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
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
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.
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,
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
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
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,
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
An abstract of "Treating Depression in Primary Care in
Low-Income Women in Santiago, Chile: A Randomized Controlled Trial" is
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>.▪