Better Care For Severely Depressed Costs Less

Depressed patients from a large HMO getting little or no relief from "usual primary care" showed significant improvement when they were placed in a new stepped-care intervention program called Collaborative Care, new research shows.

Forty percent "recovered" -- had no more than one of nine major depressive symptoms -- after three months under the new program that was tested in primary care clinics of the Group Health Cooperative of Puget Sound.

Only 23 percent of the patients who received the HMO's usual care achieved an equal level of recovery.

"That's good news for patients with persistent major depressive symptoms. Our prior trials of collaborative care also show that it's good for the HMO because the cost per case successfully treated was lower under the intervention than for usual care," said Wayne Katon, MD, of the University of Washington Medical School.

Katon, along with Michael VonKorff, ScD, of the Center for Health Studies, Group Health Cooperative, Puget Sound, Washington, headed the nine-member team of researchers conducting the study. The results of the National Institute of Mental Health-funded study appear in the December issue of the Archives of General Psychiatry.

The researchers worked with 228 patients whose moderate to severe depression was not resolved in an initial phase of six to eight weeks of treatment by their primary care physicians.

Half of them -- a mixture of 114 severe and moderate cases -- were randomized into a "usual care" group. Members of this group received a prescription for an antidepressant medication from their primary care physician, made two to three visits to that physician over the next three months, and could refer themselves to an HMO mental health specialist.

The other 114 patients were randomized into the Collaborative Care intervention group.

This intervention group had two sessions with a psychiatrist (a 50-minute initial session and 25-minute follow-up) during the first month of treatment, plus a third and fourth visit if necessary.

During these visits the psychiatrist looked into the patient's current depressive episode and stressful life events, individual and family history of mental illness, medical and social history, and the effects and side effects of the medication the patient had been taking for about two months at that point.

The psychiatrist helped the patient and primary care physician alter the dosage or choose a different medication, if necessary. Patients with severe stressors were encouraged to seek psychotherapy or were referred to support groups. Active monitoring of adherence to antidepressants and follow-up services were provided.

At the very start, each Collaborative Care patient received a book and videocassette that explained the biology and symptoms of depression and the role of medications and psychotherapy. These materials offered suggestions and tips on how to become an active partner with the physician in the course of treatment.

Three months into the study:

• 94.5 percent of the intervention patients and 63.9 percent of the usual care patients rated their care good to excellent.

• 68.8 percent of the intervention group vs. 43.8 percent of the usual care group complied with recommended dosages of antidepressants.

• The recovery rate for intervention patients was almost twice that for those in usual care (40 percent vs. 23 percent).

The researchers pointed to earlier data indicating that 6 to 10 percent of patients seen by primary care physicians show symptoms of major depression that should be treated.

The current study, they said, attempts to deal with two opposing current trends in mental health care: the decrease in availability of specialty mental health care under the changes brought on by health care reform and the growing recognition that depressed patients get better care when primary care physicians are integrated into the treatment programs.

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The Archives of General Psychiatry strives to publish original, state-of-the-art studies and commentaries of general interest to clinicians, scholars, and research scientists in psychiatry, mental health, behavioral science, and allied fields. For information about the journal contact Amy Jenkins, (312) 464-4843.