Improving mental and physical health outcomes in general healthcare ...

General Hospital Psychiatry 37 (2015) 375–386

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Improving mental and physical health outcomes in general healthcare settings: a Gedenkschrift in honor of Wayne Katon, MD (1950–2015)☆,☆☆ Dimitry S. Davydow, M.D., M.P.H. a,⁎, Jodie G. Katon, Ph.D. b,c,d, Bruce L. Rollman, M.D., M.P.H. e, Jürgen Unützer, M.D., M.P.H., M.A. a a

Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, WA, USA U.S. Department of Veterans Affairs (VA) Puget Sound Health Care System Health Services Research and Development, Seattle, WA, USA VA Office of Patient Care, Women’s Health Services, Washington, DC, USA d Department of Health Services, University of Washington, Seattle, WA, USA e Division of General Internal Medicine, Center for Research on Health Care, University of Pittsburgh, Pittsburgh, PA, USA b c

a r t i c l e

i n f o

Article history: Received 15 July 2015 Accepted 16 July 2015 Keywords: Mental and physical health outcomes General healthcare settings Wayne Katon Depression Primary care

a b s t r a c t This special article pays tribute to Wayne Katon, MD (1950–2015) with a Gedenkschrift, or review, of his prolific academic career. Abstracts of all of Dr. Katon's Medline citations were reviewed to develop a narrative of his seminal epidemiological and interventional research findings. Specifically, we describe: (a) how Dr. Katon's clinical work and observational epidemiology and health services research informed and guided interventional studies; (b) the evolution of multidisciplinary interventional trials from primary care-based psychiatric consultation to primary care-based collaborative care for depression to multicondition collaborative care; and (c) how Dr. Katon's research has informed the work of other leading researchers in the field of psychosomatic medicine and helped develop a new generation of researchers at the interface of psychiatry and primary care. For more than three decades, Dr. Katon led a multidisciplinary research team that conducted seminal epidemiological studies and randomized trials and that influenced the thinking and research in the field of psychiatry in a number of areas: (a) the importance and impact of mental disorders presenting in primary care settings and (b) the organization of effective multidisciplinary care for primary care patients with common mental disorders and comorbid medical conditions. Dr. Katon's work revolutionized the care of psychiatric illnesses in primary care and other medical care settings to the benefit of countless patients worldwide. © 2015 Elsevier Inc. All rights reserved.

1. Introduction Few researchers have had as profound an impact on science in the field of psychosomatic medicine as Dr. Wayne Katon. He began his research career at a time when our field had just begun to recognize that the majority of patients with psychiatric illnesses were not receiving any treatment [1], and that more than half of all treatment for psychiatric illnesses was provided in primary care settings rather than by psychiatrists in specialty mental healthcare settings [2]. However, little rigorous research was available on the epidemiology of common psychiatric illnesses presenting in primary care and other nonpsychiatric medical settings. Further, almost no evidence-based interventions were available to effectively address psychiatric illnesses within these healthcare settings [3].

☆ Funding: This work was done without the support of external funding. ☆☆ Disclosures: The authors have no relevant conflicts of interest to disclose. ⁎ Corresponding author at: Department of Psychiatry and Behavioral Sciences, University of Washington School of Medicine, Box 356560, 1959 NE Pacific St., Seattle, WA, 98195. Tel.: +1-206-543-1605; fax: +1-206-221-5414. E-mail address: [email protected] (D.S. Davydow). http://dx.doi.org/10.1016/j.genhosppsych.2015.07.005 0163-8343/© 2015 Elsevier Inc. All rights reserved.

Over the course of his career, Dr. Katon and his research team revolutionized this field of research. In his over 35 years as a member of the faculty of the Department of Psychiatry and Behavioral Sciences at the University of Washington, he published over 500 articles, many of them highly cited. His research team and he were awarded numerous National Institutes of Health grants, and he established a Division of Health Services and Psychiatric Epidemiology at the University of Washington that became internationally renowned for its research [4]. Festschrift is a German word referring to a tradition in academia where a respected academic is honored with a tome reviewing their academic career and accomplishments, generally presented to them by their colleagues, mentees and trainees upon retirement [5]. When such a publication is compiled posthumously, it is referred to as a Gedenkschrift [5] and serves as a lasting memorial. Few scholars in psychosomatic medicine would be more worthy of a Festschrift than Dr. Katon. Sadly, Dr. Wayne Katon passed away on March 1, 2015 at the age of 64 after a long battle with lymphoma, active and engaged with his many colleagues and friends to the day of his untimely death. The current paper is a Gedenkschrift honoring his prolific academic career. In addition to memorializing Dr. Katon's scholarly work and honoring his legacy, an important objective of this paper is to review the landmark epidemiological and interventional studies that he

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and his research team conducted and inspired. Specific points of emphasis in this review include: (a) how Dr. Katon’s clinical work and observational epidemiology and health services research informed his intervention studies; (b) the evolution of the interventional trials conducted by his research team from primary care-based psychiatric consultation to primary care-based collaborative care for depression to multicondition collaborative care; and (c) how Dr. Katon's research has informed the academic work of other leading researchers in the field of psychosomatic medicine. In order to complete this Gedenkschrift, we reviewed the abstracts of all 547 Medline citations authored or coauthored by Dr. Katon (as of June 28, 2015). We identified articles presenting original epidemiological research and/or the results of interventional trials as well as review papers of importance to the foundation of original research authored or coauthored by Dr. Katon. We included articles in this Gedenkschrift that were deemed seminal in the field of psychosomatic medicine by consensus of all authors. In addition, the first author (DSD) solicited additional information from coauthors who collaborated with Dr. Katon regarding key aspects of the background of important studies. In addition, we reviewed landmark studies directly informed by Dr. Katon's work conducted by his mentees and/or colleagues. As points of reference, the paper is organized chronologically. Papers presenting the results of key epidemiological and interventional studies authored or coauthored by Dr. Katon are summarized in Tables 1 and 2. 2. Depression, somatization and the emergence of primary care psychiatry (1980–1995) Dr. Katon's initial academic work focused on understanding the relationship of somatization with depression and on increasing awareness by nonpsychiatric physicians that patients with depression often present with somatic symptoms. This research, initiated under the mentorship of Dr. Arthur Kleinman at the University of Washington, was largely shaped by Dr. Katon's clinical work as a consultation–liaison psychiatrist [6]. In a two-part review published in 1982, Drs. Katon, Kleinman and Dr. Gary Rosen highlighted the interrelationship of somatization and major depression and misdiagnosis of major depression in primary care settings [7,8]. This review was followed by several important observational studies highlighting the key role that psychiatric illnesses such as major depression and panic disorder play in somatization and specific patient presentations such as noncardiac chest pain, chronic pain, chronic fatigue syndrome (CFS) and unexplained dizziness [9–18]. This epidemiological work laid the foundation for what would become the renowned Division of Health Services and Psychiatric Epidemiology at the University of Washington Department of Psychiatry and Behavioral Sciences. A cornerstone of this division was a T32-funded National Research Service Award, initially funded by Health Resources and Services Administration and later funded by National Institute of Mental Health, that Dr. Katon obtained for the purpose of mentoring and training psychiatrists and primary care physicians (PCPs) in epidemiology and health services research methodology. With the support of this training grant, which has been continuously funded for over 25 years, Dr. Katon mentored an entire generation of clinical health services researchers at the University of Washington, many of whom, such as Drs. Lydia Chwastiak, Paul Ciechanowski, Charles Engel, Jesse Fann, Laura Richardson, Mark Sullivan, Jürgen Unützer, Edward Walker and Douglas Zatzick, would go on to exceptional research careers of their own. Informed by his initial epidemiological studies and his clinical work consulting in a busy primary clinic, Dr. Katon began a research collaboration with Dr. Michael Von Korff, a health service researcher and epidemiologist, and Dr. Elizabeth Lin, a PCP and health services researcher, both at Group Health Research Institute (GHRI) in Seattle, WA, USA. Little did the three of them know at the time that their collaboration would span four decades and not just revolutionize psychosomatic medicine but also the care of psychiatric illnesses in general healthcare settings worldwide. Based on their findings regarding the high prevalence of major depression and unmet mental healthcare need in primary care [19],

