Elsevier

General Hospital Psychiatry

Volume 29, Issue 2, March–April 2007, Pages 91-116
General Hospital Psychiatry

Psychiatry and Primary Care
Systematic review of multifaceted interventions to improve depression care,

This work was presented, in part, at the Annual Veterans Affairs Quality Enhancement Research Initiative meeting, Alexandria, VA, December 11, 2003, and at the Twenty-Seventh Annual Meeting of the Society of General Internal Medicine, Chicago, IL, May 13, 2004.
https://doi.org/10.1016/j.genhosppsych.2006.12.003Get rights and content

Abstract

Objective

Depression is a prevalent high-impact illness with poor outcomes in primary care settings. We performed a systematic review to determine to what extent multifaceted interventions improve depression outcomes in primary care and to define key elements, patients who are likely to benefit and resources required for these interventions.

Method

We searched Medline, HealthSTAR, CINAHL, PsycINFO and a specialized registry of depression trials from 1966 to February 2006; reviewed bibliographies of pertinent articles; and consulted experts. Searches were limited to the English language. We included 28 randomized controlled trials that: (a) involved primary care patients receiving acute-phase treatment; (b) tested a multicomponent intervention involving a patient-directed component; and (c) reported effects on depression severity. Pairs of investigators independently abstracted information regarding (a) setting and subjects, (b) components of the intervention and (c) outcomes.

Results

Twenty of 28 interventions improved depression outcomes over 3–12 months (an 18.4% median absolute increase in patients with 50% improvement in symptoms; range, 8.3–46%). Sustained improvements at 24–57 months were demonstrated in three studies addressing acute-phase and continuation-phase treatments. All interventions involved care management and required additional resources or staff reassignment to implement; interventions were delivered exclusively or predominantly by telephone in 16 studies. The most commonly used intervention features were: patient education and self-management, monitoring of depressive symptoms and treatment adherence, decision support for medication management, a patient registry and mental health supervision of care managers. Other intervention features were highly variable.

Conclusion

There is strong evidence supporting the short-term benefits of care management for depression; critical elements for successful programs are emerging.

Introduction

According to projections from the World Health Organization, depression will be the second leading cause of disability in the developed world by 2020 [1]. Primary care clinicians (PCCs) care for approximately two thirds of depressed individuals [2] but frequently fail to recognize depression or undertreat it when recognized [3], [4]. This may be due to the many challenges faced by PCCs in providing care to depressed patients [5], [6], [7], [8], [9], [10], [11], [12]. Patients often present with somatic complaints that distract clinicians from recognizing depression [7], [8]. Patients who are recognized as being depressed may resist the diagnosis or referral to a mental health specialist [5]. Those who are treated with medications may be prescribed inadequate doses of antidepressants [13], [14] or may not fill their prescriptions [5]. Depressed patients may become discouraged and discontinue care because of the time required to achieve response, or they may quit taking their medications when they begin to feel better [5].

The US Preventive Services Task Force recommends screening for depression in primary care, but only if there is a system for treatment and follow-up [15]. However, it is not clear what these systems should include and how best to address the challenges faced by PCCs. Several single-component interventions, including clinician education and screening, failed to improve patient outcomes [16], [17], [18]. A growing number of randomized trials of multifaceted interventions suggest that enhancements to the care process may improve patient outcomes in primary care settings [16], [18], [19], and recent reviews suggest that multifaceted interventions that include patient-related care processes are more likely to improve depression outcomes than single-component interventions [16], [18], [20], [21], [22].

However, questions remain regarding the necessary and sufficient components and the applicability of these research findings across primary care settings [18], [22], [23]. Wagner's Chronic Care Model (CCM) provides one framework for analyzing these complex interventions [21], [24], [25]. The CCM includes six interrelated components: decision support for clinicians, self-management support for patients, delivery system redesign, clinical information systems, health care organization and community resources.

We performed a systematic review to determine: to what extent multifaceted interventions improve depression outcomes in primary care; to define key elements using the CCM; and to identify patients who are likely to benefit and the resources required for these interventions. A synthesis of the literature, with descriptions of the key components of these interventions and the resources they require, will inform health care organizations as they consider improving their depression care. Prior reviews of interventions to improve depression outcomes did not provide this information [18], [20], [26], [27], [28], [29], [30], occurred before recent randomized controlled trials (RCTs) of multifaceted interventions [8], [17], [31], [32] or were not systematic reviews [16], [33].

Section snippets

Data acquisition

We searched Medline, HealthSTAR, CINAHL, PsycINFO and a specialized registry of depression trials [34] for English-language medical literature published from 1966 to February 2006. Search terms included: (a) the MESH terms “depressive disorder” and “depression”; (b) a series of terms validated to identify clinical trials [34], [35]; and (c) a series of MESH terms and text words designed to identify studies using one or more elements of care management (Appendix A). Other sources were references

Study design and quality

Of 138 studies reviewed, 29 met all inclusion criteria [39], [40], [41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51], [52], [53], [54], [55], [56], [57], [58], [59], [60], [61], [62], [63], [64], [65], [66], [67] (Fig. 1). One of these was excluded because the intervention targeted relapse prevention for patients in remission from a depressive episode [41]. Fifty-six articles were companion papers for included studies and described methods, long-term outcomes, subgroup analyses,

Conclusions

We analyzed the components of multifaceted interventions for depressed patients in primary care settings using Wagner's CCM. The 28 studies in this review included >1800 clinicians and almost 11,000 patients in a variety of geographic locations; most were high-quality trials. Among adequately powered studies, almost all multifaceted interventions led to clinically important improvements in short-term (3–12 months) depression outcomes. Interventions that addressed acute-phase and

Acknowledgment

We thank the many authors who responded to our requests for additional data and to Janie Deveau for assistance in abstracting the data. This study was supported, in part, by the Center for Medicare and Medicaid Services, the Department of Veterans Affairs, Veterans Health Administration, Health Services Research and Development Service Project MHI 20-020 and The John D. and Catherine T. MacArthur Foundation.

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