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Journal of General Internal Medicine

, Volume 19, Issue 1, pp 78–84 | Cite as

Effectiveness of screening and treatment for depression in ambulatory indigent patients

  • David Jarjoura
  • Ann Polen
  • Elizabeth Baum
  • Denize Kropp
  • Suzanne Hetrick
  • Gregory Rutecki
Populations At Risk

Abstract

OBJECTIVE: To determine the effectiveness of screening and treatment for depression among ambulatory indigent patients visiting resident physicians.

DESIGN: Two-group randomized trial (N=33 intervention, N=28 usual care) with baseline, 6-month, and 12-month outcome measurements.

SETTING: Internal Medicine Residency Clinic.

PATIENTS: Clinic patients over 18 years of age who screened positive for depression on the PRIME-MD during a visit to their resident physician. Patients were not receiving treatment nor seeking care for any emotional problems. All patients were either enrolled in Medicaid or had income below the poverty line.

INTERVENTION: Resident physicians were educated to follow AHCPR (AHRQ; Agency for Healthcare Research and Quality) guidelines for diagnosis and treatment of depression in a primary care setting. For the intervention group patients, a screening nurse advised residents regarding the positive screen, handed them a standardized protocol outline, and attempted to arrange behavioral care. The patients in the usual care group were provided the results of the screen by the screening nurse before their visit with the resident, and advised to seek care for their symptoms.

MAIN RESULTS: Results for the primary outcome of depression symptoms measured with the Beck Depression Inventory (BDI) demonstrated that intervention was successful in reducing symptoms relative to usual care (difference=−4.9 BDI points, P=.05, 95% confidence interval [CI], −9.8 to −0.005 effect size=−0.41). During the 12-month follow-up, 70% of intervention patients were treated for depression (of these, 91% with antidepressants), while 15% of usual care patients were treated with antidepressants for depression. Another 18% of the usual care group had depression noted, but no treatment was identified. BDI differences between intervention and control groups were similar at the 6- and 12-month measures. Quality of life and costs were also measured, but differences between the groups were not significant in this regard.

CONCLUSION: Screening and treatment for depression by resident physicians was successful in reducing symptoms relative to usual care in an indigent population. Almost twice as many intervention patients as usual care controls demonstrated a substantial reduction (10 BDI points) in symptoms related to depression.

