Depression Program Promising In Primary Care Settings

Participating in a program that gives primary care practitioners the tools they need to diagnose and treat patients with depression properly was found to reduce the duration of patients’ depression by more than a month. The program also increased the time that depressed patients worked by just as much, according to a new study from RAND.

Primary care physicians have a poor track record when it comes to diagnosing and treating people with depression. The latest proof is published in the January 2001 issue of the Archives of General Psychiatry in the article “The Quality of Care for Depressive and Anxiety Disorders in the U.S.”

Investigators found that only 19 percent of patients with probable depressive or anxiety disorders received appropriate care from primary care practitioners.

To address this problem, RAND created the Partners in Care program. Researchers established and evaluated the cost of two quality improvement (QI) strategies—medications and therapy—so that patients could receive more effective care for depression in the primary care setting.

The results from the study appear in the September 19 issue of the Journal of the American Medical Association.

The study used primary care teams consisting of primary care physicians who collaborated with a “mental health specialist”—usually a psychiatrist or psychologist—and a “depression nurse specialist,” who could be a general or psychiatric nurse, at 46 primary care clinics across the country.

Researchers did not choose the clinics by random sample, but instead approached a number of managed care organizations to ask whether they would be interested in participating in the Partners in Care program. The clinics were varied in terms of geographical location, types of patients served, and organizational structure.

Primary care practitioners at the clinics underwent training sessions in which they received educational materials on the diagnosis and treatment of depression and instructions on how to use them. The practitioners included internists, family practitioners, and nurse practitioners.

“This program provided more than training to primary care providers,” said Kenneth Wells, M.D., M.P.H., a coinvestigator on the study and a professor of psychiatry at the University of California, Los Angeles. “We provided them with a depression toolkit and trained the practices to implement their own comprehensive quality improvement for depression.”

Wells said that after the researchers provided instruction, the primary care practices made their own decisions about how to use the program materials and administer treatments to patients.

The depression toolkit included patient education pamphlets and videotapes on depression and patient-tracking forms. It also included a clinician guide, based on the Agency for Healthcare Research and Quality depression guidelines, which first lists the symptoms of depression and then recommends assessment and treatment options. Pocket reminder cards summarize key points from the guide.

Primary care clinics were randomized to one of the two QI interventions, while others were randomized to provide “usual care,” which was whatever care the patient would have received without a study intervention.

For primary care clinics randomized to the QI therapy intervention, researchers provided mental health specialists with several books on cognitive-behavioral therapy (CBT) and trained them to use it for the study. Following initial training, CBT experts supervised a case for each participating therapist by reviewing weekly videotapes. Patients receiving QI therapy then received eight to 12 weeks of CBT with the therapist.

For clinics randomized to the QI medication intervention, primary care teams received training on the effectiveness and potential side effects of selective serotonin reuptake inhibitors and tricyclic antidepressants. Researchers also trained the teams to monitor closely the patients’ response to the medications.

The study, which followed 1,356 patients with depression for a two-year period ending in July 1999, assessed patient outcomes at six-month intervals.

Researchers found that overall the QI programs resulted in better outcomes for patients with depression than did usual care. Patients in clinics using the therapy intervention reported being depressed for 47 fewer days than patients receiving usual care, and patients receiving the medication intervention reported being depressed for 25 fewer days.

Patients who had the medication or therapy intervention were able to work more days compared with patients in primary care clinics practicing routine care. Those who participated in the therapy intervention worked for 21 more days, and those in the medication intervention worked 18 more days.

“This is the first time a study has shown that better depression care actually improves the employment rate for an at-risk population,” said Wells.

While providing what seems to be more comprehensive and consistent care to patients, the QI interventions cost more than the usual care that a patient would receive in a primary care clinic—almost $500 per patient for the two-year study period, researchers estimated. Average health care costs for each patient in usual care came to about $3,800, increasing by $419, or 11 percent, for patients undergoing the QI medications, and $485, or 13 percent, for patients undergoing QI therapy.

“Is $250 a year for quality improvement good value?,” asked economist Michael Shoenbaum, Ph.D., lead author on the article. “Many patients going through a bout of serious depression might be glad to pay that much for even a day’s relief,” he said in an interview with Psychiatric News.

“This seems to be very good news for medical practice,” Wells said, “suggesting that a clinically reasonable and operationally feasible intervention involving primary care and specialty partnerships with patients can be implemented in diverse organizations and improve outcomes.” ▪