Effectiveness of Team Treatment of Depression in Primary Care
Susan C. Hedrick PhD
VA Puget Sound Health Care System
Seattle, WA
Funding Period: June 1997 - March 2001

BACKGROUND/RATIONALE:
Most depression treatment takes place in primary care, where the condition continues to be under-detected and under-treated. A collaborative care model derived from chronic illness management theory has been successful in improving care in other managed care settings.

OBJECTIVE(S):
This effectiveness study adapted collaborative care to the VA primary care setting ("collaborative care") and compared it with consult-liaison care ("CL care").

METHODS:
Patients within a VA primary care clinic were randomly assigned by firm to the two interventions.
In collaborative care, existing staff resources were reorganized to form a multidisciplinary mental health specialist team. The team developed a treatment plan based on an initial assessment and suggested the plan to the primary care provider. Primary care providers' treatment efforts were then supported by brief Social Work telephone calls designed to support adherence and monitor symptomatology. Treatment results were systematically reviewed and suggestions for treatment modification were fed back to the primary providers. In CL care, the primary care providers were informed of the diagnosis and study clinicians facilitated referrals to Psychiatry residents in-clinic as requested. Mailed and in-clinic surveys and provider referral were used to recruit 168 collaborative care and 186 CL care patients who met criteria for major depression and/or dysthymia based on structured interview. Patients were excluded only if they required immediate inpatient care, had a pending mental health specialty clinic appointment, or had primary alcohol abuse. Outcome data on the SCL-20 depression symptomatology measure, Veterans SF-36, and Sheehan Disability Scale were collected at baseline, 3 and 9 months. VA utilization and costs of care were analyzed.

FINDINGS/RESULTS:
Collaborative care resulted in significantly greater improvement in depressive symptomatology from baseline to 3 months (collaborative care changed from 1.96 to 1.63 versus CL care 1.83 to 1.67, p< .05), with CL care catching up by 9 months (1.56 versus 1.58, ns). Collaborative care resulted in statistically and clinically significant greater improvement in SF-36 Mental Component scores (33.7 to 39.0 versus 35.3 to 37.5, p< .05) from baseline to 9 months and in significantly greater improvement on the Sheehan at 3 months. SF-36 Physical Component scores did not change significantly. Collaborative care significantly increased the proportion of patients given prescriptions and engaging in cognitive behavioral therapy. Total costs of inpatient and outpatient care were significantly higher in the collaborative care group. While cost of depression-related inpatient care was not higher, cost of depression-related outpatient care was significantly higher in the collaborative care group.

IMPACT:
After our research involvement was completed, our clinic continued to do systematic depression screening and evaluation and support close primary care - mental health collaboration. Current research is evaluating if collaborative care can be implemented and be effective in VA primary care clinics with different resources.

PUBLICATIONS:

Journal Articles

1. Lin P, Campbell DG, Chaney EF, Liu CF, Heagerty P, Felker BL, Hedrick SC. The influence of patient preference on depression treatment in primary care. Annals of Behavioral Medicine. 2005; 30(2): 164-73.
2. Liu CF, Hedrick SC, Chaney EF, Heagerty P, Felker B, Hasenberg N, Fihn S, Katon W. Cost-effectiveness of collaborative care for depression in a primary care veteran population. Psychiatric Services. 2003; 54(5): 698-704.
3. Hedrick SC, Chaney EF, Felker B, Liu CF, Hasenberg N, Heagerty P, Buchanan J, Bagala R, Greenberg D, Paden G, Fihn SD, Katon W. Effectiveness of collaborative care depression treatment in Veterans' Affairs primary care. Journal of General Internal Medicine. 2003; 18(1): 9-16.
4. Fischer EP, Marder SR, Smith GR, Owen RR, Rubenstein L, Hedrick SC, Curran GM. Quality Enhancement Research Initiative in Mental Health. Medical Care. 2000; 38(6 Suppl 1): I70-81.

DRA: Health Services and Systems, Mental Illness
DRE: Resource Use and Cost, Treatment
Keywords: Depression, Organizational issues, Primary care
MeSH Terms: Depression, Primary Health Care