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Systematic review with meta-analysis.
MEDLINE, HealthSTAR, and Cochrane databases searched January 1987 to June 2001 for English language articles, plus hand searches of bibliographies and contact with experts.
Study selection and analysis:
Inclusion criteria: experimental or quasi-experimental studies assessing systematic approaches to care using multiple types of treatment modalities—for example, guidelines, protocols, algorithms, or care plans, and using multiple types of treatment modalities—for example, education, reminders, and financial incentives for patients and providers. Exclusion criteria: studies reporting on single treatment types or on paediatric cases only, or lacking sufficient information to calculate an effect size. Data were extracted and study effect sizes calculated and pooled using a random effects model.
Eight care outcomes, five process outcomes (see www.ebmentalhealth.com/supplemental for table).
Nineteen studies met inclusion criteria (including 17 RCTs); 24 disease management programmes were studied. Study size ranged from 65–6055 participants and duration from 6–30 months. Disease management programmes significantly improved depression symptoms, patient satisfaction, adequacy of drug treatment, and patient adherence to treatment compared with usual care (see http://www.ebmentalhealth.com/supplemental for table). In addition, disease management programmes produced a slightly significant increase in primary care visits. The other outcomes showed no significant differences between groups.
Disease management programmes can improve outcomes and quality of care for people with depression.
Publication bias was detected, showing an absence of small negative studies.
Most depression is managed in primary care, with no input from specialist psychiatric or psychological services. Successive surveys have shown that pharmacological care for depression is inadequate and there is poor provision and uptake of psychological services.1 Strategies should therefore aim to improve the quality of care and should be targeted within primary care services.
Depression can be understood as a complex and chronic disease and interventions can be targeted to improve the quality of care using strategies such as guidelines, changes in the organisation and delivery of care, clinician education, and improved working between primary and secondary care.2
Badamgarav and colleagues synthesise rigorous evaluations of disease management programmes for depression. Their finding that depression management programmes improve depression outcomes, medication concordance and patient satisfaction are encouraging, and are in line with other reviews in this area.3
The interventions included in this review vary in intensity from simple telephone follow up of people with depression to check they are taking their tablets, through to complex interventions which combine screening, clinician education, case management, and support from secondary care. The approach of pooling diverse interventions has been resisted by others3 and it is difficult to establish which component of disease management is the “active ingredient”. Case management seems to be a likely candidate.2,3
Chronic disease management is an idea from the United States and this is the origin of most of the studies in this review. Caution should be applied in directly extrapolating the results of this review to other healthcare systems. A further finding of this and other reviews is that disease management programmes potentially cost a lot and increase healthcare use. Cost effectiveness will vary between healthcare systems and may well prohibit the implementation of this research in less well resourced healthcare systems. A key area for further research is therefore to identify the active ingredients of enhanced care for depression and to establish the most cost effective approach in healthcare settings other than the US.
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Files in this Data Supplement:
- [View PDF] - Table Pooled effect sizes of disease management programmes. Significant results are presented in bold
For correspondence: Enkhe Badamgarav, Cerner Health Insights, 9100 Wilshire Blvd., East Tower, Suite 655, Beverly Hills, California, USA, 90212;
Sources of funding: funded in part by TAP Pharmaceutical Products Inc. (Lake Forest, IL, USA) and Zynx Health (Beverly Hills, CA, USA).
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