Primary Care and Depression: Missing the Mark

New Treatment Models Needed

Annals of Internal Medicine

When it comes to treating patients with depression, primary care physicians know that they are falling short of the mark, Lisa V. Rubenstein, MD, MSPH, writes in an editorial in the (2006;145:544-545), commenting on a study that evaluated a modified version of the more intensive collaborative depression care model.

Ann Intern Med

Although the outcomes of patients managed with the modified care model did not change significantly when compared with patients managed with the usual-care model, the results of the study (. 2006; 145: 477-487) may still help point the way to needed practice changes, Dr Rubenstein notes.

The study included 41 physicians and 375 of their patients (mean age, 45.1 years) who qualified by having repeated Patient Health Questionnaire (PHQ-9) scores between 10 and 25 or a Hopkins Symptom Checklist-20 (HSCL-20) score ≥1.0. The participants, who were representative of local and national Veterans Affairs populations, were randomized to either the intervention group or the usual-care group.

The intervention group was assigned 1 psychiatrist and 1 nurse care manager. Approximately 1 to 2 weeks after study onset the depression decision support care manager called each patient to provide counseling and invite him or her to a depression education class. This was the only direct contact with patients, in contrast to the monthly contact for up to 1 year used in previous studies of intensive interventions.

PHQ-9 scores and medication and appointment data were reviewed weekly, and each patient’s record was reviewed at least monthly. Treatment progress reports for all the enrolled patients were mailed to their physicians every 3 months. Psychiatric consultations or ongoing mental health specialty care were arranged when team members felt a patient’s scores warranted referral.

Physicians with patients in the usual-care group had access to all of their PHQ-9 scores but did not receive communications about their patients’ scores from the decision support team. Physicians and patients in this group had access to mental health services, including on-site mental health experts.

P

Follow-up data were collected at 3, 6, and 12 months; data on 76% of patients were available for all 3 time points. Results showed that depression symptom scores (HSCL-20 scores) improved in both groups ( <.001).

P

After controlling for covariates, HSCL-20 scores decreased by an average of 0.382 at each time period, for a total reduction of 0.764 from baseline to up to 12 months. However, the slope of the change in HSCL-20 score did not differ between groups over this time period ( = .49). Similarly, PHQ-9 scores improved in both groups from baseline, but no significant between-group differences were found.

Nevertheless, the intervention group was more likely to be assessed for depression (93.5% vs 77.4% of the usual-care group) and to be prescribed antidepressant therapy (79.3% vs 69.3%).

P

Patients in the intervention group were more likely to attend at least 1 mental health specialty appointment (41.1% vs 27.2%) and reported being more satisfied than the usual-care group ( = .002).

The nurse care managers in the intervention group spent only about 8 hours a week with 189 patients, in contrast to the full-time care devoted to similar numbers of patients in earlier studies of intensive interventions.

&#8220;The good news&#8230;is that the intervention changed provider behavior,&#8221; Dr Rubenstein notes. &#8220;The bad news is that depression outcomes didn&#8217;t change when compared with those for patients of control group clinicians.&#8221;

He offers 3 possible explanations for the suboptimal outcomes:

1. Lack of care manager follow-up visits

2. The process changes were not enough to affect outcomes

3. The patient population may have been too ill to benefit from primary care&#8211;based interventions.

Despite the inconclusive findings of this study, they do show that practice changes are needed to ensure that patients with depression receive optimal care. &#8220;The alternative is to continue settling for low-quality depression care and its consequences: ongoing preventable damage to patients&#8217; lives. That outcome just isn&#8217;t acceptable,&#8221; Dr Rubenstein concludes.

Key points

• This study shows that even with enhanced care, depression outcomes do not always improve in primary care.

• It also shows, however, that physicians should be screening patients for depression more often.

• New practice paradigms are clearly needed to improve depression outcomes in the primary care setting.