A Randomized Trial of Telemedicine-based Collaborative Care for Depression

Abstract

Background

Evidence-based practices designed for large urban clinics are not necessarily portable into smaller isolated clinics. Implementing practice-based collaborative care for depression in smaller primary care clinics presents unique challenges because it is often not feasible to employ on-site psychiatrists.

Objective

The purpose of the Telemedicine Enhanced Antidepressant Management (TEAM) study was to evaluate a telemedicine-based collaborative care model adapted for small clinics without on-site psychiatrists.

Design

Matched sites were randomized to the intervention or usual care.

Participants

Small VA Community-based outpatient clinics with no on-site psychiatrists, but access to telepsychiatrists. In 2003–2004, 395 primary care patients with PHQ9 depression severity scores ≥12 were enrolled, and followed for 12 months. Patients with serious mental illness and current substance dependence were excluded.

Measures

Medication adherence, treatment response, remission, health status, health-related quality of life, and treatment satisfaction.

Results

The sample comprised mostly elderly, white, males with substantial physical and behavioral health comorbidity. At baseline, subjects had moderate depression severity (Hopkins Symptom Checklist, SCL-20 = 1.8), 3.7 prior depression episodes, and 67% had received prior depression treatment. Multivariate analyses indicated that intervention patients were more likely to be adherent at both 6 (odds ratio [OR] = 2.1, p = .04) and 12 months (OR = 2.7, p = .01). Intervention patients were more likely to respond by 6 months (OR = 2.0, p = .02), and remit by 12 months (OR = 2.4, p = .02). Intervention patients reported larger gains in mental health status and health-related quality of life, and reported higher satisfaction.

Conclusions

Collaborative care can be successfully adapted for primary care clinics without on-site psychiatrists using telemedicine technologies.

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Acknowledgments

This research was supported by VA IIR 00-078-3 grant to Dr. Fortney, VA NPI-01-006-1 grant to Dr. Pyne, the VA HSR&D Center for Mental Health and Outcomes Research, and the VA South Central Mental Illness Research Education and Clinical Center. Drs. Pyne and Edlund were supported by VA HSR&D Research Career Awards. Dr. Mittal was supported by the VISN 16 South Central Network Research/Career Development Grant Program and VA South Central Mental Illness Research Education and Clinical Center. We would like to gratefully acknowledge all of the research staff who worked on the project, the veterans who participated, and the staff of the VA Community-Based Outpatient Clinics in Meridian, MS; Hattiesburg, MS; Mountain Home, AR; Hot Springs, AR; El Dorado, AR; Monroe, LA; and Longview, TX. In addition, we would like to recognize Dr. Raymond Kimble who took over as site-PI at the G.V. (Sonny) Montgomery VAMC after Dr. Mittal left.

Conflicts of Interest

None disclosed.

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Correspondence to John C. Fortney PhD.

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Fortney, J.C., Pyne, J.M., Edlund, M.J. et al. A Randomized Trial of Telemedicine-based Collaborative Care for Depression. J GEN INTERN MED 22, 1086–1093 (2007). https://doi.org/10.1007/s11606-007-0201-9

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KEY WORDS

  • depression
  • telepsychiatry
  • rural