Drs. Katon, Von Korff and Lin, along with Dr. Edward Wagner of the GHRI, the father of the chronic care model [20], designed an initial randomized controlled trial (RCT) of psychiatric consultation in primary care [21]. The rationale for this initial trial was that primary care-based psychiatric consultation would increase PCP awareness of psychiatric illnesses and their role in driving care utilization, improve PCPs' psychiatric diagnostic capabilities and ultimately lead to improved treatment of psychiatric conditions, particularly depression, in primary care settings [21]. In 1992, Drs. Katon, Von Korff, Lin et al. published the results of this RCT [21]. While patients randomized to the psychiatric consultation intervention were significantly more likely to be prescribed an antidepressant, and over the course of trial, PCPs were more likely to prescribe antidepressant medications, the intervention had no significant effects on patients' psychiatric symptoms or healthcare utilization [21]. The team was able to show that improvement in depression was associated with significantly fewer disability days over the course of a 1-year follow-up (f/u) [22], but the intervention itself did not improve disability outcomes. This “negative” trial was the basis for several important insights about the treatment of depression by Dr. Katon and his research team. In particular, improved recognition of psychiatric illness and initiation of treatment were insufficient by itself. The team recognized that patients with major depression and other psychiatric illnesses require ongoing monitoring for medication adherence to ensure adequate trials and timely therapeutic response to optimize benefits of treatment when initially prescribed treatments are not effective [21]. Furthermore, the addition of behavioral components to a primary care-based psychiatric intervention may be needed in order to facilitate patient adherence with treatment [21]. 3. From psychiatric consultation to collaborative care (1995–2004) With the lessons learned from the psychiatric consultation in primary care RCT in hand, Drs. Katon, Lin, Von Korff et al. designed a new primary care-based mental health intervention. The team integrated the systems-based approaches of the chronic care model [20] and shifted focus from recognition and diagnosis of psychiatric illnesses to ensuring that primary care patients with major depression were adequately treated over time through multidisciplinary team-based care so that full therapeutic benefit could be achieved in the primary care setting. Rather than focusing on distressed high utilizers of primary care, they sought to improve depression care and depressive symptoms through increased collaboration between the consulting psychiatrist and PCP to achieve guideline-level antidepressant treatment and track patient adherence to depression treatment. A key component of the intervention was alternating patient visits with the PCP and a primary care-based psychiatric consultant after initiating antidepressant therapy to ensure adequate monitoring of outcomes and adjustment of therapy when adequate clinical response was not achieved. The research team was joined in this new RCT by Dr. Gregory Simon, a psychiatrist at GHRI, and Dr. Edward Walker, a psychiatrist at the University of Washington. In 1995, the team published the results of the trial in an article entitled, “Collaborative Management to Achieve Treatment Guidelines: Impact on Depression in Primary Care,” in the Journal of the American Medical Association (JAMA) [23]. This publication documented the first large-scale RCT of what would come to be known as collaborative care. They reported that not only were intervention patients with major depression significantly more likely to be adherent to guidelinelevel doses of antidepressants and to be more satisfied with their depression care, they were also significantly more likely to have a clinically significant (i.e., ≥ 50%) reduction in depressive symptoms over the course of f/u [23]. Dr. Katon et al. followed-up this report with a second trial in which addition of a primary care-based brief psychotherapy component delivered by a psychologist, Dr. Evette Ludman, of the GHRI, led to reductions in depressive symptoms and increased treatment adherence [24]. This


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Table 1 Summary of selected articles authored or coauthored by Wayne Katon reporting important epidemiological and health services findings. Study type

Somatic symptom studies Katon et al. Case–control 1984 [9]

Setting, population and N

Followup period (months)

Exposure(s) of interest

Outcome(s) of interest

Key findings

261 medical–surgical inpatients (100 w/ somatization and 161 w/o somatization

n/a

DSM-III diagnoses

Somatization

Major depression and personality disorders were significantly more common in somatizing patients. Only 1/3 of somatizing patients had DSM-III somatoform disorder diagnoses. 50% of somatizing patients prescribed opioids and/or sedative-hypnotics. Patients with 4–12 medically unexplained somatic symptoms had a consistent and substantial level of functional impairment. Number of lifetime and current psychiatric diagnoses significantly associated with increased number of medically unexplained somatic symptoms. Increasing number of lifetime physical symptoms in CFS patients associated with significantly higher prevalence of lifetime and current major depression and/or anxiety disorders.

Katon et al. 1991 [14]

Cross-sectional

119 primary care patients with high care utilization

n/a

Number of medically unexplained somatic symptoms DSM-III-R diagnoses

Somatization disorder


Cross-sectional

285 patients with CFS

n/a

Number of lifetime physical symptoms

Lifetime prevalence of DSM-III-R depressive and anxiety disorders

Primary care–psychiatry epidemiology Katon et al. Cross-sectional 119 primary care patients n/a 1990 [19] with high care utilization

n/a

Prevalence of DSM-III diagnoses Mental health treatment needs

Von Korff et al. Longitudinal 1992 [22] cohort

143 primary care patients with high care utilization

6, 12

Improvement in depression

Number of disability days

Hollifield et al. 1997 [31]

Case–control

123 primary care patients (62 w/ panic disorder and 61 w/o panic disorder)

n/a

Major depression Neuroticism Chronic medical illness Demographics

HRQOL

Unützer et al. 1997 [35]

Prospective cohort

2558 primary care patients ≥65 years old

24, 48

Depressive symptoms

Ambulatory medical costs

Walker et al. 2003 [34]

Retrospective cohort

1225 female primary care 60 patients

PTSD symptoms

Total healthcare costs (i.e., ambulatory and inpatient medical and mental health costs)

Depressive symptoms

Diabetes treatment adherenceHRQOL Healthcare costs

Comorbid major depression

CVD risk factors

Epidemiology of depression and diabetes Prospective 367 primary care patients 6 Ciechanowski cohort with diabetes et al. 2000 [42]


Cross-sectional

4225 primary care patients with diabetes

n/a

Two-thirds with lifetime major depression and 80% with current axis I disorder (of which current major depression was most common). One-third were previously undiagnosed, and 2/3 had unmet mental health treatment needs. Improvement in depressive symptoms from baseline was associated with a significant reduction in disability days. Patients with panic disorder reported significantly worse HRQOL vs. patients without panic disorder. Comorbid major depression was single factor most strongly associated with worse self-reported HRQOL. Increasing depressive symptom severity independently associated with significantly higher ambulatory medical costs at 2 and 4-year followup. Compared to women with no or low levels of PTSD symptoms, moderate PTSD symptoms were associated with a 38% increase in total healthcare costs while severe PTSD symptoms were associated with a 104% increase in total healthcare costs.

