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Re-engineering systems for the treatment of depression in primary care: cluster randomized controlled trial: Other confounding factors may account for results
- Samuel Y Wong (10 September 2004)
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Telephone consultations can be rewarding for the doctor.
- Richard l Davies (12 September 2004)
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Depression in primary care: telephone consultation as an augmentation strategy.
- Dr. Naseem A. Qureshi MD, IMAPA, LMIPS, Dr.Ibrahim A. Al-Hoqail, Dean, College of Medicine, MOH, Riyadh, Saudi Arabia. (19 September 2004)
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Re: Re-engineering systems for the treatment of depression in primary care: cluster randomized controlled trial: Other confounding factors may account for results
- Allen J. Dietrich, Thomas E Oxman, John W Williams, Jr, Herbert C Schulberg, Martha L Bruce, Pamela W Lee, Sheila Barry, Patrick J Raue, Jean J Lefever, Moonseong Heo, Kathryn Rost, Kurt Kroenke, Martha Gerrity, and Paul A Nutting (20 September 2004)
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Re-engineering systems for the treatment of depression in primary care: the appropriateness of the treatment applied
- Sepideh Omidvari (4 October 2004)
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Samuel Y Wong, Assistant Professor, Department of Community and Family Medicine, School of Public Health, CUHK 4/F, School of Publich Health, Prince of Wales Hospital, Chinese Universtiy of Hong Kong, Shatin, NT
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I read with interest the article by Dietrich et al [1]. It is indeed encouraging if telephone care management programmes are effective for improving patient health outcomes and satisfaction in the treatment of depression. However, before we conclude the effectiveness of telephone management programme in the treatment of depression, we should see if other confounding variables besides telephone management could have accounted for the observed results. One factor is the potential beneficial effects of increased physician visits for depression observed in the intervention group during the study. Another factor is the increased training time for the clinicians and staff in the intervention group, which could have resulted in differences in interaction and management in patients in the two groups. Indeed, results from the study showed that the physicians in the intervention group asked more about suicidal thoughts, offered more educational materials and assisted more in setting self management goals, all of these could have accounted for better treatment outcomes. In future studies, efforts should be made to see which parts of the intervention accounted for the improved outcomes, such that management could be tailored to maximize positive outcomes and minimize unnecessary use of resources. Moreover, before telephone management programmes are implemented on a large scale in the community, the cost and time associated with increased physician visits and the beneficial but modest effects achieved with the intervention when compared to usual care should be considered carefully. 1. Dietrich AJ, Oxman TE, Williams Jr JWW, et al. Re-engineering systems for the treatment of depression in primary care: cluster randomized controlled trial. BMJ 2004; 329: 602-604. Competing interests: None declared |
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Richard l Davies, general practitioner Glenlea Surgery, Stanningley, Pudsey, Leeds,LS28 6PE
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In the trial comparing telephone support for depressed patients with usual care by Dietrick et al(1) there was improved response to treatment and better remission rates and also increased patient satisfaction. Our practice has reorgansied telephone consultations into prebookable slots to allow for more organised follow up of selected patients and I find elderly patients presenting with symptoms of depression often voice their appreciation of doctor initiated phone calls. Sometimes the last portion of the consultation is taken up being thanked for making the effort to ring. Why this is I do not know, it may be because the telephone booking system is often engaged in the morning or because a trip to the doctor is potentially costly in time, carers time, money or physical effort. It may be because the doctor has taken the time and effort to initiate contact. Either way it is rewarding receiving thanks and now reasuring we may be improving outcome also. Dietrich AJ et al.Re-engineering systems for the treatment od depression in promary care: cluster randomised controlled trial.BMJ 2004;329:602-5 Competing interests: None declared |
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Dr. Naseem A. Qureshi MD, IMAPA, LMIPS, Director, CME&R POBox.2292, Buraidah Ment. Halth. Hosp., Saudi Arabia., Dr.Ibrahim A. Al-Hoqail, Dean, College of Medicine, MOH, Riyadh, Saudi Arabia.
