Improving outcomes in depression

Around 450 million people worldwide have mental or psychosocial problems, but most of those who turn to health services for help will not be correctly diagnosed or will not get the right treatment.¹ Even those whose problems are recognised may not receive adequate care. In a World Health Organization study of psychological disorders in general health care carried out in 14 countries around the world patients with major depression were as likely to be treated with sedatives as with antidepressants, although antidepressants were associated with more favourable outcomes at three month follow up. This benefit had dissipated by follow up at 12 months; but patients had only been taking drug treatment for a mean of 11 weeks, with a quarter of them doing so for less than a month.² About two thirds of patients whose illnesses were recognised and treated with drugs still had a diagnosis of mental illness at follow up one year later, and in nearly a half the diagnosis was still major depression. Indeed, there are no observational studies of routine care for patients with major depression in the United Kingdom or in the United States that have found most patients to be receiving care consistent with evidence based guidelines.

Improving outcomes for patients with major depression is not as simple as prescribing a new treatment: the whole process of care needs to be enhanced. This requires changes in the organisation and function of healthcare teams, like those already being used to improve outcomes in other chronic diseases.³ Responsibility for active follow up should be taken by a case manager (for example, a practice nurse); adherence to treatment and patient outcomes should be monitored; treatment plans should be adjusted when patients do not improve; and the case manager and primary care physician should be able to consult and refer to a psychiatrist when necessary.⁴,⁵

Change is hard work for overtaxed healthcare teams, and many might be tempted to adopt quality improvement strategies that are quick and easy. Such strategies do not usually work, however, as single initiatives. Ineffective interventions include distribution of guidelines;⁶ education for doctors and nurses that does not increase their skills or change how the healthcare team works; feedback reports on indicators of quality of care; and stand alone screening programmes. Each of these steps might be useful as part of a comprehensive programme to change the management of patients with major depression, but in isolation they are largely a waste of time and energy.

Randomised controlled trials reported since 1995, for example those by Schulberg et al ⁷ and others (see table) have established that enhanced care of major depression can lead to better outcomes than the care that patients with depression usually receive. Moreover, enhanced care improves patients' ability to function,⁸ and, although it moderately increases the costs of care per case treated, it is more cost effective than usual care.^9–13 What has been learnt from these trials about how care for depressed patients can be more effectively organised and delivered? The table summarises 12 different trials of enhanced care for major depression in primary care settings.

Both effective and ineffective interventions used treatment guidelines, patient education, and screening for depression. The interventions that consistently improved patient outcomes incorporated some form of case management with specialist support. In these trials case management typically comprised taking responsibility for following up patients; determining whether patients were continuing the prescribed treatment as intended; assessing whether depressive symptoms were improving; and taking action when patients were not adhering to guideline based treatment or when they were not showing expected improvement. In many of these experiments, case management services were provided over the telephone at low cost per case treated. Effective interventions typically employed novel and economical approaches to integrating specialist support into the primary care of patients with depression. In some interventions, the psychiatrist supervised the case manager to provide guidance on difficult clinical problems, provided consultation to the treating physician, or saw patients with more difficult problems when necessary to devise an effective treatment plan.

This evidence suggests that efforts to improve the primary care of major depression should focus on low cost case management coupled with fluid and accessible working relationships among the primary care doctor, the case manager, and a mental health specialist. This model allows most patients with depression to access effective treatment in primary care, while the minority needing ongoing specialist care can be identified and referred more reliably.

Enhanced care for people with depression will go a long way towards improving the lives of these patients. But the large gap in the quality of care cannot be closed only by the increased efforts of individual practitioners who are already overburdened. The question now is whether insurers and organisations that provide patient care will act on the scientific evidence to benefit the millions of people worldwide who are afflicted by major depression.

Table.

Elements of interventions to improve care of patients with major depression in primary care settings tested in randomised controlled trials: trials with positive versus negative results.

Randomised trial	Evidence based guideline?	Patients identified by screening?	Enhanced patient education?	Employed case management?	Level of mental health specialist involvement	Was the intervention more effective than care as usual?
Katon w1-3	Yes	No	Yes	Yes	High	Yes
Katzelnickw4	Yes	Yes	Yes	Yes	Medium	Yes
Rostw5	Yes	Yes	Yes	Yes	Medium	Yes
Hunkeler w6	Yes	No	Yes	Yes	Low	Yes
Wellsw7	Yes	Yes	Yes	Yes	Variable	Yes
Simon: case managementw8	Yes	No	Yes	Yes	Low	Yes
Peveler: nurse counsellingw9	No	No	Yes	Yes	None	Yes (but only for patients with major depression prescribed an adequate antidepressant dose)
Simon: feedback onlyw8	Yes	No	Yes	No	None	No
Peveler: patient education onlyw9	No	No	Yes	No	None	No
Callahanw10	Yes	Yes	Yes	No	None	No
Dowrickw11	Yes	Yes	No	No	None	No
Thompson6	Yes	No	No	No	None	No

The entry for Katon includes the results of three different randomised controlled trials each testing similar collaborative care interventions. All three experiments yielded positive results for collaborative care. The studies by Simon and Peveler are each reported in two different entries. The entries for these two studies represent varying results for different intervention arms evaluated within a single randomised controlled trial. 

The references cited in this table (w1-11) appear on bmj.com.