Moderate-to-severe depressive symptoms in patients with diabetes independently associated with poorer diabetes treatment adherence, worse physical and mental HRQOL and higher healthcare costs. Comorbid major depression independently associated with 1.5 to 2.0-times greater odds of ≥3 CVD risk factors. Comorbid major depression independently associated with smoking, obesity, sedentary lifestyle and HbA1c ≥8.0 in patients w/o known CVD. (continued on next page)

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Table 1 (continued) Study type






Prospective cohort


36

Comorbid major or minor depression

All-cause mortality

Lin et al. 2010 [49]

Prospective cohort


60


Microvascular and macrovascular complications of diabetes


Prospective cohort


60


Dementia


Prospective cohort

19,239 primary care patients with diabetes

60


Dementia


Longitudinal cohort

2.4 million Danish citizens ≥50 years old

84

Depression Diabetes Comorbid depression and diabetes

Dementia

n/a

Antenatal depression

PTB LBW IUGR

n/a

Demographics Psychosocial stressChronic medical comorbidity Domestic violence

Antenatal major or minor depression

Antidepressant prescription

Number of follow-up visits with a provider Continuation of antidepressant at 3 and 6 months after initial prescription

Epidemiology of depression and pregnancy outcomes 29 studies including Grote et al. Meta-analysis 48,004 women 2010 [67] of prospective studies

Melville et al. 2010 [66]

Cross-sectional

1888 women receiving prenatal care

Epidemiology of pediatric depression 6 Prospective 1205 Medicaid-covered Richardson cohort children 5–18 years old et al. seen in primary care with 2004 [61] incident depression, of whom 507 (42%) were prescribed an antidepressant

Key findings

Comorbid major depression independently associated with obesity, sedentary lifestyle and triglycerides ≥400 in patients without known CVD. Comorbid major depression independently associated with 2.30-times greater risk of mortality and comorbid minor depression independently associated with 1.67-times greater risk of mortality. Comorbid depression independently associated with 1.36-times greater risk of microvascular complications and 1.24-times greater risk of macrovascular complications of diabetes. Comorbid major depression in patients with diabetes independently associated with 2.69-times greater risk of incident dementia. During years 3 through 5 postbaseline, comorbid major depression in patients with diabetes independently associated with 2.02-times greater risk of incident dementia. Depression alone associated with 1.83-times greater risk of incident dementia. Diabetes alone associated with 1.20-times greater risk of incident dementia. Comorbid depression and diabetes associated with 2.17-times greater risk of incident dementia. Among individuals b65 years old, comorbid depression and diabetes accounted for 25% of incident dementia cases.

Antenatal depression associated with significantly increased risk of all three adverse birth outcomes. The association of antenatal depression and LBW was stronger in studies conducted in developing countries compared to those in the US or Europe. Antenatal depression associated with increased risk of PTB in US women of lower SES. 10% of women had major (5%) or minor (5%) depression. Current suicidal ideation was present in 29% of women with major depression. Psychosocial stress, domestic violence, chronic medical conditions, and Asian-American or AfricanAmerican race independently associated with increased odds of antenatal major depression.

Only 28% of youth prescribed an antidepressant had ≥3 months in the next 3 months, while 29% had no follow-up visits. SSRIs were continued by 47% youth at 3 months and 26% at 6 months. Having ≥3 provider f/u visits after initial antidepressant prescription was associated with 2.02-times greater


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Table 1 (continued) Study type


Cross-sectional


2291 teenagers ages 13–17 seen in primary care


n/a


Possible major depression (PHQ-2≥3)


Obesity and physical activity Substance abuse Interactions with parents and peers Self-rated general health

Key findings

odds of medication continuation at 3 month study f/u. Possible major depression was associated with significantly increased odds of obesity, limited physical activity, problems with schoolwork, difficulties in relationships with parents and their peers, poor self-rated general health and substance abuse.

Abbreviations (in alphabetical order): CVD = cardiovascular disease; DSM-III = Diagnostic and Statistical Manual of Mental Disorders, Third Edition; DSM-III-R = DSM, Third Edition, Revised; f/u = follow-up; IUGR = intrauterine growth restriction; LBW = low birth weight; n/a = not applicable; PHQ-9 = Patient Health Questionnaire-9; PTB = preterm birth; SES = socioeconomic status; SSRIs = selective serotonin reuptake inhibitors.

trial was the beginning of enhanced use of behavioral strategies to engage patients in care, an approach that became a hallmark of collaborative care interventions. The team found that while the primary care-based collaborative care intervention increased the cost of depression care overall (primarily due to the increased number of patient visits), the intervention was cost-effective among patients with major depression [25]. Capitalizing on the success of the initial collaborative care trials, Dr. Katon et al. conducted a f/u randomized trial adding an additional component to the original treatment paradigm, “stepped care,” in order to reflect the growing reality that more patients with depression were being started on antidepressants by their PCPs, and many might need subsequent increases in intensity of care to improve [26]. In this trial, primary care patients with persistent depression after being started on an antidepressant by their PCP 6–8 weeks prior were randomized into a collaborative care intervention in which intervention patients were seen by a primary care-based psychiatrist for at least two visits, that is, a “stepped-up” level of care [26]. The intervention also included other components utilized in their initial collaborative care RCT. This f/u trial was also successful, showing that the stepped collaborative care intervention led to symptomatic improvement and greater likelihood of remission of the depressive episode [26]. Subsequently, the team conducted an f/u trial utilizing two inperson visits with primary care-based depression care managers trained by Drs. Katon, Lin and Ludman with the aim of preventing major depressive episode recurrence [27]. While the intervention did not prevent recurrence of major depression, it did improve antidepressant adherence and reduced depressive symptom burdens [27]. In the same year, the results of an RCT, led by Dr. Peter Roy-Byrne of the University of Washington with close collaboration from Dr. Katon, which adapted collaborative care for panic disorder in primary care, were released [28]. This RCT found that a primary care-based collaborative care approach reduced severity of panic symptoms and significantly improved health-related quality of life (HRQOL) [28]. A subsequent costeffectiveness analysis of this trial showed that the collaborative care intervention did not significantly increase outpatient healthcare costs versus usual care and that intervention patients experienced significantly more anxiety free days [29]. In an another RCT, Dr. Douglas Zatzick of the University of Washington, under the mentorship of Dr. Katon, showed that an acute care-based collaborative care intervention for posttraumatic stress disorder (PTSD) and problem drinking following traumatic injury reduced PTSD symptoms and problem drinking behaviors [30]. At the same time that Dr. Katon was becoming world renowned for pioneering primary care-based collaborative care for depression, he coauthored a series of important studies on the clinical epidemiology of common mental disorders in primary care with his mentees and colleagues. These works included coauthored papers such as a report authored by Dr. Michael Hollifield identifying significantly worse HRQOL among patients with panic disorder [31], one authored by

