Psychiatry and Primary CareSystematic review of multifaceted interventions to improve depression care☆,
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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The views expressed in this manuscript are those of the authors and do not necessarily represent the views of the Department of Veterans Affairs, Center for Medicare and Medicaid Services or The John D. and Catherine T. MacArthur Foundation.
Recent epidemiologic studies have found that most patients with mental illness are seen exclusively in primary care medicine. These patients often present with medically unexplained somatic symptoms and utilize at least twice as many health care visits as controls. There has been an exponential growth in studies in this interface between primary care and psychiatry in the last 10 years. This special section, edited by Jürgen Unutzer, M.D., will publish informative research articles that address primary care-psychiatric issues.