Managing depression as a chronic disease: a randomised trial of ongoing treatment in primary care

Abstract

Objectives To evaluate the long term effect of ongoing intervention to improve treatment of depression in primary care. Design Randomised controlled trial. Setting Twelve primary care practices across the United States. Participants 211 adults beginning a new treatment episode for major depression; 94% of patients assigned to ongoing intervention participated. Intervention Practices assigned to ongoing intervention encouraged participating patients to engage in active treatment, using practice nurses to provide care management over 24 months. Main outcome measures Patients' report of remission and functioning. Results Ongoing intervention significantly improved both symptoms and functioning at 24 months, increasing remission by 33 percentage points (95% confidence interval 7% to 46%), improving emotional functioning by 24 points (11 to 38) and physical functioning by 17 points (6 to 28). By 24 months, 74% of patients in enhanced care reported remission, with emotional functioning exceeding 90% of population norms and physical functioning approaching 75% of population norms. Conclusions Ongoing intervention increased remission rates and improved indicators of emotional and physical functioning. Studies are needed to compare the cost effectiveness of ongoing depression management with other chronic disease treatment routinely undertaken by primary care.

Training Primary Care Physicians to Employ Self-Efficacy-Enhancing Interviewing Techniques: Randomized Controlled Trial of a Standardized Patient Intervention

“…30 Primary care physicians provide the bulk of care for individuals with depression, diabetes, and other chronic illnesses, 37 and research indicates that enhancing self-efficacy can improve health behaviors and outcomes among chronically ill patients. [19][20][21][22][23][24][25][26][27][28][29] Prior studies also indicate that physicians' behaviors during standardized patient encounters correlate with their behaviors during real patient visits. 38,39 In this context, the combined findings of our practicing PCP- Additional studies are warranted to examine whether the effects we observed will generalize to real patients and will lead to improved health behaviors and outcomes.…”

“…The techniques were drawn from self-efficacy theory, other relevant behavioral theories, direct observation of primary care, and research-proven approaches to enhancing self-efficacy and promoting healthy behaviors. [19][20][21][22][23][24][25][26][27][28][29] Figure 1 Study self-efficacy-enhancing interviewing techniques and their presentation sequence.…”

“…19 Theory and research indicate that self-efficacy influences myriad behaviors and can be strengthened by interventions, improving health outcomes. [19][20][21][22][23][24][25][26][27][28][29] We had previously developed a brief intervention for training resident primary care physicians (PCPs) to use self-efficacy-enhancing interviewing techniques (SEE IT). 30 The intervention was grounded in self-efficacy theory, and informed by prior interventions shown to bolster self-efficacy and improve health behaviors and outcomes.…”

Managing complex problems: treatment for common mental disorders in the UK

“…A model of care suited to chronic diseases has been effectively used for medical conditions such as hypertension, diabetes, and asthma, and evidence from well-conducted primary care based studies indicates that this approach is effective for depression (Rost et al, 2002;Dietrich et al, 2004). It appears that the principles of this management approach -explicit evidence-based guidelines, patient education for self-management, stepped care involvement of specialist resources, links with community resources -together with the organisational changes required to embed these approaches within services (information systems such as patient registers, reminders, progress indicators; and new staff roles and ways of working such as primary care nurse case managers, and tele-support) are a central part of effective interventions strategies (Von Korff & Goldberg, 2001).…”

Design of the Coordinated Anxiety Learning and Management (CALM) study: innovations in collaborative care for anxiety disorders

“…One approach to improve mental health care in primary care settings is the "collaborative care" model [4][5][6][7], closely patterned on the "chronic disease model" [8]. Various forms of the collaborative care model have been tested but some features are common to all.…”