Dr. Mark Sullivan detailing worse long-term physical functioning among coronary artery disease (CAD) patients with depressive and anxiety symptoms [32] and two reports authored by Dr. Edward Walker, the first documenting the findings of a study highlighting significantly increased healthcare costs among female primary care patients with a history of childhood abuse or neglect [33] and a second f/u study identifying similarly increased healthcare costs among female primary care patients with PTSD [34]. With Dr. Jürgen Unützer, a geriatric psychiatrist and health services researcher, he published an important observational study identifying that depression in older primary care patients was associated with substantial disability and with significantly higher healthcare costs over a 4-year f/u period [35]. The higher costs observed were primarily the result of increased general medical costs and not costs related to mental health specialty care. This observational study, in combination with Dr. Katon's pioneering interventional work, would lay the foundation for the next iteration of collaborative care. After completing his fellowship with Dr. Katon, Dr. Unützer continued to collaborate closely with Dr. Katon et al. on an adaptation of collaborative care that would target depression in older adults with significant comorbid medical problems. This adaptation incorporated into the original collaborative care model a depression care manager, supervised weekly by a psychiatrist, to deliver behavioral activation and problem-solving treatment and to facilitate antidepressant management by PCPs, while systematically tracking patient outcomes in a Web-based registry [36] and making treatment adjustments if patients were not improving as expected. This intervention would become known as the Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) program and was tested in an RCT with 1801 depressed older adults in 18 primary care clinics in five states [36]. The IMPACT program more than doubled the likelihood that patients experienced improvement in depression [36], and it was also found to reduce functional impairment from arthritis-related pain [37], increase physical activity and improve physical functioning [38]. More recent analyses found that intervention patients at one of the IMPACT sites had significantly lower risk of myocardial infarction or strokes in the years following the intervention [39]. The IMPACT program was also found to be cost-effective [40,41], returning more than US$6 for each US$1 spent on the collaborative care intervention. 4. Depression, diabetes and the evolution of team care (2000–2015) While working with on the IMPACT trial, Dr. Katon became increasingly interested in the adverse effects of comorbid major depression on diabetes mellitus. This interest was informed by his clinical work providing psychiatric consultations in a primary care clinic, where depression and diabetes were highly prevalent. Dr. Katon was joined in this new avenue of research by Dr. Paul Ciechanowski, a dually trained psychiatrist and PCP, and a fellow in Dr. Katon's T32 training program. In

380


Table 2 Summary of selected articles authored or coauthored by Wayne Katon reporting important findings from randomized controlled interventional trials. Study

Setting, population and N randomized


251 (intervention = 124, usual care control = 127) primary care patients with high care utilization





Intervention tested

Primary care-based psychiatric consultation: 1. Single psychiatric consultation in primary care comprised of: - 1 h consultation with psychiatrist - 30 min inperson case review by psychiatrist with PCP present - Joint formulation of treatment plan between psychiatrist and PCP 2. During f/u period, psychiatrist conferred w/ PCP once to assess how psychiatric treatment progressing Multifaceted primary care-based 217 depressed (major intervention: depression = 91, minor depression = 126) primary 1. At baseline, patients received care patients (intervention informative handouts on depression, psychotherapy, = 108, usual care = 109) from a single primary care “doctor-patient” relationship, questionnaire on prior clinic antidepressant side effects and informative videotape 2. PCPs had a depression training at baseline, monthly case conferences and case-by-case consultation w/ psychiatrists 3. Alternating visits with PCP (visits 1 and 3) and psychiatrist (visits 2 and 4) beginning 7 to 10 days postbaseline 4. Psychiatrist reviewed automated pharmacy data from 3–7 months post-baseline to track antidepressant adherence In addition to elements reported 153 of the 217 depressed in Katon et al. 1995, the (major depression = 65, following: minor depression = 88) 1. 4–6 visits with a psychologist primary care patients for brief psychotherapy in primary (intervention = 77, usual care with follow-up phone calls at care = 76) reported on in 2, 4, 12, and 24 weeks after final Katon et al. 1995 inperson visit 2. Case-by-case consultation between PCPs with psychologists on behavioral management of depression Stepped collaborative care: 228 primary care patients (intervention = 114, usual 1. At baseline, patients received book on depression outlining care = 114) from 4 effects of medications and primary care clinics with psychotherapy and informative persistent depression 6 to 8 weeks after prescription videotape to view with partner 2. Two inperson visits with of an antidepressant by psychiatrist in primary care clinic their PCP within 4 week period 3. Immediate feedback from psychiatrist to PCP 4. Psychiatrist reviewed monthly automated pharmacy data on antidepressant refills to track adherence Collaborative care relapse 386 primary care patients (intervention = 194, usual prevention program: 1. Patients provided with book care = 192) with and videotape on recurrent and remission of major chronic depression depression or dysthymia 2. Two inperson visits in primary treated with care and telephone f/u with antidepressants by nonphysician depression their PCP specialist trained by psychiatrist, psychologist and PCP 3. Visits with depression specialist

Outcomes assessed

Follow-up period (months)

Key findings

1. Depression 2. Anxiety 3. Somatization 4. Disability 5. Healthcare utilization

6, 12

1. Intervention patients were significantly more likely to be prescribed an antidepressant by 6 month f/u and were more likely to have filled ≥3 antidepressant prescriptions by 6 and 12 month f/u. 2. Significant increase in antidepressant prescriptions overall by PCPs receiving psychiatric consultations. 3. No significant effects on symptoms of depression or anxiety, somatization, disability or utilization.

Primary outcomes: 1. 30-day and 90-day antidepressant use at guideline doses 2. Patient satisfaction in depression care 3. Depressive symptoms

1, 4, 7

1. Intervention patients with major depression were significantly more likely to be adherent to guideline-level dosed antidepressants for ≥90 days, be satisfied with their depression care, find antidepressants helpful and to have ≥50% reduction in depressive symptoms at 4 and 7 month f/u. 2. Intervention patients with minor depression were significantly more likely to be adherent to guideline-level dosed antidepressants for ≥90 days and to find antidepressants helpful, though were not more likely to be satisfied with depression care or to have significant reduction in depressive symptoms.

Primary outcomes: 1. Treatment adherence to both antidepressants and psychotherapy visits 2. Patient satisfaction in depression care 3. Depressive symptoms (4 measures used)

1, 4, 7

Primary outcomes: 1. Patient adherence to guideline-dosed antidepressants 2. Patient satisfaction with depression care 3. Depressive symptoms

1, 3, 6

1. Intervention patients with major or minor depression were significantly more likely to be adherent to antidepressants at 4 month f/u. 2. 88% of intervention patients completed ≥4 psychotherapy visits. 3. Intervention patients with major depression had significant reduction in depressive symptoms across all 4 measures, while those with minor depression only had significant symptom reduction in 1 of 4 measures. 1. Intervention patients were significantly more likely to adhere to antidepressants at each f/u time point. 2. Intervention patients were significantly more likely to be satisfied with care of their depression at 3 and 6 month f/u. 3. Intervention patients had significant decline in depressive symptoms at 3 month f/u with nonsignificant improvement between 3 and 6 months. 4. Intervention patients significantly more likely to have remission of depression at 3 and 6 month f/u.

