FROM THE FIELD Do Clinician and Patient Adherence Predict Outcome in a Depression Disease Management Program ?

Disease management (DM) programs have been designed to overcome barriers to provider and patient adherence to treatment guidelines with the goal of improving treatment outcomes. In this article, the authors report on the acute treatment phase of a depression DM program and examine the impact of patient and provider adherence on outcomes. 154 patients from 11 practices were referred by their primary care clinicians to a DM program. The program’s main intervention was a trained nurse who visited the practices and met with patients. Patient demographics, psychiatric history, current mental health treatment, and medical comorbidity were recorded, and depressive symptoms were assessed using the Center for Epidemiologic Studies-Depression scale (CES-D). Data on adherence were gathered retrospectively from interview notes made by the DM nurse. Patients enrolled had a mean ± SD baseline CES-D score of 30.8 ± 11.0 and mean ± SD age of 49.1 ± 15.5; 78.6% were female, and 96.1% were diagnosed with unipolar depression. 109 (70.8%) completed the 6-week evaluation, and 76 (49.4%) completed the 12-week evaluation. 27.5% showed significant reduction of symptoms (at least a 50% reduction in CES-D scores) at 6 weeks, and 42.1% showed improvement by 12 weeks. Active clinician adherence at 6 and 12 weeks was 63.4% and 32.4%, respectively. Guideline adherence by physicians at 6 weeks significantly predicted 12-week outcome (F = 4.49; P = 0.04). Patient adherence to clinician recommendations within 6 weeks also strongly predicted outcome (F = 6.47; P < 0.05). In conclusion, monitoring adherence as an early “outcome” in a DM program and modifying intervention and recruitment strategies as needed may be necessary to optimize rates of clinical response. Depressive disorders are common in primary care, with a prevalence rate of approximately 22% in this setting [1]. Most patients with depression are seen by primary care clinicians rather than by specialty mental health providers [2]. However, rates of detection of depression in primary care are low, with as many as half of depressed patients in primary care not detected as depressed by their clinicians [3]. Furthermore, even when depression is detected, patients often are not adequately treated [4,5] and treatment guidelines are seldom followed [4]. Thus, primary care patients identified by clinicians as depressed seldom experience better outcomes than placebo controls in clinical trials [6,7]. A well-implemented disease management (DM) program could address some of the barriers to effective care for patients with depression. Research shows that components of DM programs such as clinician and patient education, clinician feedback, and more frequent patient monitoring can improve depression care outcomes [5,8–11]. These studies suggest that DM may improve outcomes for depression through its impact on clinician adherence to treatment guidelines. In this paper, we report the results of the acute treatment phase of a depression DM program and examine the impact of provider adherence and patient adherence to clinician treatment recommendations on outcomes.