Improving Outcomes of Depression in Primary Care
Steven K. Dobscha MD
VA Medical Center, Portland
Portland, OR
Funding Period: January 2002 - December 2004

BACKGROUND/RATIONALE:
This study is a randomized, controlled trial of a collaborative treatment intervention, Depression Decision Support (DDS). To equip providers with the knowledge and skills necessary to make best use of DDS, providers entering both arms of the study will receive the MacArthur Depression Education Program (DEP). DEP is a previously tested workshop designed to improve providers’ treatment of depressed patients. Providers in the intervention group will receive DEP followed by DDS, while control providers will receive DEP followed by usual care support. Providers in the DDS intervention group will receive serial reports of depression severity scores and pharmacy and appointment data for their patients enrolled in the study. The DDS team (psychiatrist and nurse) will review this same information, and make initial recommendations to providers. The DDS nurse will make one telephone contact with each intervention patient early in treatment. Additional time and effort expended by the DDS team will be targeted towards patients not showing improvement in depression severity.

OBJECTIVE(S):
The primary objective of this study is to determine the impact of a low-intensity care management program on outcomes of patients with major depression in the primary care setting. Secondary objectives of the study are to determine: 1) the extent to which primary care providers adhere to VA Major Depression Treatment Guidelines; and 2) the extent to which the care management intervention impacts measures of utilization.

METHODS:
Forty-four staff providers and 400 patients at VA clinic sites in the Portland VA will participate. After stratification by discipline and site, providers will be randomized into one of two groups. One group will receive DDS while the other receives usual care (including an on-site mental health team). Patients will be clustered by provider to receive intervention or usual care based on provider assignment. Potential subjects will be contacted by telephone to complete brief screening questionnaires. Patients will be included in the study if they have Patient Health Questionnaire Depression (PHQ) scores >10. There will be no restrictions by age or sex. Patients will be excluded if they have psychotic symptoms, dementia, serious suicidal ideation, very severe depression (PHQ-D >25), or have been treated by mental health clinicians within the previous six months. Patients meeting eligibility criteria will meet in-person or via videoconferencing with research assistants for initial interviews. The intervention will last 12 months. Depression symptom severity (SCL-20 score) and health related quality of life (SF-36V) at 6- and 12-months will be primary outcomes. Secondary outcomes will be measures of VA healthcare utilization, and provider adherence to VA Major Depression Guidelines. The primary analysis will be a comparison of the DDS versus usual care groups using a nested analysis of variance (ANOVA), with patients nested within provider.

FINDINGS/RESULTS:
3,103 patients completed study phone-screening; 400 patients and 44 providers participated in the study. In a pilot study of our Depression Guideline Measure (DGM), we found a broad range of adherence to depression guideline criteria ranging from 13.5 percent of patients being contacted for follow up within two weeks to 100 percent of providers documenting follow up plans. Initial interview data showed a high correlation between baseline depression and PTSD severity (.69), but surprisingly, baseline alcohol use was not related to depression or PTSD severity. We have assessed depression treatment preferences of participants, finding that veterans prefer antidepressants over other treatment options, and more frequently (32% of the time) than other patient populations previously studied. We have compared a single item used for depression screening in the VA to a two item screen using the Patient Health Questionnaire (PHQ) as a reference standard, finding that the two item screen has superior psychometric properties. We developed and tested a 4-item screen for PTSD using the PTSD Checklist (PCL) as a reference standard, finding high prevalences of trauma exposure (86%) and of PTSD (37%) in our sample. Finally, we surveyed patients who entered our study via teleconferencing (VTEL) to a community based outpatient clinic (CBOC), and found few problems with the process, and a high degree of satisfaction with informed consent and initial interview procedures.

IMPACT:
Locally, many providers and nurses have begun to independently perform serial measurements of depression severity. Results of our preliminary studies support the use of brief screens for depression and PTSD in primary care, show that treatment preferences of veterans may be different than in other patient populations, and suggest that videoconferencing can be used effectively to enroll and retain rural veteran participants in mental health research. Final results of the study will increase our knowledge of 1) the effectiveness of low-intensity care management interventions for depression in VA primary care settings, and 2) the adherence of providers to VA/DOD depression treatment guidelines.

PUBLICATIONS:

Journal Articles

1. Dobscha SK, Corson K, Gerrity MS. Depression treatment preferences of VA primary care patients. Psychosomatics. 2007; 48(6): 482-8.
2. Williams JW, Gerrity M, Holsinger T, Dobscha S, Gaynes B, Dietrich A. Systematic review of multifaceted interventions to improve depression care. General Hospital Psychiatry. 2007; 29(2): 91-116.
3. Dobscha SK, Winterbottom LM, Snodgrass LS. Reducing drug costs at a Veterans Affairs hospital by increasing market-share of generic fluoxetine. Community Mental Health Journal. 2007; 43(1): 75-84.
4. Dobscha SK, Corson K, Pruitt S, Crutchfield M, Gerrity MS. Measuring depression and pain with home health monitors. Telemedicine Journal and E-Health. 2006; 12(6): 702-6.
5. Dobscha SK, Corson K, Solodky J, Gerrity MS. Use of videoconferencing for depression research: enrollment, retention, and patient satisfaction. Telemedicine Journal and E-Health. 2005; 11(1): 84-9.
6. Corson K, Gerrity MS, Dobscha SK. Screening for depression and suicidality in a VA primary care setting: 2 items are better than 1 item. American Journal of Managed Care. 2004; 10(11 Pt 2): 839-45.
7. Dobscha SK, Gerrity MS, Corson K, Bahr A, Cuilwik NM. Measuring adherence to depression treatment guidelines in a VA primary care clinic. General Hospital Psychiatry. 2003; 25(4): 230-7.
8. Dobscha SK, Anderson TA, Hoffman WF, Winterbottom LM, Turner EH, Snodgrass LS, Hauser P. Strategies to decrease costs of prescribing selective serotonin reuptake inhibitors at a VA Medical Center. Psychiatric Services. 2003; 54(2): 195-200.

DRA: Health Services and Systems, Mental Illness
DRE: Communication and Decision Making, Treatment
Keywords: Clinical practice guidelines, Depression, Utilization patterns
MeSH Terms: none