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Intervention Summary

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Life Goals Collaborative Care (LGCC)

Life Goals Collaborative Care (LGCC) is an intervention for adults with chronic mental and physical health problems. LGCC is based on the Chronic Care Model, which identifies six areas of improvement necessary for health care systems to provide high-quality chronic disease care: (1) health system organizational support; (2) self-management support; (3) provider decision support; (4) delivery system redesign; (5) clinical information systems; and (6) access to community resources. In line with the Chronic Care Model, LGCC aims to help organizations and practices adopt a collaborative approach to treatment in which individuals are engaged in setting their own personal wellness goals. Providers have facilitated access to evidence-based clinical practice guidelines to support decisionmaking, and medical and psychiatric services are coordinated to enhance access and continuity of care. Originally developed to help individuals manage the symptoms of bipolar disorder, the intervention uses a combination of health behavior change, psychotherapy, and motivational enhancement to improve health outcomes. In addition to its primary focus on affective symptoms such as mania and depression, LGCC addresses co-occurring illnesses affecting quality of life, such as cardiovascular disease, diabetes, anxiety, and substance use.

The duration of the intervention can vary, but LGCC typically includes 4–6 weekly self-management sessions followed by wellness maintenance sessions. Sessions can be small group or individual in format and are led by a trained health specialist, who can be a social worker, counselor, nurse, psychologist, or other professional with a mental health or chronic disease background. During the initial self-management sessions, individuals work on identifying personal values and goals and learning how to manage mental health symptoms. Educational content focuses on constructing a personal symptom profile, linking an individual's choices to mental and physical health symptoms, identifying symptom triggers, and optimizing responses to symptoms and adversity. Sessions also address positive lifestyle changes to support overall wellness in areas such as nutrition, exercise, sleep, and substance use. In the maintenance sessions, individuals meet with the health specialist to discuss symptoms, track progress toward goals, troubleshoot barriers, and provide ongoing motivation for goal attainment. The delivery of sessions is manualized, and a workbook is provided for the individual's use.

LGCC has been expanded to treat depression, other mood disorders, and serious mental illness. The three studies reviewed for this summary evaluated the original LGCC program for bipolar disorder; two of the studies were conducted with veterans receiving treatment for bipolar disorder in Veterans Affairs facilities.

Descriptive Information

Areas of Interest Mental health treatment
Outcomes Review Date: February 2013
1: Affective episodes
2: Manic episodes
3: Severity of manic symptoms
4: Mental health–related quality of life
5: Physical health–related quality of life
Outcome Categories Mental health
Quality of life
Ages 26-55 (Adult)
55+ (Older adult)
Genders Male
Female
Races/Ethnicities Black or African American
White
Race/ethnicity unspecified
Non-U.S. population
Settings Outpatient
Geographic Locations Urban
Suburban
Implementation History Developed between 1992 and 1996, LGCC has been evaluated in five randomized controlled trials with more than 1,000 participants. LGCC programs have been implemented at mental health and primary care sites in the United States (California, Colorado, Massachusetts, Michigan, and Pennsylvania), France, and the Netherlands.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations LGCC has been adapted for use with mood disorders, including unipolar depression; serious mental illness, with a focus on physical health wellness; and substance use disorders. It also has been adapted for veterans, including those receiving telehealth services. Intervention materials for LGCC for bipolar disorder have been translated into Spanish and French.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: February 2013

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Bauer, M. S., McBride, L., Williford, W. O., Glick, H., Kinosian, B., Altshuler, L., … Sajatovic, M. (2006). Collaborative care for bipolar disorder: Part II. Impact on clinical outcome, function, and costs. Psychiatric Services, 57(7), 937-945.  Pub Med icon

Study 2

Simon, G. E., Ludman, E. J., Bauer, M. S., Unützer, J., & Operskalski, B. (2006). Long-term effectiveness and cost of a systematic care program for bipolar disorder. Archives of General Psychiatry, 63(5), 500-508.  Pub Med icon

Study 3

Kilbourne, A. M., Post, E. P., Nossek, A., Drill, L., Cooley, S., & Bauer, M. S. (2008). Improving medical and psychiatric outcomes among individuals with bipolar disorder: A randomized controlled trial. Psychiatric Services, 59(7), 760-768.  Pub Med icon

Supplementary Materials

Bauer, M. S., Kirk, G. F., Gavin, C., & Williford, W. O. (2001). Determinants of functional outcome and healthcare costs in bipolar disorder: A high-intensity follow-up study. Journal of Affective Disorders, 65(3), 231-241.  Pub Med icon

