Depression Outcomes in Adults Attending Family Practice Were Not Improved by Screening, Stepped-Care, or Online CBT during a 12-Week Study when Compared to Controls in a Randomized Trial

Abstract

There is uncertainty regarding possible benefits of screening for depression in family practice, as well as the most effective treatment approach when depression is identified. Here, we examined whether screening patients for depression in primary care, and then treating them with different modalities, was better than treatment-as-usual (TAU) alone. Screening was carried out for depression using the 9-item Patient Health Questionnaire (PHQ-9), with a score of ≥10 indicating significant depressive symptoms. PHQ-9 scores were given to family physicians prior to patients being seen (except for the Control group). Patients (n = 1,489) were randomized to one of four groups. Group #1 were controls (n = 432) in which PHQ-9 was administered, but results were not shared. Group #2 was screening followed by TAU (n = 426). Group #3 was screening followed by both TAU and the opportunity to use an online cognitive behavioral therapy (CBT) treatment program (n = 440). Group #4 utilized an evidence-based Stepped-care pathway for depression (n = 191, note that this was not available at all clinics). Of the study sample 889 (60%) completed a second PHQ-9 rating at 12 weeks. There were no statistically significant differences in baseline PHQ-9 scores between these groups. Compared to baseline, mean PHQ-9 scores decreased significantly in the depressed patients over 12 weeks, but there were no statistically significant differences between any groups at 12 weeks. Thus, for those who were depressed at baseline Control group (Group #1) scores decreased from 15.3 ± 4.2 to 4.0 ± 2.6 (p < 0.001), Screening group (Group #2) scores decreased from 15.5 ± 3.9 to 4.6 ± 3.0 (p < 0.001), Online CBT group (Group #3) scores decreased from 15.4 ± 3.8 to 3.4 ± 2.7 (p < 0.01), and the Stepped-care pathway group (Group #4) scores decreased from 15.3 ± 3.6 to 5.4 ± 2.8 (p < 0.05). In conclusion, these findings from this controlled randomized study do not suggest that using depression screening tools in family practice improves outcomes. They also suggest that much of the depression seen in primary care spontaneously resolves and do not support suggestions that more complex treatment programs or pathways improve depression outcomes in primary care. Replication studies are required due to study limitations.

The effectiveness and cost-effectiveness of e-health interventions for depression and anxiety in primary care: A systematic review and meta-analysis

“…1). Finally, we included 14 relevant RCTs comparing 33 treatments in 4183 participants (Hallgren et al, 2016;Kivi et al, 2014;Hoifodt et al, 2013;Levesque et al, 2011;Moreno et al, 2012;Montero-Marin et al, 2016;Nordgren et al, 2014;Simon et al, 2011;Silverstone et al, 2017;Salisbury et al, 2016;Gilbody et al, 2015;Hilty et al, 2007;Kessler et al, 2009;Burton et al, 2016).…”

Which instruments to support diagnosis of depression have sufficient accuracy? A systematic review

“…A second systematic review [67] found that quality improvement programs, where screening was an integral part of the management, led to a reduction in depression scores. However, a recent study, where patients were randomized to screening with the PHQ-9 to guide management, concluded that screening had no impact on outcome after 12 weeks [68].…”

Patterns of change and their relationship to outcome and follow-up in group and individual psychotherapy for depression.

“…Our findings are relevant from a cost-efficacy perspective, because if patients are properly assessed at the beginning, they can be promptly assigned to the most suitable therapeutic modality, thus saving unnecessary care costs and multiple futile efforts (Meeuwissen et al, 2019). In stepped care models, low-intensity treatment is recommended for all patients, and those who do not improve in the first step are referred to a high-intensity treatment (Bower & Gilbody, 2005;Silverstone et al, 2017; The National Institute for Health and Care Excellence -NICE, 2018). The results of this approach are likely to improve if patients who will not benefit from the low-intensity treatment, but may benefit from the high-intensity modality, can be identified at baseline (Lorenzo-Luaces, DeRubeis, van Straten, & Tiemens, 2017).…”