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Improved treatment of depression reported

Coordination of services already available improves patient satisfaction

Patients treated for depression in primary care centers showed significant improvement and increased satisfaction with care when clinicians employed a quality-improvement approach that coordinates modest resources already available at many community practices, reports a research team led by Dartmouth Medical School (DMS). The study appears in the Sept. 11 issue of British Medical Journal (BMJ).

"Other studies have provided guidance on steps to enhance primary care of depression. But this study shows how to translate such actions from the page to routine practice."

- Allen J. Dietrich

The clinical trial of "Re-Engineering Systems for the Primary Care Treatment of Depression"- RESPECT-Depression for short, reported that 60 percent of patients responded substantially to the approach within six months, with 90 percent rating their care as good or excellent. Officials at the Defense Department say they are developing a modified model of the approach for use with soldiers returning from war and their families.

Developed by the MacArthur Initiative on Depression and Primary Care, the RESPECT-Depression approach integrates work by primary care clinicians who manage patients, centralized care managers who provide telephone support, and psychiatrists who supervise the care managers and offer suggestions to clinicians about treatment and management. At each practice, these professionals are trained by internal staff members, using materials RESPECT-Depression researchers developed and the organizations customized to each setting.

"This is a big step forward for patients, for clinicians and for insurers," said  Allen J. Dietrich, Professor of Community and Family Medicine and co-chair of the MacArthur Initiative. "Other studies have provided guidance on steps to enhance primary care of depression. But this study shows how to translate such actions from the page to routine practice."

John W. Williams, Jr., Associate Professor of Medicine at Duke University Medical Center is also co-chair of the MacArthur Initiative.

A 1998 U.S. Surgeon General's report on mental health found that two-thirds of people with a diagnosable mental illness do not receive treatment. The report said primary care is an important portal to get people into treatment - especially for those reluctant to seek mental-health services or who are unaware that they need them. However, few programs nationwide are expressly organized to integrate mental health services and primary care.

A number of studies have found benefits from enhanced care programs, including telephone counselors, in the primary care treatment of depression. However, many health care practices often find those approaches were not feasible without the substantial technical and financial support that researchers provided during clinical trials.

Five health-care organizations in the United States, three large medical groups and two insurance plans, and 60 of their affiliated practices took part in the RESPECT-Depression clinical trial between February 2002 and February 2003. Researchers randomly assigned 400 patients diagnosed with depression to treatment using either the RESPECT-Depression approach or usual care practices.

After six months of treatment, 60 percent of RESPECT-Depression patients had responded substantially to treatment, compared with 47 percent in usual care (a 28 percent increase). Remission rates for RESPECT-Depression patients were 37 percent versus 27 percent for usual care (a 40 percent increase), and 90 percent of RESPECT-Depression patients rated their depression care as either good or excellent versus 75 percent with usual care (a 20 percent increase). All five participating organizations have since taken steps to sustain and expand their use of the approach.

"Thanks to the RESPECT-Depression system, we have made what I believe is a permanent transformation in the way people with depression are cared for in primary care practices in our system," said Neil Korsen, Research Director with the Maine Medical Center's Family Practice residency program in Portland. The other organizations participating in the clinical trial were: Intermountain Health Care in Salt Lake City, Utah; Colorado Access in Denver, Colo.; Highmark Blue Cross Blue Shield in Pittsburgh, Penn.; and ProHealth Physicians Group in Bloomfield, Conn. The evaluation center, led by Herbert C. Schulberg, was based at Cornell University.

The Defense Department's Deployment Health Clinical Center, located at Walter Reed Army Medical Center in Washington, DC, is actively working with the RESPECT-Depression team to develop a modified model that will help meet the post-war primary care needs of returning soldiers and their families.

"Soldiers returning home from war often struggle with depression, post-traumatic stress disorder, and other problems, and they are often reluctant or unable to seek the care of a specialist," said Charles C. Engel, Director of the center. "An approach based on the RESPECT-Depression model adapted for the care of these other conditions holds enormous promise. It could improve early access to needed services and reduce stigma by locating the care in the primary care setting."

The John D. and Catherine T. MacArthur Foundation formed the Initiative on Depression and Primary Care in 1995, charging a group of primary care physicians and mental health experts with helping primary care clinicians take a major step forward in enhancing the quality of depression care they provide. The World Health Organization has estimated that depression was the fourth highest cause of disability and premature death worldwide in 1990, and will be the second highest cause by 2020.

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Last Updated: 12/17/08