Bauer, M. S., McBride, L., Williford, W. O., Glick, H., Kinosian, B., Altshuler, L., … Sajatovic, M. (2006). Collaborative care for bipolar disorder: Part I. Intervention and implementation in a randomized effectiveness trial. Psychiatric Services, 57(7), 927-936.  Pub Med icon

Bauer, M. S., Vojta, C., Kinosian, B., Altshuler, L., & Glick, H. (2000). The Internal State Scale: Replication of its discriminating abilities in a multisite, public sector sample. Bipolar Disorders, 2(4), 340–346.  Pub Med icon

Ware, J. Jr., Kosinski, M., & Keller, S. D. (1996). A 12-item Short-Form Health Survey: Construction of scales and preliminary tests of reliability and validity. Medical Care, 34(3), 220-233.  Pub Med icon

Outcomes

Outcome 1: Affective episodes
Description of Measures Affective episodes, including episodes of depressive symptoms and episodes of manic/hypomanic symptoms, were assessed using the Longitudinal Interval Follow-Up Evaluation (LIFE). This semistructured interview uses Timeline Followback (TLFB) methodology to provide weekly psychiatric symptom ratings (PSRs) for mania and depression based on the number of DSM-IV criteria endorsed: no or minimal symptoms (PSR of 1 or 2), subthreshold symptoms (PSR of 3 or 4), or episode (PSR of 5 or 6).

Clinicians administered the LIFE at baseline and at 8-week intervals over a 3-year study period. The total duration of manic episodes during 24 months of follow-up (the last 2 years of the study) was calculated by summing the number of weeks in which participants had depression and/or mania PSRs of 3 or higher.
Key Findings In a 3-year study, veterans with bipolar disorder recruited from Veterans Affairs hospitals were randomly assigned to receive the intervention or continued usual care through a current or newly assigned psychiatrist. Over 24 months of follow-up, participants in the intervention group had 6.2 fewer weeks in an affective episode compared with those in the control group (p = .041).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.7 (0.0-4.0 scale)
Outcome 2: Manic episodes
Description of Measures Manic episodes were assessed using the Longitudinal Interval Follow-Up Evaluation (LIFE). This semistructured interview uses Timeline Followback (TLFB) methodology to provide weekly psychiatric symptom ratings (PSRs) for mania and depression based on the number of DSM-IV criteria endorsed: no or minimal symptoms (PSR of 1 or 2), subthreshold symptoms (PSR of 3 or 4), or episode (PSR of 5 or 6).

Clinicians administered the LIFE at baseline and at follow-up assessments. In one study, assessments were conducted at 8-week intervals over a 3-year study period; in a second study, assessments were conducted at 3-month intervals over a 2-year study period. The total duration of manic episodes during 24 months of follow-up (the last 2 years in the first study and both years of the second study) was calculated by summing the number of weeks in which participants had mania PSRs of 3 or higher.
Key Findings In a 3-year study, veterans with bipolar disorder recruited from Veterans Affairs hospitals were randomly assigned to receive the intervention or continued usual care through a current or newly assigned psychiatrist. Over 24 months of follow-up, participants in the intervention group had 4.5 fewer weeks of manic episodes compared with those in the control group (p = .017).

In a 2-year study, patients with bipolar disorder recruited from behavioral health clinics were randomly assigned to receive the intervention or usual care (continued care through their current mental health provider). Over 24 months of follow-up, participants in the intervention group had fewer weeks of clinically significant mania compared with those in the usual care group (19.2 weeks vs. 24.7 weeks; p = .01).
Studies Measuring Outcome Study 1, Study 2
Study Designs Experimental
Quality of Research Rating 3.4 (0.0-4.0 scale)
Outcome 3: Severity of manic symptoms
Description of Measures Severity of manic symptoms was assessed using the Longitudinal Interval Follow-Up Evaluation (LIFE). This semistructured interview uses Timeline Followback (TLFB) methodology to provide weekly psychiatric symptom ratings (PSRs) for mania and depression based on the number of DSM-IV criteria endorsed: no or minimal symptoms (PSR of 1 or 2), subthreshold symptoms (PSR of 3 or 4), or episode (PSR of 5 or 6).

