No abstract

Nurse telehealth care improves clinical outcomes of antidepressant drug treatment and patient satisfaction and fits well within busy primary care settings.

Objective To determine the long term effectiveness of collaborative care management for depression in late life. Design Two arm, randomised, clinical trial; intervention one year and follow-up two years. Setting 18 primary care clinics in eight US healthcare organisations. Patients 1801 primary care patients aged 60 and older with major depression, dysthymia, or both. Intervention Patients were randomly assigned to a 12 month collaborative care intervention (IMPACT) or usual care for depression. Teams including a depression care manager, primary care doctor, and psychiatrist offered education, behavioural activation, antidepressants, a brief, behaviour based psychotherapy (problem solving treatment), and relapse prevention geared to each patient's needs and preferences. Main outcome measures Interviewers, blinded to treatment assignment, conducted interviews in person at baseline and by telephone at each subsequent follow up. They measured depression (SCL-20), overall functional impairment and quality of life (SF-12), physical functioning (PCS-12), depression treatment, and satisfaction with care. Results IMPACT patients fared significantly (P < 0.05) better than controls regarding continuation of antidepressant treatment, depressive symptoms, remission of depression, physical functioning, quality of life, self efficacy, and satisfaction with care at 18 and 24 months. One year after IMPACT resources were withdrawn, a significant difference in SCL-20 scores (0.23, P < 0.0001) favouring IMPACT patients remained. Conclusions Tailored collaborative care actively engages older adults in treatment for depression and delivers substantial and persistent long term benefits. Benefits include less depression, better physical functioning, and an enhanced quality of life. The IMPACT model may show the way to less depression and healthier lives for older adults.

Risk adjustment for physical health is essential when setting performance standards or cost expectations for mental health treatment. Excluding persons with chronic health problems from mental health service evaluations restricts generalizability of research findings and may promote interventions that are inappropriate for many persons with serious mental illness.

These findings reaffirm the value of antipsychotic medication in preventing relapse and rehospitalization. The absence of family treatment differences may be because both conditions engaged families.

The prevention of major depression is an important research goal which deserves increased attention. Depressive symptoms and disorders are particularly common in primary care patients and have a negative impact on functioning and well-being comparable with other major chronic medical conditions. The San Francisco Depression Prevention Research project conducted a randomized, controlled, prevention trial to demonstrate the feasibility of implementing such research in a public sector setting serving low-income, predominantly minority individuals: 150 primary care patients free from depression or other major mental disorders were randomized to an experimental cognitive-behavioral intervention or to a control condition. The experimental intervention group reported a significantly greater reduction in depressive levels. Decline in depressive levels was significantly mediated by decline in the frequency of negative conditions. Group differences in the number of new episodes (incidence) of major depression did not reach significance during the 1-year trial. We conclude that depression prevention trials in public sector primary care settings are feasible, and that depressive symptoms can be reduced even in low-income, minority populations. To conduct randomized prevention trials that can test effects on incidence with sufficient statistical power, subgroups at greater imminent risk have to be identified.

Connecticut State Hospital's entire resident population (n = 1,300) was screened on an arbitrary target day to determine eligibility for clozapine. Sixty percent of 803 patients with schizophrenia or schizoaffective disorder diagnoses met Food and Drug Administration (FDA)- approved criteria for clozapine use as judged by review of past medication trial records and by the responsible physicians. Eighty-eight percent of these patients were medically cleared, and of those cleared, 63 percent agreed to clozapine treatment. Of the patients who began a clozapine trial, 76 percent were still taking the drug 12 months later. Preliminary findings from a randomized trial of clozapine versus usual care (n = 227) indicate that discharge rates associated with clozapine and usual care do not differ. Once discharged, however, patients assigned to clozapine are less likely to be readmitted. Hence, clozapine may be more cost-effective than usual care. However, before savings can be realized, State governments will have to make up-front investments of approximately $140 million simply to give patients hospitalized on a single day a year's access to clozapine.

Clozapine demonstrated cost-effectiveness on some but not all measures of effectiveness when the alternative was a range of conventional antipsychotic medications.