Key words

depression treatment low-income patients randomized trial 

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References

  1. 1.
    Pignone MP, Gaynes BN, Rushton JL, et al. Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force. Ann Intern Med. 2002;136:765–76.PubMedGoogle Scholar
  2. 2.
    U.S. Preventive Services Task Force. Screening for depression: recommendations rationale. Ann Intern Med. 2002;136:760–4.Google Scholar
  3. 3.
    Magruder-Habib K, Zung W, Feussner J. Improving physicians’ recognition and treatment of depression in general medical care. Results from a randomized clinical trial. Med Care. 1990;28:239–50.PubMedCrossRefGoogle Scholar
  4. 4.
    Sliman R, Donahue T, Jarjoura D, Ognibene A. Recognition of depression by internal medicine residents. J Community Health. 1992;17:143–52.PubMedCrossRefGoogle Scholar
  5. 5.
    Docherty J. Barriers to the diagnosis of depression in primary care. J Clin Psychiatry. 1997;58:5–10.PubMedGoogle Scholar
  6. 6.
    Mulrow CD, Williams JW Jr, Chiquette E, et al. Efficacy of newer medications for treating depression in primary care patients. Am J Med. 2000;108:54–64.PubMedCrossRefGoogle Scholar
  7. 7.
    Broadhead E, Blazer D, George L, Tse C. Depression, disability days, and days lost from work in a prospective epidemiologic survey. JAMA. 1990;264:2524–8.PubMedCrossRefGoogle Scholar
  8. 8.
    Broadhead W, Leon A, Weissman M, et al. Development and validation of the SDDS-PC screen for multiple mental disorders in primary care. Arch Fam Med. 1995;4:211–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Blazer D, Kessler R, McGonagle K, Swartz M. The prevalence and distribution of major depression in a national community sample: The National Comorbidity Survey. Am J Psychiatry. 1994;151:979–86.PubMedGoogle Scholar
  10. 10.
    Lehman A. The effects of psychiatric symptoms on quality of life assessments among the chronic mentally ill. Evaluation Program Planning. 1983;6:143–51.CrossRefGoogle Scholar
  11. 11.
    Linn L, Yager J. The effect of screening, sensitization, and feedback on notation of depression. J Med Educ. 1980;55:942–9.PubMedGoogle Scholar
  12. 12.
    Lipsey M, Wilson D. The efficacy of psychological, educational, and behavioral treatment: confirmation from meta-analysis. Am Psychol. 1993;48:1181–209.PubMedCrossRefGoogle Scholar
  13. 13.
    Manning WG, Wells KB. The effects of psychological distress and psychological well-being on use of medical services. Med Care. 1992;30:541–53.PubMedCrossRefGoogle Scholar
  14. 14.
    Regier DA, Narrow WE, Rae DS, et al. The de facto US mental and addictive disorders service system. Epidemiologic catchment area prospective 1-year prevalence rates of disorders and services. Arch Gen Psychiatry. 1993;50:85–94.PubMedGoogle Scholar
  15. 15.
    Spitzer RL, Williams JB, Kroenke K, et al. Utility of a new procedure for diagnosing mental disorders in primary care: the PRIME-MD 1000 Study. JAMA. 1994;272:1749–56.PubMedCrossRefGoogle Scholar
  16. 16.
    Spitzer R, Kroenke K, Linzer M, et al. Health related quality of life in primary care patients with mental disorders. JAMA. 1995;274:1511–7.PubMedCrossRefGoogle Scholar
  17. 17.
    Wells KB, Stewart A, Hays RD, et al. The functioning and well being of depressed patients. Results from the Medical Outcomes Study. JAMA. 1989;262:914–9.PubMedCrossRefGoogle Scholar
  18. 18.
    Rost K, Nutting P, Smith J, Werner J, Duan N. Improving depression outcomes in community primary care practice. A randomized trial of the QuEST intervention. J Gen Intern Med. 2001;16:143–9.PubMedCrossRefGoogle Scholar
  19. 19.
    Katon W, Russo J, Von Korff M, et al. Long-term effects of a collaborative care intervention in persistently depressed primary care patients. J Gen Intern Med. 2002;17:741–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Gilbody S, Whitty P, Grimshaw J, Thomas R. Educational and organizational interventions to improve the management of depression in primary care. JAMA. 2003;289:3145–51.PubMedCrossRefGoogle Scholar
  21. 21.
    Kesler R, Berglund P, Demler O, et al. The epidemiology of major depressive disorder. JAMA. 2003;289:3095–105.CrossRefGoogle Scholar
  22. 22.
    Callahan CM, Hendrie HC, Dittus RS, et al. Improving treatment of late life depression in primary care: a randomized clinical trial. J Am Geriatr Soc. 1994;42:839–46.PubMedGoogle Scholar
  23. 23.
    Depression Guideline Panel. Depression in primary care, volume 1: Detection and Diagnosis; 2: Treatment of major depression. Rockville, Md: US Department of Health and Human Services, US Public Health Service, Agency for Health Care Policy and Research; 1993 (Publication AHCPR 93-0550-1).Google Scholar
  24. 24.
    Danziger S, Corcoran M, Danziger S, et al. Barriers to the employment of welfare recipients. In: Cherry R, Rodgers W III, eds. Prosperity for All? The Economic Boom and African Americans. New York: Russell Sage Foundation; 2000:245–78.Google Scholar
  25. 25.