Primary outcomes: 1. Adherence to guidelinedosed antidepressants 2. Depressive symptoms 3. Relapse/Recurrence of depression episode

3, 6, 9, 12

1. Intervention patients significantly more likely to be adherent to antidepressant treatment. 2. There was a modest intervention effect of decreasing depressive symptoms. 3. There were no significant differences between intervention and usual care in preventing depressive episode recurrences.


381

Table 2 (continued) Study


Roy-Byrne et al. 2001 [28]

115 primary care patients with panic disorder from 3 primary care clinics (intervention = 57, usual care = 58)

Unützer et al. 2002 [36], Lin et al. [37]

1801 primary care patients ≥60 years old from 18 primary care clinics (intervention = 906, usual care = 895) with major depression (17%), dysthymia (30%) or both (53%)

Zatzick et al. 2004 [30]

120 survivors of traumatic injuries recruited at a Level I trauma center (intervention = 59, usual care = 61)


329 patients with diabetes and comorbid major depression or dysthymia from 9 primary care clinics (intervention = 164, usual care = 165)

Intervention tested

focused on antidepressant adherence, enhancing self-efficacy along with behavioral activation and problem solving, and development of personal relapse prevention plan Collaborative care for panic disorder in primary care: 1. PCPs received lecture on panic disorder and treatment strategies 2. Initial 1 h evaluation visit with psychiatrist in primary care clinic where paroxetine started 3. Informational video on panic disorder and antidepressants mailed to patients 4. Psychiatric f/u as follows: week 2: 10–15 min telephone call by psychiatrist, week 4: 30 minute inperson visit with psychiatrist, week 6: 10–15 min telephone call with psychiatrist, months 3–12: 5 telephone calls with psychiatrist 5. All medication adjustments made by psychiatrist IMPACT collaborative care management for late-life depression: 1. Patients received educational booklet and videotape about latelife depression 2. Visits in primary care with depression care manager (nurse or psychologist) for 12 months 3. Sessions between patients and care manager included focus on medication adherence and PST 4. Depression care manager reviewed cases weekly with supervising psychiatrist and liaison PCP 5. Depression care manager worked with patient's PCP to start/adjust antidepressants 6. Stepped care protocol in which patients who do not improve are offered inperson psychiatric consultation Stepped collaborative care for PTSD following traumatic injury: 1. Case management by a master's level trauma support specialist for 6 months postinjury 2. Trauma support specialist provided brief intervention for alcohol misuse in patients with positive alcohol screens on admission 3. At 3 months postinjury, patients with PTSD offered pharmacotherapy by a psychiatrist, psychotherapy by a psychologist or both with ongoing treatment for 6–12 months postinjury 4. Weekly case reviews between trauma support specialist, psychiatrist and psychologist Collaborative care for patients with diabetes in primary care: 1. Three nurses trained in collaborative care treatment of depression and delivery of PST to work as care managers

Outcomes assessed


Key findings

Primary outcomes: 1. Panic disorder severity 2. Anxiety sensitivity 3. Depressive symptoms 4. Adherence to guidelinedoses of paroxetine 5. HRQOL

3, 6, 9, 12

Primary outcomes: 1. Depressive symptoms 2. Depression treatment response defined as ≥ 50% decrease in depressive symptoms from baseline 3. Adherence to antidepressants and psychotherapy 4. Patient satisfaction with depression care 5. Health-related functional impairment

3, 6, 12

1. Intervention patients more likely to receive adequately-dosed antidepressants and more likely to be adherent with medications at 3 and 6-month f/u. 2. Intervention patients had significantly lower panic symptom severity vs. usual care at 6-month f/u. 3. Intervention patients had significantly lower scores on anxiety sensitivity measures vs. usual care at all f/u time points. 4. Intervention patients had significantly fewer depressive symptoms vs. usual care at all f/u time points. 5. Intervention patients had significantly better SF-36 role functioning vs. usual care. 1. At 12 month f/u, intervention patients were 3.45-times more likely to have ≥50% decrease in depressive symptoms from baseline. 2. Depressive symptom severity was significantly lower in intervention patients vs. usual care at 12-month f/u. 3. Intervention patients were more adherent with antidepressants and reported greater satisfaction with depression care. 4. Intervention patients had significant improvements in functioning and HRQOL vs. usual care, and reported less arthritisrelated pain.

Primary outcomes: 1. PTSD symptom severity 2. % meeting criteria for PTSD diagnosis 3. Alcohol abuse/ dependence

1, 3, 6, 12

1. Intervention patients had significantly lower levels of PTSD symptoms during f/u. 2. While there was no difference in % of patients meeting PTSD diagnostic criteria in the intervention group during f/u, there was a 6% increase in patients meeting PTSD diagnostic criteria in the usual care group. 3. At 6 month f/u, the prevalence of alcohol abuse/dependence decreased by 20% in the intervention group vs. 7% in usual care. This effect was sustained at 12-month f/u.

Primary outcomes: 1. Depressive symptoms 2. Patient global assessment of depression improvement 3. Patient satisfaction with

3, 6, 12

1. Intervention patients had significantly better adherence to antidepressant medications vs. usual care. 2. Intervention patients had significant decreases in depressive (continued on next page)

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Katon et al. 2010 [53], Von Korff et al. [55], Lin et al. [56]

214 patients with diabetes, CAD, and/or both with comorbid depression (intervention = 106, usual care = 108) from 14 primary care clinics

Richardson et al. 2014 [65]

101 adolescents ages 13–17 with depression from 9 primary care clinics (intervention = 50, usual care = 51)


205 women (120 without health insurance or with

Intervention tested

Outcomes assessed

2. Patients offered initial choice of antidepressant (prescribed by PCP) or PST (delivered by care manager) 3. Nurse care managers followed patients twice per month for first 3 months 4. Stepped treatment for patients with persistent depression at 12 weeks including addition of antidepressant or PST, antidepressant switch and/or psychiatric consultation 5. Once patients reached ≥50% reduction in depressive symptoms, telephone f/u with nurse care managers only 6. Nurse care managers supervised by psychiatrists, psychologist and PCP TEAMcare collaborative care for patients with depression and chronic illnesses: 1. Treat-to-target program targeting depressive symptoms, HbA1c, blood pressure and lipids 2. Patients work collaboratively with nurse care managers and their PCP 3. Patients seen by nurse care manager every 2–3 weeks in primary care clinic for depression and medical condition f/u 4. Nurse care managers trained on guideline level medication treatment of depression and chronic medical conditions and collaborated with PCPs (who prescribed medications) on dose adjustments 5. Maintenance phase after patients reached treatment target levels with monthly telephone calls by nurse care manager 6. Nurse care managers supervised by psychiatrist, psychologist and PCP Collaborative care for adolescent depression: 1. Patients received developmentally sensitive educational materials and parental involvement encouraged 2. Care delivered by master’s-level clinicians (depression care manager) supervised in weekly meetings by psychiatrist, psychologist and pediatrician 3. Medications prescribed by PCP 4. Patients and parents given initial choice of treatment: antidepressant, brief CBT (delivered by depression care manager) or both 5. Inperson follow-up with depression care manager every 1–2 weeks until clinical response (symptom decrease ≥50%) or remission, then followed by monthly f/u out to 12 months 6. Patients without response by 8 weeks had stepped increase in care Women's health-based collaborative care for depression:

depression care 4. Adherence to antidepressants 5. HbA1c levels

Primary outcomes: Simultaneous modeling of depression, HbA1c, LDL cholesterol and systolic blood pressure at 12 months


Key findings

symptoms over time vs. usual care. 3. Intervention patients were 3.5times more likely to have higher global assessment of depression improvement ratings at 6 and 12month f/u vs. usual care. 4. Intervention patients were significantly more satisfied with depression care vs. usual care. 5. In spite of improvements in depression, there were no significant differences in HbA1c levels between intervention vs. usual care patients.

