BMJ 2001;323:948-949 ( 27 October )

Editorials

Improving outcomes in depression

The whole process of care needs to be enhanced

Around 450 million people worldwide have mental or psychosocial problems, but most of those who turn to health services for help will not be correctly diagnosed or will not get the right treatment.¹ Even those whose problems are recognised may not receive adequate care. In a World Health Organization study of psychological disorders in general health care carried out in 14 countries around the world patients with major depression were as likely to be treated with sedatives as with antidepressants, although antidepressants were associated with more favourable outcomes at three month follow up. This benefit had dissipated by follow up at 12 months; but patients had only been taking drug treatment for a mean of 11 weeks, with a quarter of them doing so for less than a month.² About two thirds of patients whose illnesses were recognised and treated with drugs still had a diagnosis of mental illness at follow up one year later, and in nearly a half the diagnosis was still major depression. Indeed, there are no observational studies of routine care for patients with major depression in the United Kingdom or in the United States that have found most patients to be receiving care consistent with evidence based guidelines.

Improving outcomes for patients with major depression is not as simple as prescribing a new treatment: the whole process of care needs to be enhanced. This requires changes in the organisation and function of healthcare teams, like those already being used to improve outcomes in other chronic diseases.³ Responsibility for active follow up should be taken by a case manager (for example, a practice nurse); adherence to treatment and patient outcomes should be monitored; treatment plans should be adjusted when patients do not improve; and the case manager and primary care physician should be able to consult and refer to a psychiatrist when necessary. ^{4 5}

Change is hard work for overtaxed healthcare teams, and many might be tempted to adopt quality improvement strategies that are quick and easy. Such strategies do not usually work, however, as single initiatives. Ineffective interventions include distribution of guidelines;⁶ education for doctors and nurses that does not increase their skills or change how the healthcare team works; feedback reports on indicators of quality of care; and stand alone screening programmes. Each of these steps might be useful as part of a comprehensive programme to change the management of patients with major depression, but in isolation they are largely a waste of time and energy.

Randomised controlled trials reported since 1995, for example those by Schulberg et al ⁷ and others (see table) have established that enhanced care of major depression can lead to better outcomes than the care that patients with depression usually receive. Moreover, enhanced care improves patients' ability to function,⁸ and, although it moderately increases the costs of care per case treated, it is more cost effective than usual care.^9-13 What has been learnt from these trials about how care for depressed patients can be more effectively organised and delivered? The table summarises 12 different trials of enhanced care for major depression in primary care settings.

View this table: [in this window] [in a new window]   Elements of interventions to improve care of patients with major depression in primary care settings tested in randomised controlled trials: trials with positive versus negative results.

Both effective and ineffective interventions used treatment guidelines, patient education, and screening for depression. The interventions that consistently improved patient outcomes incorporated some form of case management with specialist support. In these trials case management typically comprised taking responsibility for following up patients; determining whether patients were continuing the prescribed treatment as intended; assessing whether depressive symptoms were improving; and taking action when patients were not adhering to guideline based treatment or when they were not showing expected improvement. In many of these experiments, case management services were provided over the telephone at low cost per case treated. Effective interventions typically employed novel and economical approaches to integrating specialist support into the primary care of patients with depression. In some interventions, the psychiatrist supervised the case manager to provide guidance on difficult clinical problems, provided consultation to the treating physician, or saw patients with more difficult problems when necessary to devise an effective treatment plan.

This evidence suggests that efforts to improve the primary care of major depression should focus on low cost case management coupled with fluid and accessible working relationships among the primary care doctor, the case manager, and a mental health specialist. This model allows most patients with depression to access effective treatment in primary care, while the minority needing ongoing specialist care can be identified and referred more reliably.

Enhanced care for people with depression will go a long way towards improving the lives of these patients. But the large gap in the quality of care cannot be closed only by the increased efforts of individual practitioners who are already overburdened. The question now is whether insurers and organisations that provide patient care will act on the scientific evidence to benefit the millions of people worldwide who are afflicted by major depression.

Michael Von Korff, senior investigator. 

Center for Health Studies, Group Health Cooperative, Seattle, WA 98101, USA (Vonkorff.m{at}ghc.org)

David Goldberg, professor emeritus. 

Institute of Psychiatry, King's College, London SE5 8AF (d.goldberg{at}iop.kcl.ac.uk)

Footnotes

References cited in the table appear on the BMJ's website

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1.	World Health Organization. World health report 2001: mental health: new understanding, new hope. Geneva: WHO, 2001.
2.	Goldberg DP, Privett M, Ustun B, Simon G, Linden M. The effects of detection and treatment on the outcome of major depression in primary care: A naturalistic study in 15 cities. Br J Gen Pract 1998; 48: 1840-1844[Medline].
3.	Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996; 74: 511-544[Medline].
4.	Katon W, Von Korff M, Lin E, Simon G. Rethinking practitioner roles in chronic illness: the specialist, primary care physician, and the practice nurse. Gen Hosp Psychiatry 2001; 23: 138-144[CrossRef][Medline].
5.	Von Korff M, Tiemens B. Individualized stepped care of chronic illness. West J Med 2000; 172: 133-137[CrossRef][Medline].
6.	Thompson C, Kinmonth AL, Stevens L, Peveler RC, Stevens A, Ostler KJ, et al. Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomized controlled trial. Lancet 2000; 355: 185-191[CrossRef][Medline].
7.	Schulberg HC, Block MR, Madonia MJ, Scott CP, Rodriguez E, Imber SD, et al. Treating major depression in primary care practice. Eight-month clinical outcomes. Arch Gen Psychiatry 1996; 53: 913-919[Abstract].
8.	Ormel H, Von Korff M. Synchrony of change in depression and disability: what next? Arch Gen Psychiatry 2000; 57: 381-382[Free Full Text].
9.	Lave J, Frank R, Schulberg H, Kamlet M. Cost-effectiveness of treatments for major depression in primary care practice. Arch Gen Psychiatry 1998; 55: 645-651[Abstract/Free Full Text].
10.	Von Korff M, Katon W, Bush T, Lin E, Simon G, Saunders K, et al. Treatment costs, cost offset, and cost-effectivness of collaborative management of depression. Psychosom Med 1998; 60: 143-149[Abstract/Free Full Text].
11.	Simon G, Manning W, Katzelnick D, Perarson S, Henk H, Helstad C. Cost-effectiveness of systematic depression treatment for high utilizers of general medical care. Arch Gen Psychiatry 2001; 58: 181-187[Abstract/Free Full Text].
12.	Simon GE, Katon WJ, Von Korff M, Unutzer J, Lin EH, Walker EA, et al. Cost-effectiveness of a collaborative care program for primary care patients with persistent depression. Am J Psychiatry 2001; 158: 1638-1644[Abstract/Free Full Text].
13.	Schoenbaum M, Unutzer J, Sherbourne C, Duan N, Rubenstein LV, Miranda J, et al. Cost-effectiveness of practice-initiated quality improvement for depression: results of a randomized controlled trial. JAMA 2001; 286: 1325-1330[Abstract/Free Full Text].

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Overview for depression interventions could have been better

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Improving outcomes in depression

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