*180. Collaborative Care Improves Depression Treatment in VA Primary Care: Results of a Randomized Controlled Trial

EF Chaney, VA PSHCS MHS; SC Hedrick, HSR&D COE, Seattle; BL Felker, VA PSHCS MHS; CF Liu, HSR&D COE Seattle; DM Greenberg, VA PSHCS MHS; P Heagerty, University of Washington

Objectives: Depression is the second most prevalent medical condition in the VA and has a worse impact on function and quality of life than other common chronic conditions. Most depression treatment takes place in primary care, where, in spite of improvement efforts, the condition continues to be under-detected and under-treated. In other managed care settings, a collaborative care model based on principles of managing chronic illness has been successful in improving care. This effectiveness study adapted collaborative care to the VA primary care setting and compared the resulting innovative integrated team care approach (team) with traditional consult-liaison treatment (CL).

Methods: Patients within a VA primary care clinic were randomly assigned by firm to the two interventions. In the CL intervention, the primary care provider referred study patients to Psychiatry residents in-clinic for treatment. In the team intervention, a team of psychiatrist, psychologist, and social workers developed a treatment plan, based on an initial assessment, and provided the plan to the primary care provider. Primary care providers' treatment efforts were then supported by patient education materials followed by brief Social Work telephone calls designed to support adherence, address treatment barriers, and monitor symptomatology. Treatment results were systematically reviewed and suggestions for treatment modification were fed back to the primary providers. In both treatment arms, if initial treatment efforts were ineffective, patients could be referred to Mental Health specialty clinics.

Several screening methods including mailed and in-clinic surveys and provider referral were used to recruit 168 team and 188 CL study 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, had primary alcohol abuse, or were too impaired to participate in the screening interview. Outcome data on the SCL-20 depression symptomatology measure, SF-36V, and Sheehan functional impairment measure were collected at baseline, 3 and 9 months.

Results: Team care resulted in significantly greater improvement in depressive symptomatology at 3 months (mean change of .34 versus .14, p<.05), with CL care catching up by 9 months (mean change of .41 versus .25, ns). Team care also resulted in significantly greater improvement on the Sheehan at 3 months (mean change .63 versus -.09, p<.05). SF-36 Physical Component scores were not affected by the interventions. Team care resulted in statistically and clinically significant greater improvement in SF-36 Mental Component scores (p<.05, ½SD change) at 3 and at 9 months compared to CL.

Conclusions: Results suggest that the collaborative care model can be adapted successfully to the VA primary care setting and result in improved patient outcomes, compared to a more traditional active consult-liaison treatment model.

Impact: The positive results of this study should encourage the application of collaborative care models in the VA for the treatment of depression and other chronic conditions.