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Sir: By and large, depression is the commonest psychiatric disorder in primary care settings. Moreover, depression is reported to comorbid with a variety of physical disorders such as diabetes mellitus, cancers, HIV/AIDS, and cardiovascular diseases and others and the patients with these comorbid physical disorders are also mostly managed in primary care. Depression is found to have reciprocal cause-effect relationship with aforesaid chronic physical disorders. Furthermore, depression has a major impact on the outcome of these co-occurring diseases, which in turn also have known effect on the outcome of depression. The exclusion criteria of this study [1] didn't reveal whether or not depressed patients with co- occurring chronic physical diseases were excluded from this interventional research, though DSM-IV criteria that exclude such patients population which also applies to the mentioned excluded disorders, were used for the diagnosis of major depression and dysthymia. The authors of this study excluded patients with suicidal ideations [SIs] at index interview, which may reflect a methodological weakness of the study. The argument is that SIs may also emerge at any time during the intervention period. Were such patients dropped from the study? The SIs emerging mid-way through the intervention period may indicate certain worrying things; suicidal ideations are inherent part of depression and must be monitored throughout the intervention phase and follow-up; may be depression was worsening in severity and there was no effect of intervention; and may be SIs were antidepressants-induced and this is the hottest topic at the interface of psychiatry and pharmaceuticals. The authors of this study have evaded all this completely. Finally, overall this study is highly influential in providing evidenced-based data that the condition of patients with devastating depression can be improved elegantly if quality improvement strategies are interlocked with telephone consultations and immediate psychiatric expertise. Reference: Allen J Dietrich, Thomas E Oxman, John W Williams, Jr, Herbert C Schulberg, Martha L Bruce, Pamela W Lee, Sheila Barry, Patrick J Raue, Jean J Lefever, Moonseong Heo, Kathryn Rost, Kurt Kroenke, Martha Gerrity, and Paul A Nutting. Re-engineering systems for the treatment of depression in primary care: cluster randomised controlled trial. BMJ 2004; 329: 602-0 Competing interests: None declared |
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Allen J. Dietrich, Professor, Community and Family Medicine Dartmouth Medical School, Thomas E Oxman, John W Williams, Jr, Herbert C Schulberg, Martha L Bruce, Pamela W Lee, Sheila Barry, Patrick J Raue, Jean J Lefever, Moonseong Heo, Kathryn Rost, Kurt Kroenke, Martha Gerrity, and Paul A Nutting
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Dr. Wong comments that the process of care involved in the intervention for this study had a number of components, not just telephone care management. We agree about the importance of education to develop clinicians and practices that are prepared to manage depression well. Clinician education no doubt contributed to the improvement in suicide assessment and other aspects of the process of care described in Table 3. The third component of our intervention, better linkage between mental health and primary care, is important as well in providing surpervision for care management and informal advice to primary care clinicians. Distinguishing those aspects of the intervention that are critical to its impact from those that could be done without is an important next step in this research. We will gain insights in this area as we continue with data analysis. Previous research suggests that multicomponent interventions are more likely than single component interventions to impact clinician behavior and to improve patient outcomes. For a clinical area as challenging as achieving remission from major depressive disorder, we would expect multicomponent interventions to be needed as well. In addition to the process of care, this study addresses the process of change--helping clinicians implement and sustain changes in their routines with support from established quality improvement resources. Other studies have shown that certain changes in the process of care like telephone care management improve outcomes. This study adds to that literature by showing one way to achieve that enhanced process of care through a structured process of change. Allen J. Dietrich, MD; Thomas E. Oxman, MD; John W. Williams, Jr MD, MHS Competing interests: None declared |
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Sepideh Omidvari, Assistant Professor_Psychiatrist Iranian Institute for Health Sciences Research, P.O.Box 13145-1756, Tehran, Iran.
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In a trial to improve depression outcomes using an evidence based model for management of depression in primary care by Dietrich et al (1) better outcomes and increased patient satisfaction have been reported comparing with usual care. However, some questions remain. The participants had to meet the criteria of the Diagnostic and Statistical Manual of Mental Disorders fourth edition for major depressive disorder or dysthymic disorder. Patients with mild symptoms were excluded but those with moderate to severe symptoms were clinically eligible and enrolled. According to the mental disorders patient health questionnaire, 47% of usual care patients and 51% of intervention patients had generalized anxiety disorder, panic disorder, or both. The patterns of management were "drugs alone", "counseling alone", or both. There is evidence that either pharmacotherapy or psychotherapy alone is effective in patients with "mild" major depressive episodes(2),(3). In addition several studies and reports have found that the combination of cognitive or behavior therapy with pharmacotherapy is more effective than either approach alone in treatment of panic disorder(4). Thus the question is: was the management used appropriate? Another shortcoming is that the study did not indicate whether the participants who received counseling, took antidepressants, simultaneously or not? The outcome of depression in patients who received counseling alone is not clear. References: 1. Dietrich AJ, Oxman TE, Williams JW, Schulberg HC, Bruce ML, et al. Re-engineering systems for the treatment of depression in primary care: cluster randomized controlled trial. BMJ, Sep 2004; 329:602-0. 2. Contributing editors. Mood disorders. In: Sadock BJ, Sadock VA. Kaplan & Sadock's Synopsis of Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2003: 561. 3. Akiskal HS, section ed. Mood disorders. In: Sadock BJ, Sadock VA. Kaplan & Sadock's Comprehensive Textbook of Psychiatry. 7th ed. Vol I. Philadelphia: Lippincott Williams & Wilkins; 2000: 1378. 4. Contributing editors. Anxiety disorders. In: Sadock BJ, Sadock VA. Kaplan & Sadock`s Synopsis of Psychiatry. 9th ed. Philadelphia: Lippincott Williams & Wilkins; 2003: 608. Competing interests: None declared |
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