Improving depression outcomes in community primary care practice

Abstract

OBJECTIVE: To determine whether redefining primary care team roles would improve outcomes for patients beginning a new treatment episode for major depression. DESIGN:Following stratification, 6 of 12 practices were randomly assigned to the intervention condition. Intervention effectiveness was evaluated by patient reports of 6-month change in 100-point depression symptom and functional status scales. SETTING:Twelve community primary care practices across the country employing no onsite mental health professional.PATIENTS: Using two-stage screening, practices enrolled 479 depressed adult patients (73.4% of those eligible); 90.2% completed six-month follow-up. INTERVENTION:Two primary care physicians, one nurse, and one administrative staff member in each intervention practice received brief training to improve the detection and management of major depression. MAIN RESULTS:In patients beginning a new treatment episode, the intervention improved depression symptoms by 8.2 points (95% confidence interval [CI], 0.2 to 16.1; P = .04). Within this group, the intervention improved depression symptoms by 16.2 points (95% CI, 4.5 to 27.9; P = .007), physical role functioning by 14.1 points (95% CI, 1.1 to 29.2; P = .07), and satisfaction with care (P = .02) for patients who reported antidepressant medication was an acceptable treatment at baseline. Patients already in treatment at enrollment did not benefit from the intervention. CONCLUSIONS:In practices without onsite mental health professionals, brief interventions training primary care teams to assume redefined roles can significantly improve depression outcomes in patients beginning a new treatment episode. Such interventions should target patients who report that antidepressant medication is an acceptable treatment for their condition. More research is needed to determine how primary care teams can best sustain these redefined roles over time.

Reduction of Patient-Reported Antidepressant Side Effects, by Type of Collaborative Care

“…Using a rating scale from 1 to 5, with 1 indicating “strongly agree” and 5 indicating “strongly disagree,” subjects were asked whether they would be concerned about side effects if they took antidepressant medications (24), and to rate the extent to which they felt antidepressant medications were effective in treating depression. Using a scale from 1 to 4, with 1 indicating “definitely acceptable” and 4 indicating “definitely not acceptable,” subjects were asked to rate the extent to which they viewed taking antidepressants as acceptable for treating depression (19,20). …”

“…Trials of collaborative care have demonstrated increased initiation of and adherence to antidepressant therapy (19–21). However, to the best of our knowledge, no studies have examined the impact of collaborative care models on the side effects reported by patients.…”

Is the United States Preventive Services Task Force still a voice of caution?

“…[20][21][22][23] According to the task force, these trials "screened all patients for depression, enrolled only those screening positive, and returned results of screening to clinicians in the intervention group only." 10 The USPSTF told The BMJ that, if anything, this would have led to more conservative estimates of screening benefit.…”

“…24 Critics point out, however, that none of the four studies included an unscreened control group, and three of the studies compared optimized with usual care, meaning that any benefit in health outcomes could be because of optimized care and not screening (though not all found a benefit). [20][21][22][23] The fourth study provided usual care to both arms but found that the intervention arm, in which providers were told of screening results, "did not lead to improved patient outcomes." 22 Wanda Filer, president of the American Academy of Family Physicians, told The BMJ that the academy supported the task force recommendations on depression screening.…”

Contents of General Practitioner-Patient Consultations in the Treatment of Depression

“…As mentioned, we found some differences in reported emphases from recommended guidelines, e.g., WHO guideline for the management of depression. 10 This could stimulate and guide educational programs 10,15,[18][19][20][21][22] and possibly also help to develop guidelines that have a better fit with clinical reality. There are several limitations to this study.…”