Managing depression as a chronic disease: a randomised trial of ongoing treatment in primary care. (Primary care).

Abstract

Objectives To evaluate the long term effect of ongoing intervention to improve treatment of depression in primary care.

Design Randomised controlled trial.

Setting Twelve primary care practices across the United States.

Participants 211 adults beginning a new treatment episode for major depression; 94% of patients assigned to ongoing intervention participated.

Intervention Practices assigned to ongoing intervention encouraged participating patients to engage in active treatment, using practice nurses to provide care management over 24 months.

Main outcome measures Patients' report of remission and functioning.

Results Ongoing intervention significantly improved both symptoms and functioning at 24 months, increasing remission by 33 percentage points (95% confidence interval 7% to 46%), improving emotional functioning by 24 points (11 to 38) and physical functioning by 17 points (6 to 28). By 24 months, 74% of patients in enhanced care reported remission, with emotional functioning exceeding 90% of population norms and physical functioning approaching 75% of population norms.

Conclusions Ongoing intervention increased remission rates and improved indicators of emotional and physical functioning. Studies are needed to compare the cost effectiveness of ongoing depression management with other chronic disease treatment routinely undertaken by primary care.

Introduction

Depression is increasingly viewed as a chronic illness, (1 2) as depressed individuals experience high rates of symptom recurrence (3-6) and sustained functional impairment. (7) In recognition of the chronicity of the condition, most trials of depression treatment incorporate principles of chronic disease management into the interventions tested (8-10) but test interventions for only six months or less. Brief depression interventions have little sustained impact, leading investigators to quip that "no intervention has much impact longer than two months after it ends." This lack of sustained effect is not surprising given that many primary care patients whose depression recurs after brief intervention ends fail to get high quality care. (11)

To evaluate whether applying principles of chronic disease management in the long term can achieve sizeable and sustained improvements in symptoms and functioning, we tested an intervention to improve depression treatment on an ongoing basis.

Methods

Assignment

We conducted the study in 12 community primary care practices across the United States, none of which employed onsite mental health professionals to treat depression. (12) We randomised the 12 practices to enhanced or usual care.

Patient eligibility criteria

Patients presenting for routine visits at the selected practices between April 1996 and September 1997 completed a two stage screening questionnaire, which identified patients reporting five or more of the nine criteria for major depression listed in the Diagnostic and Statistical Manual of …