The MIDUS team experienced a number of challenges in successfully implementing the collaborative care model within its clinic. Insight into these challenges may help your team better prepare. Some of the challenges included:
- Patient volumes. One third of patients in our HIV clinic reported moderate to severe depressive symptoms. Over time, the volumes became difficult to manage. Optimal patient loads seems to be about 100/BHC. One strategy to consider to address increasing workloads include raising the PHQ 9 threshold for the BHCs from 10 to 15.
- Psychiatric comorbidity and addiction issues. Our process revealed a high rate of undiagnosed post-traumatic stress disorder and bipolar as well as other mental illness within this patient population. This led to a higher time investment by the BHC for each patient.
- Urban, poor population. Urban poverty adds a complex level of chaos to our patients’ daily lives. Patients would often not respond to follow-up calls, change their phone numbers frequently, often lack access to reliable transportation, and not show up for follow-up appointments.
- Stigma around mental health. Patients were often unwilling or embarrassed to discuss their mental health challenges. BHCs had to spend time to build a rapport with patients until they felt comfortable opening up.
Any clinic seeking to implement the model should be prepared for high proportions of people living with HIV to present with symptoms of depression and have the proper capacity to meet their needs.
The benefits of implementing a collaborative care model for depression outweighed the challenges. We were successful consistently screening, identifying, and re-measuring depressive symptoms in a primary care HIV clinic. While we experienced challenges, they were not insurmountable and primarily concerned issues with patient volume and clinical staff capacity. Any clinic seeking to implement the model should be prepared for high proportions of people living with HIV to present with symptoms of depression and have the proper capacity to meet their needs.