Clinicians administered the LIFE at baseline and at 3-month intervals over a 2-year study period. The total duration of manic episodes over 24 months of follow-up was calculated by summing the number of weeks in which participants had mania PSRs of 3 or higher.
Key Findings Patients with bipolar disorder recruited from behavioral health clinics were randomly assigned to receive the intervention or usual care (continued care through their current mental health provider). The intervention and control groups were equivalent in severity of manic symptoms at baseline. By the end of the 2-year study, the intervention group had a significantly greater reduction in mean level of mania symptoms compared with the control group (p < .05).
Studies Measuring Outcome Study 2
Study Designs Experimental
Quality of Research Rating 3.1 (0.0-4.0 scale)
Outcome 4: Mental health–related quality of life
Description of Measures Mental health–related quality of life was assessed using the mental component score (MCS) from the Medical Outcomes Study 36-item Short Form Health Survey. The Short Form Health Survey was administered by a clinician at baseline and at 24-week intervals over a 3-year study period. Examples of items used to assess mental quality of life include "How much time during the past 4 weeks have you felt calm and peaceful?" and "How much time during the past 4 weeks did you have a lot of energy?" Response options were on a scale from 1 ("all of the time") to 5 ("none of the time").
Key Findings Veterans with bipolar disorder recruited from Veterans Affairs hospitals were randomly assigned to receive the intervention or continued usual care. Over the 3-year study, participants in the intervention group showed a significant improvement in mental health-related quality of life compared with participants in the control group (p < .05). The effect size for this finding was small (Cohen's d = 0.27).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.7 (0.0-4.0 scale)
Outcome 5: Physical health–related quality of life
Description of Measures Physical health–related quality of life was assessed using the Short-Form Health Survey (SF-12), a self-reported measure of general health functioning. The SF-12 generates two subscale scores reflecting physical and mental quality of life. Possible scores on each subscale range from 0 to 100, with higher scores indicating better health. The survey was completed by participants at baseline and at 3- and 6-month follow-up (study duration was 6 months).
Key Findings Veterans with bipolar disorder and cardiovascular disease–related risk factors, recruited from a large Department of Veterans Affairs mental health facility, were randomly assigned to receive the intervention or continued usual care. From baseline to 6-month follow-up, participants in the intervention group showed a slight improvement in physical health–related quality of life, while those in the usual care group showed a decline on this measure (p < .05). The effect size for observed difference was medium (Cohen's d = 0.32).
Studies Measuring Outcome Study 3
Study Designs Experimental
Quality of Research Rating 3.6 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 26-55 (Adult) 91% Male
9% Female
76% White
24% Non-U.S. population
Study 2 26-55 (Adult) 68% Female
32% Male
88% White
12% Race/ethnicity unspecified
Study 3 26-55 (Adult)
55+ (Older adult)
91% Male
9% Female
90% White
10% Black or African American

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

  1. Reliability of measures
  2. Validity of measures
  3. Intervention fidelity
  4. Missing data and attrition
  5. Potential confounding variables
  6. Appropriateness of analysis

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures
Validity
of Measures
Fidelity Missing
Data/Attrition
Confounding
Variables
Data
Analysis
Overall
Rating
1: Affective episodes 4.0 4.0 3.3 3.5 3.5 4.0 3.7
2: Manic episodes 4.0 4.0 2.9 3.1 3.3 3.3 3.4
3: Severity of manic symptoms 4.0 4.0 2.5 2.5 3.0 2.5 3.1
4: Mental health–related quality of life 4.0 4.0 3.3 3.5 3.5 4.0 3.7
5: Physical health–related quality of life 4.0 4.0 3.5 3.5 3.0 3.5 3.6

Study Strengths

All measures used in the studies are well-established, standardized instruments with good reliability and validity. In two of the three studies reviewed, multiple methods were used to monitor fidelity (such as review of sites' caseload of patients with BPD, participants' completion of the first phase of the intervention; the number of unscheduled mental health contacts with mental health providers; care manager logs and chart review), all of which showed acceptable to good levels of program implementation and fidelity. In one study, the use of intent-to-treat analysis and mixed-effects models adequately controlled for attrition. All three studies used a randomized experimental study design. Two studies had an adequate sample size and power. For all studies, the analyses used were appropriate for the study design.

Study Weaknesses

In one study, intervention fidelity was not monitored using a tested instrument. One study had a considerable amount of attrition that was not accounted for in the analyses. In two studies, findings may have been influenced by a number of potential confounds, including medication management of participants, providers' treatment of participants in both study groups, and the provision of make-up sessions by telephone rather than in an in-person, group setting. One study had a small sample size.

Readiness for Dissemination
Review Date: February 2013

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Bauer, M. (2012). The Internal State Scale (ISS) version 2 and the ChronoBook scoring key and summary. Providence, RI: Author.

Bipolar Systems (Internal State Scale)

Health Specialist-Level Fidelity Assessment of Self-Management Session

Kilbourne, A. M. (n.d.). Life Goals Collaborative Care health specialist manual. Ann Arbor, MI: Author.

Kilbourne, A. M. (n.d.). Life Goals Collaborative Care implementation manual. Ann Arbor, MI: Author.

Kilbourne, A. M. (n.d.). Registry fidelity measures: Consumer-level fidelity to the core CCM functions. Ann Arbor, MI: Author.

