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Primary care clinics of 3 health management organisations (HMOs) in the US (Wisconsin, Washington, and Massachusetts).
407 patients who were 25–63 years of age (mean age 45 y, 77% women) with continuous health plan enrolment for ≥2 years, were frequent healthcare users (ambulatory visits per year above the 85th percentile for previous 2 years), and screened positive for current major depression or major depression in partial remission with a score ≥15 on the Hamilton Depression Rating Scale (HDRS). 47% had ≥1 chronic medical disorder. Exclusion criteria included recent treatment for substance abuse, previous treatment for schizophrenia or bipolar disorder, life threatening medical illness, or active mental health specialty treatment for depression. 93% of patients completed the blinded telephone assessment at 12 months.
82 physician practices were allocated to the depression management programme (DMP) (n=218), and 81 were allocated to usual care (n=189). DMP consisted of physician education (2 hour training session and provision of psychiatrists as consultants at each HMO), patient education (a booklet entitled Depression isn't just a medical problem and videotaped educational materials), antidepressant treatment (pharmacotherapy algorithm adjusted for individual clinical need), and treatment coordination.
Main outcome measures
Change in HDRS scores and number of healthcare visits.
Analysis was by intention to treat. Patients in the DMP group had greater improvements in depression score at 6 weeks (p=0.04), 3 months (p=0.02), 6 months (p<0.001), and 12 months (p<0.001) than patients in the usual care group (table⇓). Patients in the DMP group had more healthcare visits (mean increase 1.6 visits) during 12 months of follow up relative to the previous year whereas patients in the usual care group had a decrease in healthcare visits (mean decrease 2.0 visits) (p=0.02 for the difference between groups).
In depressed patients who are frequent users of general medical care, a depression management programme led to greater clinical improvement but did not decrease healthcare visits.
Depressive illness is common, disabling, and mostly managed in primary care without recourse to specialist services. Received wisdom is that management is suboptimal: up to 50% of cases are missed by practitioners, and treatment of detected cases is of inadequate intensity and duration. Educational interventions for practitioners using clinical guidelines to improve recognition and management have been evaluated, but have shown no benefit. At least 3 reasons may explain this: education may be insufficient to change practitioner behaviour, study design may have been inadequate to detect true benefit, or the principles on which guidelines are based may be at fault. One reason to suspect the latter is that most of the evidence base comes from secondary care, reflecting a lack of research in primary care. “Sensitivity” of practitioners has been emphasised at the expense of “specificity”, which may result in failure to target patients who may benefit most from more intensive management.
The studies by Katzelnick et al and Simon et al report the efficacy and cost effectiveness of a practice based intervention to improve depression management in the managed care context of 3 US HMOs. In a 2 stage screening procedure, patients with consultation rates above the 85th percentile for ≥2 years were identified, and those in whom there was evidence of untreated depressive disorder (DSM-IV diagnosis, HDRS score ≥15) were recruited (about 5% of the total registered population). The study had high completion rates, but only patients enrolled with the HMO for ≥2 years were eligible. This limits the replicability and generalisability of the work for other settings (such as UK general practice), biasing against groups such as the long term unemployed or elderly. Half the sample had ≥1 comorbid chronic physical illness, presumably accounting in part for their high consultation rates.
Depression management programmes have already been shown to be of benefit for unselected depressed patients in primary care. In this study, programme patients in the DMP had better outcomes than those receiving usual care, with significantly greater reductions in depression scores and higher quality of life ratings. The authors estimate a number needed to treat of 5 to achieve 1 additional remission, although it is not clear how remission was defined for this calculation. This is a screening study, however, and the “number needed to screen” to achieve 1 additional remission is close to 17. Consultation rates in the intervention group increased further, while those in the usual care group decreased slightly. It is not possible to identify which component of the programme was of most benefit, but it seems likely on clinical grounds that the initial visit for assessment and initiation of management (which did not occur in the usual care group) would have had considerable impact.
In analysing the cost effectiveness of the programme, the construct of “depression free days” was used. It is important to understand how these were derived. As depression scores were only assessed at 6 weeks and 3, 6, and 12 months, most of the data were interpolated. HDRS scores ≤7 were taken as “depression free” (score 0) while scores ≥22 were taken as “fully symptomatic” (score 1). Linear interpolation was used to model recovery, allowing calculation of a number between 0 and 1 for each day, and “depression free days” by dividing the total scores by the number of days in the period between estimates. This is clearly a notional construct, and its name is misleading, because many of the periods will have contained no true depression free days, only partially depression free days.
The costs of the intervention appear high, and there was no evidence of the hoped for “cost offset” effect by reduction in other sources of healthcare cost, perhaps not surprising given the high prevalence of comorbid physical illness. It should be noted that the authors observed that the study was insufficiently powered to compare frequency of inpatient admission, which is costly, and this might have led to failure to detect benefits. The study also only had 1 year of follow up, and benefits may take longer to be detected.
The clinical “bottom line” is that it is possible to identify unmet need and improve outcome in this segment of the primary care population, but substantial additional resources are required. Although these are not out of line with the costs of treating other important conditions, priorities have to be established to permit shifting of existing resources away from other therapeutic areas, or investment of greater resources in this one.
The depression management programme included the following elements:
- An evaluation visit with the primary care physician
- The provision of an information booklet before the evaluation visit to
encourage acceptance of treatment: Katzelnick DJ, Simon GE, Pearson SD, et
al. Depression isn�t just a mental problem. Available on request from
- Pharmacotherapy for eligible patients: physicians were given a specific
pharmacotherapy algorithm but could adjust treatment according to individual
clinical need. Patients who had tolerated and responded to a particular
antidepressant were given that antidepressant. All others received
sertraline, 50 mg/day to start. The dose was increased at 4 weeks if
patients did not improve, with a maximum dose of 200 mg/day. Patients who
did not respond to sertraline were given nortriptyline, 25 mg/day to start
and titrated to 100 mg/day if needed. If patients still did not respond,
then physicians were strongly encouraged to refer patients to psychiatrists.
- Referral to psychiatrists for patients with psychotic symptoms, mania, or
- Ongoing monitoring, feedback, and as needed specialty consultation.
- An evaluation visit with the primary care physician
Source of funding: Pfizer Pharmaceuticals Inc, New York, USA.
For correspondence: Dr D J Katzelnick, Madison Institute of Medicine, 7617 Mineral Point Road, Madison, WI 53717, USA. Fax +1 608 827 2444.
A modified version of this abstract appears in ACP Journal Club.
website extra Additional information appears on the Evidence-Based Mental Health websitewww.ebmentalhealth.com
↵† Information provided by author.
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