Primary Care Research

Studies examine effectiveness and cost-effectiveness of depression quality improvement programs in primary care

Negative events such as financial strain, job loss, relationship difficulties, and illness can precipitate depression. A depression quality improvement (QI) program, which boosts primary care resources for psychotherapy (QI-Therapy), can reduce the occurrence of such negative life events, further protecting patients from emotional distress, finds a new study. Psychotherapy may help patients improve the quality of social relationships and interpersonal skills that may contribute to some of these problems, notes Kenneth B. Wells, M.D., M.P.H., of the RAND Corporation. A second study of the QI-Therapy and QI-Meds program reveals it to be cost-effective for both primary care patients with minor depression and depressive disorder. Both studies were supported by the Agency for Healthcare Research and Quality (HS08349) and are briefly described here.

Sherbourne, C.D., Edelen, M.O., Zhou, A., and others (2008, January). "How a therapy-based quality improvement intervention for depression affected life events and psychological well-being over time." Medical Care 46(1), pp. 78-84.

This study compared the impact of the 6-12 month QI-Therapy program with usual care among patients diagnosed with depression at 46 primary care clinics in 6 managed care organizations. The patients were randomized to usual care or one of two QI interventions (medication or psychotherapy). This study focused on 1,300 patients in the QI-Therapy groups at any of 4 points: baseline or followup year 1, 5, or 9. The researchers examined the impact of the QI-Therapy program on negative life events at 5-year followup, and modeled the relationship between QI program implementation, life events, and mental health over a 9-year period.

The model showed that QI-Therapy not only improved patients' psychological well-being at 1 year, but it also reduced negative life events at year 5. Moreover, better mental health and fewer negative life events at year 5 were associated with improved psychological well-being at year 9. The QI-Therapy program provided resources for patients and their providers for depression treatments, including resources to facilitate access to therapy. This approach set up a chain of events that included improved mental health that endured over 9 years, and had somewhat unexpected long-term and independent effects on reducing the occurrence of negative life events.

These preliminary findings underscore the potential usefulness of focusing on life circumstances unique to the individual when explaining the course of depression. One might speculate that persons with less depression have fewer arguments or losses of relationships or job problems. Also, certain benefits of therapy—improved coping, learning to avoid or manage difficult situations, or making structural changes in one's life (such as developing new relationships or moving to a new neighborhood)—may be protective in terms of negative life events.

Wells, K.B., Schoenbaum, M., Duan, N., and others (2007, October). "Cost-effectiveness of quality improvement programs for patients with subthreshold depression or depressive disorder." Psychiatric Services 58(10), pp. 1269-1278.

A QI program that improves access to psychotherapy (QI-Therapy) and antidepressant medication (QI-Meds) is cost-effective for managing care of primary care patients who suffer from minor (subthreshold) depression or depressive disorder, concludes this study. The cost of the QI programs was $2,028 per quality-adjusted life year (QALY) for those with subthreshold depression and $53,716 per QALY for those with depressive disorder. This is similar to the cost-effectiveness of many widely used medical therapies, note the authors. They examined the cost-effectiveness of managing care of 746 primary care patients with 12-month depressive disorder and 502 with current depressive symptoms but no disorder (subthreshold depression). The patients were randomly assigned to enhanced usual care or to QI-Meds or QI-Therapy for 6 to 12 months. The QI programs emphasized symptom monitoring and adjusting treatment as symptoms changed, rather than necessarily routing patients with minor depression directly to use of antidepressants, for example.

The researchers calculated that the costs of the intervention per se—as distinct from intervention effects on use of services and medication—were $86 per patient in the QI-Meds group and $79 per patient in the QI-Therapy group. These costs did not vary much by degree of depression. The researchers conclude that implementing QI programs, which emphasize adjusting treatment decisions to changing patient needs over time, is cost-effective relative to usual care among primary care patients with minor depression and depressive disorder.

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