LGCC Blank Sample Registry [Access database]

Life Goals Collaborative Care consumer workbook. (2010).

Life Goals Collaborative Care Training Evaluation Form

Life Goals Collaborative Care training for bipolar disorder: Agenda. (2009, June 12). Rachel Upjohn Depression Center.

Supplemental Handouts on Facilitating Change in Life Goals: Some MI Epiphanies

Training materials and handouts:

  • Collaborative Care
  • Personal Depression Symptom Profile
  • Physical Health Role Play
  • Working From Your Core Values

Training presentations [PowerPoint slides]:

  • Kilbourne, A., Bauer, M. S., Clogston, J., & Nord, K. (2011). Life Goals Collaborative Care for bipolar disorder: Part 1 and 2.
  • Life Goals Collaborative Care for Bipolar Disorder (for 1-day training)
  • Life Goals Train-the-Trainer
  • Overview of Life Goals Self-Management Sessions (for 1-day training, afternoon only)

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials
Training and Support
Resources
Quality Assurance
Procedures
Overall
Rating
4.0 4.0 3.5 3.8

Dissemination Strengths

The implementation manual is clearly written and comprehensive, covering core program elements, agency readiness, staffing and space requirements, implementation costs, staff training, and health specialists' roles and responsibilities. The health specialist manual provides step-by-step instruction for conducting the sessions and discusses aspects of a culturally competent practice. The available training options address all aspects of implementation. Technical assistance support is provided monthly in multiple formats to assist with issues that arise in program implementation. Several fidelity tools and a sample patient database are provided for outcome monitoring and quality assurance.

Dissemination Weaknesses

No guidance is provided about how supervisors should monitor the quality and fidelity of health specialists' delivery of the intervention.

Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
LGCC Implementation Manual Free Yes
LGCC Provider Manual Free Yes
LGCC Consumer Workbook Free Yes
1-day, off-site Health Specialist training $200 per person, maximum of 30 people Yes
2-day, on-site Health Specialist training and consultation $1,000 plus travel expenses No
2-hour in-service for administrators and staff $275 No
Posttraining technical assistance by email and phone (up to 6 months as needed) Free No
Fidelity measures Free No

Additional Information

A Microsoft Access-based patient registry is available at no cost for sites that would like to use it instead of or in addition to their current documentation process.

Replications

Selected citations are presented below. An asterisk indicates that the document was reviewed for Quality of Research.

Aubry, J. M., Charmillot, A., Aillon, N., Bourgeois, P., Mertel, S., Nerfin, F., … de Andrés, R. D. (2012). Long-term impact of the life goals group therapy program for bipolar patients. Journal of Affective Disorders, 136(3), 889-894.  Pub Med icon

Goodrich, D. E., Kilbourne, A. M., Lai, Z., Post, E. P., Bowersox, N. W., Mezuk, B., … Bauer, M. S. (2012). Design and rationale of a randomized controlled trial to reduce cardiovascular disease risk for patients with bipolar disorder. Contemporary Clinical Trials, 33(4), 666-678.  Pub Med icon

Kilbourne, A. M., Goodrich, D. E., Lai, Z., Post, E. P., Schumacher, K., Nord, K. M., … Bauer, M. S. (2013). Randomized controlled trial to assess reduction of cardiovascular disease risk in patients with bipolar disorder: The Self-Management Addressing Heart Risk Trial (SMAHRT). Journal of Clinical Psychiatry, 74(7), e655-e662.  Pub Med icon

Kilbourne, A. M., Goodrich, D. E., Lai, Z., Clogston, J., Waxmonsky, J., & Bauer, M. S. (2012). Life Goals Collaborative Care for patients with bipolar disorder and cardiovascular disease risk. Psychiatric Services, 63(12), 1234-1238.  Pub Med icon

Kilbourne, A. M., Li, D., Lai, Z., Waxmonsky, J., & Ketter, T. (2013). Pilot randomized trial of a cross-diagnosis collaborative care program for patients with mood disorders. Depression and Anxiety, 30(2), 116-122.  Pub Med icon

Van der Voort, T. Y., van Meijel, B., Goossens, P. J., Renes, J., Beekman, A. T., & Kupka, R. W. (2011). Collaborative care for patients with bipolar disorder: A randomised controlled trial. BMC Psychiatry, 11, 133.  Pub Med icon

Contact Information

To learn more about research, contact:
Amy M. Kilbourne, Ph.D., M.P.H.
(734) 845-3502
amykilbo@umich.edu

To learn more about implementation or research, contact:
Mark S. Bauer, M.D.
(857) 364-6380
Mark.Bauer@va.gov

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.