Depressed Patients Do Better When They Get RESPECT

A manualized program for treating depression in primary care settings that emphasizes collaboration between psychiatrists and primary care physicians—as well as telephone case management—appears to offer significant improvement in patient outcome over standard care.

In a randomized clinical trial involving three large medical group practices, two health plans, and more than 400 patients, the manualized program, called “Re-Engineering Systems for the Primary Care Treatment of Depression” (RESPECT-Depression), was found to significantly improve response to treatment, rates of remission, and satisfaction with care.

A report on the trial appears in the September British Medical Journal (BMJ).

Developed by the MacArthur Initiative on Depression and Primary Care, RESPECT-Depression integrates work by primary care clinicians who manage patients, centralized care managers who provide telephone support, and psychiatrists who supervise the care managers and offer suggestions to clinicians about treatment and management.

At each practice, clinicians and staff are trained using materials developed by RESPECT-Depression researchers and customized to each setting by the organizations.

The MacArthur Initiative is making the RESPECT-Depression materials available at no cost to medical practices that want to adopt it. Those materials can be downloaded from the Web at<www.depression-primarycare.org/clinicians/re_engineering/>.

The essential components include training primary care clinicians in the use of the RESPECT-Depression materials, telephone care management, and closer relationships between mental health and primary care clinicians, said Allen Dietrich, M.D., a professor of community and family medicine at Dartmouth Medical School and co-chair of the MacArthur Initiative.

“Professionals work together through these three components and provide more systematic patient education, promotion of patient self-management, and monitoring of suicide risk. Especially important is supporting modification of the management plan if the patient's symptoms are not improving.”

Follow-up Much More Likely

In the study, 405 patients with depression were randomly assigned to treatment using the RESPECT-Depression model or standard care. At six months, 60 percent of 177 patients receiving the intervention had responded to treatment compared with 47 percent of 146 patients in usual-care practices. At six months, 37 percent of the intervention patients showed remission compared with 27 percent of the usual-care patients.

Ninety percent of the intervention patients rated their depression care as good or excellent at six months compared with 75 percent of usual-care patients.

The organizations participating in the clinical trial were Intermountain Health Care in Salt Lake City, Colorado Access in Denver, Highmark Blue Cross Blue Shield in Pittsburgh, and ProHealth Physicians Group in Bloomfield, Conn. The evaluation center was led by Herbert C. Schulberg, Ph.D., and was based at Cornell University.

Dietrich said physicians using the intervention were found by independent evaluators to be more thorough about evaluating suicide risk, more likely to hand patients educational material about depression, and more likely to promote self-management on behalf of the patient.

“It's also true that the RESPECT patients were much more likely to get a series of follow-up contacts from the clinician,” Dietrich said.“ They had both more follow-up visits over the three months following the index visit—following the first visit. And they were also much, much more likely to get a telephone support call.”

Treating Returning Soldiers

The military is also interested in adopting the model for treatment of soldiers returning from overseas.

In a teleconference press briefing about the BMJ report, Charles C. Engel, M.D., director of the Defense Department's Deployment Health Clinical Center at Walter Reed Army Medical Center in Washington, D.C., said the center is working with the RESPECT-Depression team to develop a modified model of the approach that will help meet the post-war primary care needs of returning soldiers and their families.

“The RESPECT model could improve early access to needed services, improve the effectiveness of those services, and reduce stigma by locating the care in a primary care setting,” said Engel.

APA's Darrel Regier, M.D., M.P.H., who also participated in the teleconference, called RESPECT an “excellent” model that can be integrated into similar programs for other chronic diseases at the primary care setting, so that it would not require additional staffing beyond what is already available.

Regier is head of APA's Office of Research and the American Psychiatric Institute for Research and Education.

“I think a major problem is probably disseminating it to the smaller office practices that don't have additional staff available and that don't already have a preexisting infrastructure of the type that the five organizations had,” Regier said. “But if, in fact, this model can be demonstrated to be sustained, I think it will be a very nice contribution.”

Regier added that the RESPECT model supports the close monitoring of antidepressant medication use—especially around suicidal ideation.“ If physicians were using this kind of instrument on a routine basis, they would be able to address the safety issues that have been raised,” Regier said.

The report, “Re-engineering Systems for the Treatment of Depression in Primary Care: Cluster Randomised Controlled Trial,” is posted online at<www.depression-primarycare.org/images/pdf/bmj.pdf>.▪