manageable, we were able to regularly monitor patient flow and clinical outcome. Once a patient was deemed eligible, engagement was conducted at the first appointment, with an explanation of the ICP, clinical team, and interventions.

Patient Eligibility

Another challenge was to ensure that patients entering the ICP were appropriate for both interventions. All referrals are screened through a chart review—by the team psychologist to ensure eligibility for the therapy component, followed by an assessment from the team physician. This assessment included all the baseline scales (QIDs, PACs, and the Alcohol Use Disorders Identification Test) and diagnostic confirmation.

Early Outcomes of the Pilot Program

The pilot program, which began in December 2013, was evaluated. Results of the evaluation suggest that ICP has enhanced access to evidence-based integrated care for patients with concurrent major depressive disorder and alcohol dependence. There is preliminary evidence that the ICP has improved treatment retention, which we have defined as the proportion of patients completing the 16-week pathway divided by the total number admitted to the ICP. A preliminary comparison of retention rates for the pathway (N=28) and for treatment as usual (N=92) conducted in August 2014 showed significantly lower dropout in the ICP cohort (46% versus 78%, p<.05). ICP’s short wait from referral to treatment (<14 days) may have contributed, because long waits may diminish motivation and lead to disengagement.

Patient satisfaction with the ICP has been high: all patients endorsed being satisfied or very satisfied with the overall care. Preliminary results also show a clinically meaningful reduction of symptoms for both depression and alcohol dependence. ICP patients experienced a significant reduction in depressive symptom severity on the basis of QIDS and Beck Depression Inventory and a reduction in the percentage of heavy drinking days (from 42% to 23%, p<.04). No significant changes in severity of cravings, number of drinking days per week, and drinks per drinking day were observed between the start and end of treatment [see online supplement].

Conclusions

Results suggest that the ICP is a feasible and potentially effective approach to treat concurrent major depressive disorder and alcohol dependence at an academic tertiary care hospital. On the basis of the pilot findings, the clinical team and hospital management are developing a strategy for increasing treatment capacity within the ICP. The growth strategy will include incorporating a group CBT option, building treatment capacity by recruiting additional clinical staff and training nonpsychologists to deliver the CBT protocol, growing the ICP through other clinical programs in the hospital, and beginning to accept external referrals. Further research, including implementation in a variety of settings, is required to establish expanded applicability and effectiveness.