6, 12

1. Intervention patients had significant decreases in HbA1c, LDL cholesterol, systolic blood pressure and depressive symptoms at 12 month f/u vs. usual care. 2. Interventions patients were significantly more likely to have ≥ 1 adjustment in insulin doses, antihypertensive medications and antidepressants. 3. Intervention patients had significantly better functioning and reported significantly better HRQOL vs. usual care. 4. Intervention patients reported significantly greater satisfaction with care for diabetes, CAD and depression.

6, 12 Primary outcome: Change in depressive symptoms from baseline to 12 month f/u Secondary outcomes: 1. Functional impairment 2. Clinical response (≥50% decrease in depressive symptoms) 3. Depression remission (PHQ-9≤5)

1. Intervention patients had significant decreases in depressive symptoms by 12-month f/u vs. usual care. 2. Intervention patients were 3.3times more likely to have clinical response in depression. 3. Intervention patients were 3.9times more likely to achieve remission of depression. 4. There were no significant differences in functional impairment between intervention and usual care patients.

Primary outcomes: 1. Depressive symptoms

1. Intervention patients had significant decreases in depressive

6, 12, 18


383



Intervention tested

Outcomes assessed

public health insurance and 85 with private health insurance) seen in 2 OB-GYN clinics (intervention = 102, usual care = 103)

1. MSW depression care managers 2. Charity care for medications for uninsured patients 3. Patients met inperson or via phone with depression care manager every 1–2 weeks for up to 12 months, with monthly contacts once patients had ≥50% depressive symptom decrease and/or remission 4. Patient choice of initial treatment: antidepressant, PST or both 5. Care manager worked collaboratively with OB-GYN on antidepressant prescription and dose adjustments 6. Stepped care escalation for patients without response by 8 weeks 7. Care manager supervised by psychiatrist, psychologist and OB-GYN

2. Patient-rated global improvement in depression 3. Satisfaction with depression treatment 4. Self-rated quality of mental healthcare


Key findings

symptoms and were significantly more likely to have ≥50% reduction in symptoms as well as be satisfied with their depression care vs. usual care. 2. Effect size of intervention was significantly greater among women without health insurance or with public insurance (d = 0.81 at 12 months, d = 0.59 at 18 months) vs. women with private health insurance (d = 0.39 at 12 months, d = 0.23 at 18 months)

Abbreviations (in alphabetical order): CBT = cognitive–behavioral therapy; LDL = low-density lipoprotein; MSW = master's degree in social work; PST = problem-solving therapy.

2000, Drs. Ciechanowski and Katon, along with Dr. Joan Russo, a research psychologist and statistician at the University of Washington, authored an important cohort study identifying that depression in patients with diabetes was independently associated with worse glycemic control, poorer HRQOL and greater healthcare costs [42]. Following up on these findings, Dr. Katon et al. designed a new cohort study that would inform much of what we know about the relationship of depression and diabetes, the Pathways study [43]. This study would utilize the Diabetes Registry at Group Health to follow over 4100 patients with diabetes for 5 years and would also incorporate a randomized trial of collaborative care for depression in over 300 of these patients who had comorbid depression. Dr. Katon and his colleagues hypothesized that since depression led to worse adherence to diabetes treatments [42], treating depression effectively should not only improve depression-related outcomes but also glycemic control. In 2004, the results of the Pathways RCT were published in the Archives of General Psychiatry [44]. Dr. Katon et al. reported that while an IMPACT model of collaborative care for depression delivered by clinician-supervised care managers significantly improved depression outcomes in primary care patients with diabetes, it did not significantly improve glycemic control as assessed by glycosylated hemoglobin (HbA1c) levels [44]. Based on this negative result, the research team recognized that passive improvement of diabetes by improving depression alone was not likely to occur and improving diabetes outcomes in patients with comorbid diabetes and depression would require more active diabetes-targeted intervention [44]. However, the intervention was found to be cost-effective for improving depression outcomes with a net economic benefit of nearly US$1000 per patient treated [45]. Dr. Katon et al. identified key aspects of the long-term health effects of comorbid depression in patients with diabetes through the Pathways Epidemiologic Study. Seminal findings from this cohort study included that comorbid depression in patients with diabetes was independently associated with a greater number of CAD risk factors [46], greater burden of diabetes symptoms [47], worse diabetes-treatment adherence and self-care [48], more long-term diabetes-related microvascular and macrovascular complications [49] and mortality at 5 and 10-year f/u [50,51]. The lack of effect on diabetes outcomes seen in the Pathways RCT became clearer to the research team in light of what had been learned

about how to improve outcomes for depression. Synthesizing the findings on the impact of comorbid depression on health behaviors in patients with diabetes from the Pathways Epidemiologic Study as well as taking stock of potentially key ingredients missing from the intervention tested in the Pathways RCT, Dr. Katon and his research team designed a new multidisciplinary intervention that fully integrated psychiatric, behavioral science, healthcare systems and primary care intervention strategies. Recognizing that patients with diabetes frequently have multiple comorbidities, including depression, CAD and hypertension [52], the team designed an intervention that utilized the same principles of their prior collaborative care interventions for depression and extended them to diabetes management and CAD risk factor modification. Treat-to-target strategies of enhanced primary care practice for managing hypertension, poor glycemic and lipid control and depression were adapted by Dr. Elizabeth Lin for multicondition case management, while Dr. Evette Ludman adapted behavioral strategies for engaging patients in chronic disease management for use in multicondition case management. The team developed new approaches for efficient supervision of the nurse care managers who delivered the intervention, focusing supervision on the patients who were not achieving improved outcomes. Healthcare systems strategies of the chronic care model [20] were fully integrated into the intervention, including a patient database that tracked nurse care manager contacts with patients and patient progress toward achieving treatment goals. This multicondition collaborative care intervention, known as TEAMcare, was tested in an RCT in 214 primary care patients with poorly controlled diabetes mellitus, CAD or both, in addition to comorbid depression [53,55,56]. In 2010, Dr. Katon et al. reported in the New England Journal of Medicine that multicondition collaborative care not only significantly improved depressive symptoms but also led to lower HbA1c, better blood pressure control and lower cholesterol levels in intervention patients compared to usual care [53]. Subsequent reports from the trial identified that the intervention was cost-effective [54], patients had improved functioning [55] and that dose adjustments through the “treat-to-target” intervention were critically important in achieving improvements in blood pressure, glycemic, lipid and depression outcomes [56]. The TEAM-care trial was immediately influential, leading to implementation efforts across the United States, including a large dissemination and

