Psychiatrists Don't Let Poverty Be Bar to Depression Care

Nine years ago, Greg Simon, M.D., took a sabbatical from his work as an investigator at the Center for Health Studies at the Group Health Cooperative in Seattle. He went to live in Chile. There, he came to know Chilean psychiatrist and researcher Ricardo Araya, M.D., Ph.D.

What Simon and Araya did not anticipate at the time was that they, along with other Chilean colleagues, were going to alter dramatically the delivery of depression treatment in Chile.

It all started with Simon and Araya discussing the plight of depressed, low-income women in Chile. They wondered whether a depression-treatment program introduced into government-funded primary-care clinics might help these women since such clinics are the major source of health care for the poor in Chile. And because these clinics are underfunded and underresourced, such a program, they envisioned, would be a simple add-on to operation as usual.

Several nurses or social workers at each clinic would be trained to provide group psychotherapy and teach problem-solving techniques to depressed women visiting the clinic, as well as monitor the women's treatment progress and act as the women's care managers. If a patient were severely or persistently depressed, her care manager would consult with a clinic doctor about treatment. If the doctor decided to prescribe an antidepressant for her, it would be generic, not name brand, which is considerably cheaper in Chile. And if the doctor decided that she needed a psychiatric assessment, it would be arranged.

Simon and Araya then applied for a grant from the U.S. National Institute of Mental Health (NIMH) to study whether their conceptualized program might be clinically effective. The grant came through after Simon returned to Seattle, so it was Ricardo and his colleagues in Chile who conducted the study, with some long-distance consultation from Simon.

A total of 240 women diagnosed with major depression agreed to participate in the study. They were randomized to either the depression-treatment program or usual care in a primary-care clinic, which might include antidepressant medication or a referral for a psychiatric assessment.

Intervention Subjects Did Better

Subjects in the intervention group showed large and significantly better symptom and functional outcomes at three and six months relative to those in usual care, the investigators reported in the March 22, 2003, Lancet.

Although the researchers are not sure why subjects in the intervention group did better than those in the control group, they believe that it was due, at least in part, to the use of antidepressants. Antidepressants, they learned, had been prescribed more often, and for a longer duration, for the intervention group than for the control group. However, when the researchers adjusted their data for antidepressant use, subjects in the intervention group still did significantly better. The investigators suspected that group psychotherapy and systematic follow-up also contributed to the intervention group's superior outcome.

After that, Simon, Araya, and their group set out to conduct a study of how the costs of their program compared with the costs of the “usual” depression care offered in the government-funded, primary-care clinics. This inquiry was also financed by NIMH.

Their program turned out to be more expensive, but only marginally so, they reported in the August American Journal of Psychiatry. Or as Simon explained during an interview, “The extra cost per person per year to keep them depression free was 10,000 Chilean pesos—that is, on the order of $25.” This compares very favorably with the costs of innovative depression-treatment programs in the United States, which usually cost a few hundred dollars extra per person per year, Simon said.

In fact, Simon explained, “You are starting in the United States with a place where people are getting moderately good care, and you are trying to change moderately good to good, but in the developing world, you are usually starting from a place where people aren't getting any care at all, so there is a lot more room for improvement. And since there is a lot more room for improvement, with a relatively modest investment, you get more out of it.”

Selling the Program

Then came the biggest challenge—getting the Chilean government to implement the program in its public health care system.

“There were both scientific and political issues,” Simon explained. “You have to have the evidence that it is effective, but you also have to establish connections with people who have the decision-making power. So Ricardo and I were really working both of those issues—doing the study to generate the scientific evidence, but also working with people in the ministry of health to develop relationships there, to make it happen.”

And it did. The program is now being implemented in the Chilean public primary-care system, which serves about a third of the Chilean population, Simon said.

Flush with victory, Simon, Araya, and their colleagues are asking: Might the same program also prove to be clinically effective in Chile's privately funded health care sector? “We're trying to get some funding to find out,” he said.

Finally, might the same program also benefit depressed women in other Latin American countries? Simon, Araya, and their team would like to determine that as well.

An abstract of “Treating Depression in Primary Care in Low-Income Women in Santiago, Chile: A Randomized Controlled Trial” is posted at<www.thelancet.com/journals/lancet/article/PIIS0140673603128255/abstract>.“ Cost-Effectiveness of a Primary Care Treatment Program for Depression in Low-Income Women in Chile” is posted at<http://ajp.psychiatryonline.org/cgi/content/full/163/8/1362>.▪