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Journal of General Internal Medicine

, Volume 16, Issue 3, pp 143–149 | Cite as

Improving depression outcomes in community primary care practice

A randomized trial of the quest intervention
  • Kathryn Rost
  • Paul Nutting
  • Jeffrey Smith
  • James Werner
  • Naihua Duan
Original Articles

Abstract

OBJECTIVE: To determine whether redefining primary care team roles would improve outcomes for patients beginning a new treatment episode for major depression.

DESIGN: Following stratification, 6 of 12 practices were randomly assigned to the intervention condition. Intervention effectiveness was evaluated by patient reports of 6-month change in 100-point depression symptom and functional status scales.

SETTING: Twelve community primary care practices across the country employing no onsite mental health professional.

PATIENTS: Using two-stage screening, practices enrolled 479 depressed adult patients (73.4% of those eligible); 90.2% completed six-month follow-up.

INTERVENTION: Two primary care physicians, one nurse, and one administrative staff member in each intervention practice received brief training to improve the detection and management of major depression.

MAIN RESULTS: In patients beginning a new treatment episode, the intervention improved depression symptoms by 8.2 points (95% confidence interval [CI], 0.2 to 16.1; P=.04). Within this group, the intervention improved depression symptoms by 16.2 points (95% CI, 4.5 to 27.9; P=.007), physical role functioning by 14.1 points (95% CI, 1.1 to 29.2; P=.07), and satisfaction with care (P=.02) for patients who reported antidepressant medication was an acceptable treatment at baseline. Patients already in treatment at enrollment did not benefit from the intervention.

CONCLUSIONS: In practices without onsite mental health professionals, brief interventions training primary care teams to assume redefined roles can significantly improve depression outcomes in patients beginning a new treatment episode. Such interventions should target patients who report that antidepressant medication is an acceptable treatment for their condition. More research is needed to determine how primary care teams can best sustain these redefined roles over time.