    American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th edn. Washington, DC: American Psychiatric Association; 1994.Google Scholar
  26. 26.
    DeRubeis R, Gelfand L, Tang T, Simons A. Medication versus cognitive behavior therapy for severely depressed outpatients: meta-analysis of four randomized comparisons. Am J Psychiatry. 1999;156:1007–13.PubMedGoogle Scholar
  27. 27.
    Katon W, Robinson P, Von Korff M, et al. A multifaceted intervention to improve intervention of depression in primary care. Arch Gen Psychiatry. 1996;53:924–32.PubMedGoogle Scholar
  28. 28.
    Hunkeler E, Meresman J, Hargreaves W, 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
  29. 29.
    Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve intervention guidelines: impact on depression in primary care. JAMA. 1995;273:1026–31.PubMedCrossRefGoogle Scholar
  30. 30.
    Bhatia SC, Bhatia SK. Major depression: selecting safe and effective treatment. Am Fam Physician. 1997;55:1683–98.PubMedGoogle Scholar
  31. 31.
    American Psychiatric Association. Practice guideline for major depression disorders in adults. Am J Psychiatry. 1993;150:1–26.Google Scholar
  32. 32.
    Kane RL, Ouslander JG, Abrass IB. Essentials of Clinical Geriatrics. New York: McGraw-Hill; 1984.Google Scholar
  33. 33.
    Schulberg H, Katon W, Simon G, Rush A. Treating major depression in primary care practice. An update of the AHCPR guidelines. Arch Gen Psychiatry. 1998;55:1121–7.PubMedCrossRefGoogle Scholar
  34. 34.
    Schulberg H, Katon W, Simon G, Rush A. Best clinical practice: guidelines for managing major depression in primary medical care. J Clin Psychiatry. 1999;60(suppl 7):19–26.PubMedGoogle Scholar
  35. 35.
    Beck A, Ward C, Mendelson M, Mock J, Erbaugh J. An inventory for measuring depression. Arch Gen Psychiatry. 1961;4:53–63.Google Scholar
  36. 36.
    Beck AT, Steer RA, Brown GK. Manual for Beck Depression Inventory — II. San Antonio, Tex: Psychological Corporation; 1996.Google Scholar
  37. 37.
    Ware J, Snow KK, Kosinski M, Gandek B. SF-36 Health Survey: manual and interpretation guide. Boston: The Health Institute, New England Medical Center; 1993.Google Scholar
  38. 38.
    Ware J, Gandek B. The SF-36 Health Survey: developmental use in mental health research and the IQOLA Project. Int J Mental Health. 1994;23:49–73.Google Scholar
  39. 39.
    Vonesh EF, Chinchilli VM. Linear and Nonlinear Models for the Analysis of Repeated Measurements. New York: Marcel Dekker; 1997.Google Scholar
  40. 40.
    Frison L, Pocock S. Repeated measures in clinical trials: analysis using mean summary statistics and its implications for design. Stat Med. 1992;11:1685–704.PubMedCrossRefGoogle Scholar
  41. 41.
    Laird N. Further comparative analysis of pretest-posttest research designs. Am Stat. 1983;37:329–30.CrossRefGoogle Scholar
  42. 42.
    Jarjoura D. Crossing controls to treatment in repeated measures trials. Control Clin Trials. 2003;24:306–23.PubMedCrossRefGoogle Scholar
  43. 43.
    SAS Institute Inc. SAS Proc Mixed Software. Cary, NC: SAS Institute Inc; 2002.Google Scholar
  44. 44.
    Walsh B, Seidman S, Sysko R, Gould M. Placebo response in studies of major depression: variable, substantial, and growing. JAMA. 2002;287:1840–7.PubMedCrossRefGoogle Scholar
  45. 45.
    Ware J, Kosinski M, Keller SD. SF-36 physical and mental health summary scales: a user’s manual. Boston: The Health Institute, New England Medical Center; 1994.Google Scholar
  46. 46.
    Von Korff M, Katon W, Bush T, et al. Treatment costs, cost offset, and cost-effectiveness of collaborative management of depression. Psychosomatics. 1998;60:143–9.Google Scholar
  47. 47.
    Lave J, Frank R, Schulberg H, Kamlet M. Cost-effectiveness of treatments for major depression in primary care practice. Arch Gen Psychiatry. 1998;55:645–51.PubMedCrossRefGoogle Scholar
  48. 48.
    ENRICHD Investigators Writing Committee. Effect of treating depression and low perceived social support on clinical events after myocardial infarction. JAMA 203;289:3106–16.Google Scholar
  49. 49.
    House A, Knapp P, Bamford J, Vail A. Mortality at 12 and 24 months after stroke may be associated with depression symptoms at 1 month. Stroke. 2001;32:696–701.PubMedGoogle Scholar
  50. 50.
    Ciechanowski P, Katon W, Russo J. Depression and diabetes. Impact of depressive symptoms on adherence, function, and costs. Arch Intern Med. 2000;160:3278–85.PubMedCrossRefGoogle Scholar

Copyright information

© Society of General Internal Medicine 2004

Authors and Affiliations

  • David Jarjoura
    • 1
  • Ann Polen
    • 2
  • Elizabeth Baum
    • 2
  • Denize Kropp
    • 1
  • Suzanne Hetrick
    • 3
  • Gregory Rutecki
    • 4
  1. 1.Received from Community Health SciencesNortheastern Ohio Universities College of Medicine (NEOUCOM)Rootstown
  2. 2.Internal Medicine (NEOUCOM) Affiliated Hospitals of CantonCanton
  3. 3.Portage County Mental Health and Recovery BoardKent
  4. 4.Internal Medicine, Evanston Northwestern Healthcare, Feinberg School of MedicineNorthwestern UniversityEvanston

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