BMJ 2002;325:934 ( 26 October )

Primary care

Managing depression as a chronic disease: a randomised trial of ongoing treatment in primary care

Kathryn Rost, professor, a Paul Nutting, director of research, b Jeffrey L Smith, project director, a Carl E Elliott, statistical analyst, a Miriam Dickinson, biostatistician. a

a Center for Studies in Family Medicine, Department of Family Medicine, University of Colorado Health Sciences Center, UCHSC at Fitzsimons, PO Box 6508 Mail Stop F496, Aurora, CO 80045-0508, USA, b Center for Research Strategies, 225 East 16th Avenue, Suite 1150, Denver, CO 80203, USA

Correspondence to: Kathryn Rost Kathryn.Rost{at}UCHSC.edu

Objectives: To evaluate the long term effect of ongoing intervention to improve treatment of depression in primary care.
Design: Randomised controlled trial.
Setting: Twelve primary care practices across the United States.
Participants: 211 adults beginning a new treatment episode for major depression; 94% of patients assigned to ongoing intervention participated.
Intervention: Practices assigned to ongoing intervention encouraged participating patients to engage in active treatment, using practice nurses to provide care management over 24 months.
Main outcome measures: Patients' report of remission and functioning.
Results: Ongoing intervention significantly improved both symptoms and functioning at 24 months, increasing remission by 33 percentage points (95% confidence interval 7% to 46%), improving emotional functioning by 24 points (11 to 38) and physical functioning by 17 points (6 to 28). By 24 months, 74% of patients in enhanced care reported remission, with emotional functioning exceeding 90% of population norms and physical functioning approaching 75% of population norms.
Conclusions: Ongoing intervention increased remission rates and improved indicators of emotional and physical functioning. Studies are needed to compare the cost effectiveness of ongoing depression management with other chronic disease treatment routinely undertaken by primary care.

What is already known on this topic
Most trials of depression treatment incorporate principles of chronic disease management into the interventions tested in recognition of the chronicity of the condition

Research shows that brief implementation of these interventions has little or no impact on depressive symptoms and functioning a year after the intervention ends

What this study adds
Ongoing efforts to improve depression management yield ongoing benefits for patients starting a new treatment episode for depression

These results encourage health services to make a small but continuing investment in their depressed populations to reduce the substantial disability they bear, matching the duration of the intervention to the chronicity of the condition




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