Key words

primary care depression outcomes quality 

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References

  1. 1.
    Rost KM, Zhang M, Fortney J, Smith J, Coyne J, Smith GR Jr. Persistently poor outcomes of undetected major depression in primary care. Gen Hosp Psychiatry. 1998;20:12–20.PubMedCrossRefGoogle Scholar
  2. 2.
    Schulberg HC, McClelland M, Gooding W. Six-month outcomes for medical patients with major depressive disorders. J Gen Intern Med. 1987;2:312–7.PubMedCrossRefGoogle Scholar
  3. 3.
    Schulberg HC, Block MR, Madonia MJ, et al. The ‘usual care’ of major depression in primary care practice. Arch Fam Med. 1997;6:334–9.PubMedCrossRefGoogle Scholar
  4. 4.
    Simon GE, VonKorff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med. 1995;4: 99–105.PubMedCrossRefGoogle Scholar
  5. 5.
    Lin EHB, Katon WJ, Von Korff M, et al. Relapse of depression in primary care: rate and clinical predictors. Arch Fam Med. 1998;7:443–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Wells KB, Burnam A, Rogers W, Hays R, Camp P. The course of depression in adult outpatients: results from the Medical Outcomes Study. Arch Gen Psychiatry. 1992;49:788–94.PubMedGoogle Scholar
  7. 7.
    Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA. 1995;273:1026–31.PubMedCrossRefGoogle Scholar
  8. 8.
    Katzelnick DJ, Simon GE, Pearson SD, et al. Randomized trial of a depression management program in high utilizers of medical care. Arch Fam Med. 2000;9:345–51.PubMedCrossRefGoogle Scholar
  9. 9.
    Wells KB, Sherbourne CD, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA. 2000;283:212–20.PubMedCrossRefGoogle Scholar
  10. 10.
    Schulberg HC, Block MR, Madonia MJ, et al. Treating major depression in primary care practice: eight-month clinical outcomes. Arch Gen Psychiatry. 1996;53:913–9.PubMedGoogle Scholar
  11. 11.
    Miranda J, Munoz R. Intervention for minor depression in primary care patients. Psychosom Med. 1994;56:136–42.PubMedGoogle Scholar
  12. 12.
    Williams JW Jr, Rost K, Dietrich AJ, Ciotti MC, Zyzanski SJ, Cornell J. Primary care physicians’ approach to depressive disorders: Effects of physician specialty and practice structure. Arch Fam Med. 1999;8:58–67.PubMedCrossRefGoogle Scholar
  13. 13.
    Hunkeler EM, Meresman J, Hargreaves WA, et al. Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. Arch Fam Med. 2000;9:700–8.PubMedCrossRefGoogle Scholar
  14. 14.
    Simon GE, Von Korff M, Rutter C, Wagner E. Randomised trial of monitoring, feedback, and management of care by telephone to improve depression treatment in primary care. Br Med J. 2000;320:550–4.CrossRefGoogle Scholar
  15. 15.
    Mynors-Wallis L, Davies I, Gray A, Barbour F, Gath D. A randomised controlled trial and cost analysis of problem-solving treatment for emotional disorders given by community nurses in primary care. Br J Psychiatry. 1997;170:113–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Klerman GL, Budman S, Berwick D, et al. Efficacy of a brief psychosocial intervention for symptoms of stress and distress among patients in primary care. Med Care. 1987;25:1078–88.PubMedCrossRefGoogle Scholar
  17. 17.
    Depression Guideline Panel. Depression in Primary Care: Volume 1. Detection and Diagnosis. Clinical Practice Guideline, Number 5. (AHCPR Publication No. 93-0550). Rockville, Md: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1993.Google Scholar
  18. 18.
    Depression Guideline Panel. Depression in Primary Care: Volume 2. Treatment of Major Depression. Clinical Practice Guideline, Number 5. (AHCPR Publication No. 93-0551). Rockville, Md: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research; 1993.Google Scholar
  19. 19.
    Rost K, Nutting P, Smith J, Coyne J, Cooper-Patrick L, Rubenstein L. The role of competing demands in the treatment provided primary care patients with major depression. Arch Fam Med. 2000;9:150–4.PubMedCrossRefGoogle Scholar
  20. 20.
    Rost K, Nutting PA, Smith J, Werner JJ. Designing and implementing a primary care intervention trial to improve the quality and outcome of care for major depression. Gen Hosp Psychiatry. 2000;22:66–77.PubMedCrossRefGoogle Scholar
  21. 21.
    World Health Organization. Composite International Diagnostic Interview for Primary Care, Version 2.0. Geneva, Switzerland: World Health Organization; 1996.Google Scholar
  22. 22.
    Zimmerman M, Coryell W, Wilson S, Corenthal C. Evaluation of symptoms of major depressive disorder: Self-report vs. clinician ratings. J Nerv Ment Dis. 1986;174:150–3.PubMedCrossRefGoogle Scholar
  23. 23.
    Prochaska JO, DiClemente CC, Norcross JC. In search of how people change: applications to addictive behaviors. Am Psychol. 1992;47:1102–14.PubMedCrossRefGoogle Scholar
  24. 24.
    Horwitz SM, Hoagwood K, Stiffman AR, et al. Measuring youth’s use of mental health services: Reliability of the SACA-Services Assessment for Children and Adolescents. Psychiatr Serv. In press.Google Scholar
  25. 25.
    Howard KI, Kopta SM, Krause MS, Orlinsky DE. The dose-effect relationship in psychotherapy. Am Psychol. 1986;41:159–64.PubMedCrossRefGoogle Scholar
  26. 26.
    Covi L, Primakoff L. Cognitive group therapy. In: Frances AJ, Hales RE, eds. American Psychiatric Press Review of Psychiatry, Vol. 7. Washington, DC: American Psychiatric Press; 1988: 608–21.Google Scholar
  27. 27.
    Myers JK, Weissman MM. Use of a self-report symptom scale to detect depression in a community sample. Am J Psychiatry. 1980;137:1081–4.PubMedGoogle Scholar
  28. 28.
    McHorney CA, Ware JE Jr, Raczek AE. The MOS 36-item shortform health survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs. Med Care. 1993;31:247–63.PubMedCrossRefGoogle Scholar
  29. 29.
    Bryk AS, Raudenbush SW. Hierarchical Linear Models: Applications and Data Analysis Methods. Newbury Park, Ca: Sage Publications; 1992.Google Scholar
  30. 30.
    Katon W, Robinson P, Von Korff M, et al. A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry. 1996;53:924–32.PubMedGoogle Scholar
  31. 31.
    Goldberg D. A classification of psychological distress for use in primary care settings. Soc Sci Med. 1992;35:189–93.PubMedCrossRefGoogle Scholar
  32. 32.
    Katon W, Von Korff M, Lin E, et al. Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. Arch Gen Psychiatry. 1999;56:1109–15.PubMedCrossRefGoogle Scholar
  33. 33.
    Dowrick C, Buchan I. Twelve month outcome of depression in general practice: does detection or disclosure make a difference? Br Med J. 1995;311:1274–6.Google Scholar
  34. 34.
    Linn LS, Yager J. The effect of screening, sensitization, and feedback on notation of depression. J Med Educ. 1980;55:942–9.PubMedGoogle Scholar
  35. 35.
    Zhang M, Rost KM, Fortney JC. Earnings changes for depressed individuals treated by mental health specialists. Am J Psychiatry. 1999;156:108–14.PubMedGoogle Scholar

Copyright information

© Blackwell Science Inc 2001

Authors and Affiliations

  • Kathryn Rost
    • 1
  • Paul Nutting
    • 2
  • Jeffrey Smith
    • 1
  • James Werner
    • 3
  • Naihua Duan
    • 4
  1. 1.Received from the Center for Studies in Family Medicine, Department of Family MedicineUniversity of Colorado Health Sciences CenterDenver
  2. 2.Center for Research StrategiesDenver
  3. 3.Center for Research in the Health and Behavioral SciencesUniversity of Colorado at DenverDenver
  4. 4.Center for Community Health, Neuropsychiatric InstituteUniversity of California at Los AngelesLos Angeles

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