Intended for healthcare professionals

Primary Care

Re-engineering systems for the treatment of depression in primary care: cluster randomised controlled trial

BMJ 2004; 329 doi: (Published 09 September 2004) Cite this as: BMJ 2004;329:602
  1. Allen J Dietrich, professor (allen.j.dietrich{at},
  2. Thomas E Oxman, professor1,
  3. John W Williams Jr, professor2,
  4. Herbert C Schulberg, professor3,
  5. Martha L Bruce, professor3,
  6. Pamela W Lee, senior research associate3,
  7. Sheila Barry, project director1,
  8. Patrick J Raue, assistant professor3,
  9. Jean J Lefever, research data specialist3,
  10. Moonseong Heo, assistant professor3,
  11. Kathryn Rost, professor4,
  12. Kurt Kroenke, professor5,
  13. Martha Gerrity, associate professor6,
  14. Paul A Nutting, director of research7
  1. 1 Dartmouth Medical School, HB 7250, Hanover, NH 03755, USA
  2. 2 Center for Health Services Research. Durham Veterans Affairs Medical Center, Durham, NC 27705, USA
  3. 3 Weill Medical College of Cornell University, White Plains, NY 10605, USA
  4. 4 University of Colorado Health Sciences Center, UCHSC at Fitzsimmons, Aurora, CO 80010, USA
  5. 5 Regenstrief Institute, Indianapolis, IN 46202-2859, USA
  6. 6 Portland Veterans Administration Medical Center, Portland, OR 97207-1034, USA
  7. 7 Center for Research Strategies, Denver, CO 80203-1694, USA
  1. Correspondence to: A J Dietrich
  • Accepted 19 July 2004


Objective To test the effectiveness of an evidence based model for management of depression in primary care with support from quality improvement resources.

Design Cluster randomised controlled trial.

Setting Five healthcare organisations in the United States and 60 affiliated practices.

Patients 405 patients, aged ≥ 18 years, starting or changing treatment for depression.

Intervention Care provided by clinicians, with staff providing telephone support under supervision from a psychiatrist.

Main outcome measures Severity of depression at three and six months (Hopkins symptom checklist-20): response to treatment (≥ 50% decrease in scores) and remission (score of < 0.5).

Results At six months, 60% (106 of 177) of patients in intervention practices had responded to treatment compared with 47% (68 of 146) of patients in usual care practices (P = 0.02). At six months, 37% of intervention patients showed remission compared with 27% for usual care patients (P = 0.014). 90% of intervention patients rated their depression care as good or excellent at six months compared with 75% of usual care patients (P = 0.0003).

Conclusion Resources such as quality improvement programmes can be used effectively in primary care to implement evidence based management of depression and improve outcomes for patients with depression.


  • We thank James E Barrett, Leon Eisenberg (initiative steering committee), Laurie Garduque, Robert Rose (John D and Catherine T MacArthur Foundation) for their contributions to this work. For their leadership: Wayne Cannon, Brenda Reiss-Brennan, and Debby Giordano (Intermountain Health Care); Neil Korsen, Lisa M Letourneau, and Robert McArtor, (MaineHealth); James Cox-Chapman, Jonathan Rosen, and Steven Cole MD of ProHealth; Marshall Thomas MD and Jeannette Waxmonsky PhD of Colorado (Access); and Alan Axelson, Carol Chase, and Scott Leatherbery (Highmark, an independent licensee of the Blue Cross Blue Shield Association). Training manuals and other resources are available at

  • Contributors AJD, TEO, JWWJr, HCS, KR, PAN, MG, and KK initiated and designed the study. AJD, TEO, JWWJr, HCS, MLB, PWL, PJR, and JJL acquired, analysed, and interpreted the data. AJD, TEO, HCS, MLB, and JJL drafted the paper. AJD, TEO, JWWJr, HCS, MLB, PWL, PJR, SB, MH, KR, PAN, MG, and KK revised the paper. AJD, TEO and JWWJr obtained funding. PWL and PJR provided administrative support. SB acquired an interpreted the data and carried out fieldwork. JJL, MH, and KR provided statistical expertise. MH analysed and interpreted the data. AD is guarantor for the paper.

  • Funding John D and Catherine T MacArthur Foundation through its initiative on depression and primary care. The staff participated in discussions about the conceptualisation of the study, but were not otherwise involved. The views expressed in this article are those of the authors and do not necessarily represent the views of the foundation or of the US Department of Veterans Affairs.

  • Competing interests AJD has received honorariums from Forest Laboratories and Pfizer and has consulted for Wyeth Pharmaceuticals. TEO has received honorariums from Pfizer for presenting at two conferences on primary care education. JWWJr has received honorariums from GlaxoSmithKline, Pfizer, and Wyeth-Ayerst and has received funding from Eli Lilly and Pfizer. MLB has received an unrestricted education grant from Janssen Pharmaceuticals. KR has been reimbursed by Forest Pharmaceuticals for attending a symposium. KK has received research support and honorariums from Eli Lilly and Wyeth and honorariums from Pfizer. PAN has been funded by Eli Lilly to study patient perceptions of the options for hormone replacement therapy as presented by primary care clinicians.

  • Ethical approval Our study was approved by the committees for the protection of human participants at Dartmouth Medical School, Weill Medical College of Cornell University, and participating organisations.

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