Can a collaborative-care intervention to support medication adherence and psychotherapy improve care and outcomes for adults with depression?

Improving opportunities for appropriate depression treatment had a positive affect on the process and outcomes of care among adult patients treated at 46 primary care clinics.

Why is this important?

Health care for depression is often not optimal (Wang et al. 2005; Wells et al. 1999), despite the effectiveness of antidepressant medication and specific psychotherapies (Wells et al. 1996). Some simple improvement approaches such as reminders and feedback have not proven successful for depression care (Bambauer et al. 2006; Rollman et al. 2002), suggesting a need for more rigorous interventions to support change.

Interventions

Mental health experts recruited six managed care organizations to participate in a collaborative-care intervention (known as Partners in Care), trained local expert leaders to provide education and feedback on evidence-based care to local clinicians, and screened patients for probable depression (Rubenstein et al. 1999).

Local experts trained local depression nurse specialists to contact intervention patients for education and initial assessment, the results of which local primary care physicians were asked to consider in making treatment plans. Forty-six primary care clinics were randomized to usual care or one of two intervention groups.

• In a Quality Improvement Medications intervention group, nurse specialists were trained to provide follow-up assessments and monthly contact to support medication adherence for six months or one year. (Patients had usual access to mental health specialty care.)
• In a Quality Improvement Therapy group, local psychotherapists were trained to provide 12 to 16 sessions of cognitive behavior therapy, for which health plans reduced their normal patient copayment. (Patients could access other therapy for the usual copayment.)

Findings

The intervention demonstrated positive effects on quality of care and patient outcomes after one year as compared with patients who received usual care (Wells et al. 2000). Specifically, quality improvement patients were:

• more likely to receive appropriate care (counseling or antidepressant medication at an appropriate dose), by 9 percentage points;
• more likely to see a mental health specialist, by 6 percentage points;
• less likely to have probable depressive order, by 10 percentage points;
• more likely to retain employment after one year (among those employed at baseline), by five percentage points; and
• more likely to receive care that matched their preferences, by 10–14 percentage points (data not shown).

After five years, the proportion with probable depression remained 6 percentage points lower among intervention than usual care patients (not shown) (Wells et al. 2004). The incremental cost of the intervention was $419 to $485 per patient (Schoenbaum et al. 2001), although there was no overall increase in medical visits.

Implications

A carefully designed quality improvement program can significantly improve the process and outcomes of depression care. Cost-effectiveness was comparable to other accepted medical interventions (Schoenbaum et al. 2001).

Partners in Care was one of 11 comprehensive quality improvement interventions for depression care examined in a recent systematic review (Gunn et al. 2006). Eight of the interventions demonstrated 10 percent to 33 percent higher rate of recovery from depression over varying time periods. Common components included:

• a multi-professional approach to patient care;
• a structured management plan;
• scheduled patient follow-up; and
• enhanced inter-professional communication.

Improvement Ideas and Resources

Resources related to the Partners in Care intervention are available from RAND Health.

Measure:

The Partners in Care study was a group-level randomized controlled trial conducted during 1996–1997. The sample included 1,356 adult patients (913 in the intervention groups and 443 in the control group) who screened positive for probable depression, intended to use the clinic in the next 12 months, spoke English or Spanish, and had coverage for mental health specialty care. There were no significant differences between intervention and control patients at baseline in use of services, health-related quality-of-life, or employment status. Probable depressive disorder was defined as having "two weeks or more of depressed mood or loss of interest in pleasurable activities during the last year or persistent depression over the year, plus having at least one week of depression in the last 30 days." Rates shown in the charts were adjusted for covariates and weighted for probability of enrollment, attrition, and wave response. Differences between rates shown for control and combined intervention groups were statistically significant (Wells et al. 2000).

Limitations:

Data were based on patient self-reports, which might be subject to recall bias. Generalizability to other organizations outside a research study is not known.

Source:

Enrolled patients completed a telephone interview (95% response rate) and a mail survey at baseline (88% response rate), with follow-up surveys every six months (response rate 85% at six months and 83% at 12 months). The Partners in Care Study was conducted by researchers at RAND Health; the University of California, Los Angeles; Georgetown University Medical Center; and VA Greater Los Angeles Health System (Wells et al. 2000).

References:

* Indicates source of data used in the chart(s).Bambauer, K. Z., A. S. Adams, F. Zhang et al. 2006. Physician Alerts to Increase Antidepressant Adherence: Fax or Fiction? Archives of Internal Medicine 166 (5): 498–504.

Gunn, J., J. Diggens, K. Hegarty et al. 2006. A Systematic Review of Complex System Interventions Designed to Increase Recovery from Depression in Primary Care. BMC Health Services Research 6 (1): 88.

Rollman, B. L., B. H. Hanusa, H. J. Lowe et al. 2002. A Randomized Trial Using Computerized Decision Support to Improve Treatment of Major Depression in Primary Care. Journal of General Internal Medicine 17 (7): 493–503.

Rubenstein, L. V., M. Jackson-Triche, J. Unutzer et al. 1999. Evidence-Based Care for Depression in Managed Primary Care Practices. Health Affairs (Millwood) 18 (5): 89–105.

Schoenbaum, M., J. Unutzer, C. Sherbourne et al. 2001. Cost-Effectiveness of Practice-Initiated Quality Improvement for Depression: Results of a Randomized Controlled Trial. Journal of the American Medical Association 286 (11): 1325–30.

Wang, P. S., M. Lane, M. Olfson et al. 2005. Twelve-Month Use of Mental Health Services in the United States: Results from the National Comorbidity Survey Replication. Archives of General Psychiatry 62 (6): 629–40.

Wells, K., C. Sherbourne, M. Schoenbaum et al. 2004. Five-Year Impact of Quality Improvement for Depression: Results of a Group-Level Randomized Controlled Trial. Archives of General Psychiatry 61 (4): 378–86.

Wells, K. B., M. Schoenbaum, J. Unutzer et al. 1999. Quality of Care for Primary Care Patients with Depression in Managed Care. Archives of Family Medicine 8 (6): 529–36.

* Wells, K. B., C. Sherbourne, M. Schoenbaum et al. 2000. Impact of Disseminating Quality Improvement Programs for Depression in Managed Primary Care: A Randomized Controlled Trial. Journal of the American Medical Association 283 (2): 212–20.

Wells, K. B., R. Sturm, C. D. Sherbourne et al. 1996. Caring for Depression. Cambridge: Harvard University Press.