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implementation project funded by the Centers for Medicare and Medicaid Innovation, the COMPASS project, which was advised by Drs. Katon and Lin on the adaptation of TEAM-care principles to other care settings. As TEAM-care dissemination was moving forward, Dr. Katon and his research team continued to focus on important epidemiological work in the area of depression and diabetes comorbidity. A specific avenue of epidemiological investigation Dr. Katon focused on during this time was the relationship of depression, diabetes and dementia risk. This important work began with a study using data from 3800 diabetes patients in Pathways that found that comorbid major depression was independently associated with increasing risk of dementia diagnosis [57]. This study was subsequently followed up with a larger cohort study of over 19,000 patients with diabetes in Northern California that confirmed the previously identified association between comorbid major depression and increased dementia risk [58], as well as a third study analyzing data from the Action to Control Cardiovascular Risk in Diabetes trial which found that comorbid major depression was associated with increased risk of cognitive decline in patients with diabetes [59]. However, Dr. Katon was interested in furthering this work by estimating the differential risks conferred by depression or diabetes on the development of dementia, as well as the impact of comorbid depression and diabetes on dementia risk among middle-aged adults. To answer these questions, Dr. Katon reached out to Dr. Mogens Vestergaard, a Danish PCP and epidemiologist who directs a research group conducting studies on mental health in primary care settings using data from the massive Danish health registries. In an article published posthumously in JAMA Psychiatry that reported on research utilizing data from over 2.4 million Danish adults over age 50, Dr. Katon, Dr. Dimitry Davydow, a recent T-32 fellow, and their Danish colleagues found that diabetes alone was associated with 20% greater risk of dementia, depression alone was associated with an over 80% greater risk of dementia and that having both was associated with 107% greater risk [60]. Further, this study found that 25% of all dementia cases in Danish adults between the ages of 50 and 65 were potentially attributable to comorbidity between depression and diabetes [60]. 5. Improving depression care for women and children (2004–2015) Dr. Katon was also influential in improving access to high-quality mental healthcare for adolescents and pregnant women, two patient populations with particular difficulties obtaining needed care. This interest was sparked by his collaboration with Dr. Laura Richardson, an adolescent medicine specialist at the University of Washington. Their initial work identified gaps in mental healthcare for youth with Medicaid coverage in Washington state [61], found increased healthcare utilization and costs among adolescents with asthma and comorbid depressive and/or anxiety disorders [62], reported increased health-risk behaviors among adolescents with depression [63], and validated the Patient Health Questionnaire-2 (PHQ-2) as a screening instrument for depression in adolescents in primary care settings [64]. These studies informed an RCT of collaborative care for depressed adolescents in primary care which found significant reductions in depressive symptoms and greater likelihood of depression remission among those randomized to the intervention [65]. Dr. Katon's work in maternal mental healthcare was spurred by a fellow in his T-32 program, Dr. Jennifer Melville, an obstetriciangynecologist, as well as by collaboration with social worker and researcher, Dr. Nancy Grote, both with interests in this area. Important epidemiological works from these collaborations included a crosssectional study documenting a high prevalence of suicidal ideation among depressed women receiving prenatal care [66] and a metaanalysis of cohort studies identifying that linked perinatal depression to a range of adverse birth outcomes, particularly among socioeconomically disadvantaged women [67]. These studies were followed by a successful RCT of collaborative care for depression in two obstetrics– gynecology clinics [68,69] and a third RCT of collaborative care focusing on improving perinatal depression in socioeconomically disadvantaged women whose results are forthcoming [70].

6. The impact of Wayne Katon's academic work The work that Dr. Katon and his team conducted have had tremendous influence on clinical research to improve the care of psychiatric illnesses in primary care and other nonmental health specialty settings. The results of the initial depression collaborative care trials by Dr. Katon et al. influenced a multicenter randomized trial led by Dr. Kenneth Wells at University of California in Los Angeles, the Depression Patient Outcomes Research Team or Partners in Care trial [71]. This study showed that treatment approaches could be generalized to diverse community primary care settings with improved long-term outcomes for depressed patients [71]. At GHRI, Dr. Gregory Simon carried out a successful large trial of telephonic care management informed by the studies of collaborative care [72]. This study and several subsequent studies by Dr. Simon et al. at GHRI utilized collaborative care approaches with enhanced efficiency of delivering care management interventions including both medication management and psychotherapeutic components [72–74]. In 2002, the US Preventive Services Task Force revised a previous recommendation against routine screening for depression in primary care settings, concluding that depression screening could be effective “when screening is coupled with system changes that help ensure adequate treatment and follow-up,” recognizing that when principles of collaborative care for depression were applied, improved recognition of depression in primary care settings could improve patient outcomes [75]. Subsequently, a 2006 meta-analysis of 37 randomized trials found the collaborative care approach to be effective in improving depression outcomes [76], results replicated by a 2012 Cochrane Collaboration systematic review of 79 trials of collaborative care for depression and anxiety disorders [77]. Most of the intervention trials of the last decade have incorporated aspects of the collaborative care work of Dr. Katon and his research team in order to address depression in several medically ill populations, including in patients with cardiac disease [78,79], patients with human immunodeficiency virus [80], low-income patients with diabetes [81] and cancer patients [82–85]. Collaborative care has also been adapted to improve care of neuropsychiatric symptoms of dementia [86] and to reduce pain and decrease dependence on opioid analgesics in primary care patients with chronic pain [87]. Perhaps, the most effective way of conveying the impact of Dr. Katon's academic work is through the words of his colleagues. Dr. Michael Sharpe, Professor of Psychological Medicine at Oxford University and principal investigator of the SMaRT Oncology RCTs of collaborative care for depression in patients with cancer, observed that, “Wayne’s work and collaborative care was the basis of our work in cancer. His focus on major depression as an important but tractable problem informed the focus of my work and his collaborative care models were the basis of our depression care system” (personal communication — Dr. Michael Sharpe). These sentiments were echoed by Dr. Kurt Kroenke, Professor of Medicine at Indiana University, who said, “In our own collaborative trials on pain, and then pain/depression, the seminal work hugely influenced us” (personal communication — Dr. Kurt Kroenke), and by Dr. Jeffrey Huffman, director of the Cardiac Psychiatry Research Program at the Massachusetts General Hospital, who said, “Wayne influenced my work—and our team’s work—at every possible step. It was his work in collaborative care that generated the ideas for both our SUCCEED and MOSAIC collaborative care studies, and the collaborative care model used in these settings was adapted for inpatient care but wholly modeled on his innovative model of care. He was one-of-akind, a real aspirational model for all of us who try to do research that affects the lives of people with comorbid mental health and medical conditions” (personal communication — Dr. Jeffrey Huffman). 7. Conclusion In a career spanning four decades, Dr. Wayne Katon and his research team revolutionized the care for common psychiatric illnesses such as depression in primary care settings. Using rigorous epidemiological,


