Characteristics of Effective Collaborative Care for Treatment of Depression: A Systematic Review and Meta-Regression of 74 Randomised Controlled Trials

Abstract

BackgroundCollaborative care is a complex intervention based on chronic disease management models and is effective in the management of depression. However, there is still uncertainty about which components of collaborative care are effective. We used meta-regression to identify factors in collaborative care associated with improvement in patient outcomes (depressive symptoms) and the process of care (use of anti-depressant medication).Methods and FindingsSystematic review with meta-regression. The Cochrane Collaboration Depression, Anxiety and Neurosis Group trials registers were searched from inception to 9th February 2012. An update was run in the CENTRAL trials database on 29th December 2013. Inclusion criteria were: randomised controlled trials of collaborative care for adults ≥18 years with a primary diagnosis of depression or mixed anxiety and depressive disorder. Random effects meta-regression was used to estimate regression coefficients with 95% confidence intervals (CIs) between study level covariates and depressive symptoms and relative risk (95% CI) and anti-depressant use. The association between anti-depressant use and improvement in depression was also explored. Seventy four trials were identified (85 comparisons, across 21,345 participants). Collaborative care that included psychological interventions predicted improvement in depression (β coefficient −0.11, 95% CI −0.20 to −0.01, p = 0.03). Systematic identification of patients (relative risk 1.43, 95% CI 1.12 to 1.81, p = 0.004) and the presence of a chronic physical condition (relative risk 1.32, 95% CI 1.05 to 1.65, p = 0.02) predicted use of anti-depressant medication.ConclusionTrials of collaborative care that included psychological treatment, with or without anti-depressant medication, appeared to improve depression more than those without psychological treatment. Trials that used systematic methods to identify patients with depression and also trials that included patients with a chronic physical condition reported improved use of anti-depressant medication. However, these findings are limited by the observational nature of meta-regression, incomplete data reporting, and the use of study aggregates.

Collaborative Care for Anxiety Disorders in Primary Care: a Systematic Review and Meta-Analysis

“…We found that studies performed in the US had a greater effect size compared to European studies, which is in contrast with previous findings [25]. The US studies were also considerably more homogeneous than the European studies, which may be related to similarities and differences in healthcare systems between the US and Europe [16].…”

Clinical effectiveness and cost-effectiveness of collaborative care for depression in UK primary care (CADET): a cluster randomised controlled trial

“…Our observed effect size was less than that used to power the study, although the 95% CI around it (0.26, 95% CI 0.07 to 0.46) encompassed our original target (0.4). Our result also lies within the 95% CI of the SMD found in the most recent meta-analysis of collaborative care, 73 which includes our results (overall SMD 0.28, 95% CI 0.23 to 0.33), and is no different from US (SMD 0.28, 95% CI 0.21 to 0.35), non-US excluding the UK (SMD 0.36, 95% CI 0.13 to 0.59), and other UK (SMD 0.32, 95% CI 0.07 to 0.57) trials. 23 Collaborative care is as effective in the UK health-care system, an example of an integrated health system with a well-developed primary care sector, as in the USA.…”

Cognitive–behavioural therapy and short-term psychoanalytic psychotherapy versus brief psychosocial intervention in adolescents with unipolar major depression (IMPACT): a multicentre, pragmatic, observer-blind, randomised controlled trial

“…69,70 The incorporation of collaborative care for depression in adults has been shown to provide added value for the treatment of depression in adults over and above psychological and/or medication treatments. 71,72 The BPI treatment manualised for this study emerged from the treatment as usual in ADAPT. The intervention is a treatment based on restructuring and codification of the principles and practices found in the domains of skilled assessment, listening, information-giving, advising, problem-solving, safety, caring and explaining about adolescent depression.…”