health services research and behavioral science research to inform the development of high-quality interventions such as collaborative care, Dr. Katon blazed a scholarly trail that is unparalleled in psychosomatic medicine. The influence and impact of his work will live on through his publications and through the generations of investigators that he personally mentored as well as through mentees of close collaborators and colleagues. Dr. Katon was a paragon of scholarship in psychosomatic medicine and psychiatry. His life and work are epitomized by Bessie A. Stanley's “What is Success?” [88], “To leave the world a bit better, whether by a healthy child, a garden patch, or a redeemed social condition; to know that even one life has breathed easier because you have lived – that is to have succeeded.” Acknowledgements The authors thank Drs. Elizabeth Lin, M.D., M.P.H., Gregory Simon, M.D., M.P.H., and Michael Von Korff, Sc.D., of GHRI, and members of Dr. Katon's research team, for contributions to this paper. The authors also thank Dr. Kurt Kroenke, M.D., of Indiana University, and Dr. Michael Sharpe, M.D. of Oxford University, for reviewing prior versions of this paper. References [1] Shapiro S, Skinner EA, Kramer M, Steinwachs DM, Regier DA. Measuring need for mental health services in a general population. Med Care 1985;23:1033–43. [2] Shapiro S, Skinner EA, Kessler LG, Von Korff M, German PS, Tischler GL, et al. Utilization of health and mental health services: three catchment area sites. Arch Gen Psychiatry 1984;41:971–8. [3] Von Korff M, Katon W, Lin EHB, Wagner EH. Evaluation of psychiatric consultationliaison in primary care settings. Gen Hosp Psychiatry 1987;9:102–10. [4] Davydow DS, Unützer J. In memoriam: Wayne Katon, MD (1950 – 2015). Gen Hosp Psychiatry 2015;37:195–6. [5] Festschrift. http://en.wikipedia.org/wiki/Festschrift. [Accessed June 3, 2015]. [6] Katon WJ. The development of a randomized trial of consultation-liaison psychiatry in distressed high utilizers of primary care. Psychiatr Med 1991;9:577–91. [7] Katon W, Kleinman A, Rosen G. Depression and somatization: a review – part I. Am J Med 1982;72:127–35. [8] Katon W, Kleinman A, Rosen G. Depression and somatization: a review – part 2. Am J Med 1982;72:241–7. [9] Katon W, Ries RK, Kleinman A. A prospective DSM-III study of 100 consecutive somatization patients. Comp Psychiatry 1984;25:305–14. [10] Katon W, Egan K, Miller D. Chronic pain: psychiatric diagnoses and family history. Am J Psychiatry 1985;142:1156–60. [11] Beitman BD, Basha I, Flaker G, DeRosear L, Mukerji V, Trombka L, et al. Atypical or nonanginal chest pain: panic disorder or coronary artery disease? Arch Intern Med 1987;147:1548–52. [12] Katon W, Hall ML, Russo J, Cormer L, Hollifield M, Vitaliano PP. Chest pain: relationship of psychiatric illness to coronary arteriography results. Am J Med 1988;84:1–9. [13] Simon GE, Katon WJ, Sparks PJ. Allergic to life: psychological factors in environmental illness. Am J Psychiatry 1990;147:901–6. [14] Katon W, Lin E, Von Korff M, Russo J, Lipscomb P, Bush T. Somatization: a spectrum of severity. Am J Psychiatry 1991;138:34–40. [15] Katon WJ, Buchwald DS, Simon GE, Russo JE, Mease PJ. Psychiatric illness in patients with chronic fatigue and those with rheumatoid arthritis. J Gen Intern Med 1991;6: 277–85. [16] Katon W, Russo J. Chronic fatigue syndrome criteria: a critique of the requirement for multiple physical complaints. Arch Intern Med 1992;152:1604–9. [17] Sullivan M, Clark MR, Katon WJ, Fischl M, Russo J, Dobie RA, et al. Psychiatric and otologic diagnoses patients complaining of dizziness. Arch Intern Med 1993;153: 1479–84. [18] Clark MR, Katon W, Russo J, Kith P, Sintay M, Buchwald D. Chronic fatigue: risk factors for symptom persistence in a 2 ½ year follow-up study. Am J Med 1995;98: 187–95. [19] Katon W, Von Korff M, Lin E, Lipscomb P, Russo J, Wagner E, et al. Distressed high utilizers of medical care: DSM-III-R diagnoses and treatment needs. Gen Hosp Psychiatry 1990;12:355–62. [20] Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996;74:511–44. [21] Katon W, Von Korff M, Lin E, Bush T, Russo J, Lipscomb P, et al. A randomized trial of psychiatric consultation with distressed high utilizers. Gen Hosp Psychiatry 1992; 14:86–98. [22] Von Korff M, Ormel J, Katon W, Lin EHB. Disability and depression among high utilizers of health care: a longitudinal analysis. Arch Gen Psychiatry 1992;49:91–100. [23] Katon W, Von Korff M, Lin E, Walker E, Simon GE, Bush T, et al. Collaborative treatment to achieve treatment guidelines: impact on depression in primary care. JAMA 1995;273:1026–31. [24] Katon W, Robinson P, Von Korff M, Lin E, Bush T, Ludman E, et al. A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry 1996;53:924–32.

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[25] Von Korff M, Katon W, Bush T, Lin EH, Simon GE, Saunders K, et al. Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression. Psychosom Med 1998;60:143–9. [26] Katon W, Von Korff M, Lin E, Simon G, Walker E, Unützer J, et al. Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch Gen Psychiatry 1999;56:1109–15. [27] Katon W, Rutter C, Ludman EJ, Von Korff M, Lin E, Simon G, et al. A randomized trial of relapse prevention of depression in primary care. Arch Gen Psychiatry 2001;58:241–7. [28] Roy-Byrne PP, Katon W, Cowley DS, Russo J. A randomized effectiveness trial of collaborative care for patients with panic disorder in primary care. Arch Gen Psychiatry 2001;58:869–76. [29] Katon WJ, Roy-Byrne PP, Russo J, Cowley D. Cost-effectiveness and cost offset of a collaborative care intervention for primary care patients with panic disorder. Arch Gen Psychiatry 2002;59:1098–104. 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[49] Lin EH, Rutter CM, Katon W, Heckbert SR, Ciechanowski P, Oliver MM, et al. Depression and advanced complications of diabetes: a prospective cohort study. Diabetes Care 2010;33:264–9. [50] Katon WJ, Rutter C, Simon G, Lin EHB, Ludman E, Ciechanowski P, et al. The association of comorbid depression with mortality in patients with type 2 diabetes. Diabetes Care 2005;28:2668–72. [51] Coleman SM, Katon W, Lin E, Von Korff M. Depression and death in diabetes; 10-year follow-up of all-cause and cause-specific mortality in a diabetic cohort. Psychosomatics 2013;54:428–36. [52] American Diabetes Association. Standards of medical care in diabetes – 2008. Diabetes Care 2008;31:S12–54. [53] Katon WJ, Lin EHB, Von Korff M, Ciechanowski P, Ludman EJ, Young B, et al. Collaborative care for patients with depression and chronic illness. N Engl J Med 2010;363: 2611–20. [54] Katon W, Russo J, Lin EHB, Schmittdiel J, Ciechanowski P, Ludman E, et al. 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