• Nearly 10% of the population, or about 18.8 million

Americans suffer from a depressive disorder at some

time in their lives. 

• The United States spends about $44 billion per year

in both direct (i.e., medical care) and indirect 

(i.e. lost productivity) costs related to depression.

• About one out of every three veterans visiting

primary care have some symptoms of depression, and

one in eight to ten have major depression that

requires treatment with psychotherapy or

antidepressants. In addition, 40% of veterans with

post-traumatic stress disorder (PTSD) also suffer

from depression.

• Most patients with depression do not complete

adequate care under usual VA or private sector

conditions.

• Successful treatment of depression requires: 

o Collaboration between primary care and mental

health

o Screening and assessment to identify the

condition, structured symptom monitoring to

guide treatment, and brief care management

(e.g., 10 minute nurse phone calls), emphasizing patient self-management support

o Either psychotherapy and/or antidepressants

PRACTICE PRACTICE Matters Matters

August, 2004 VOL. 9 ISSUE 2

A publication of the VA Office of Research and Development, Health Services Research and Development Service

COLLABORATIVE

TREATMENT

FOR

DEPRESSION
2 PRACTICEMatters

BACKGROUND

A depressive disorder is an illness with

symptoms that can last for weeks, months, or years.

Most people know a friend or loved one who has

experienced the devastatingly vicious cycle of

major depression, with symptoms that interfere

with daily living. Yet despite the fact that

depression is treatable, the helplessness and stigma

that can accompany this condition make successful

treatment difficult. 

Imagine a busy primary care clinic, and a

patient who either does not recognize or is

ashamed to consider that his or her fatigue, apathy,

insomnia, or chronic pain are related to depression.

This patient also feels disorganized, forgetful, and

hopeless - not the characteristics of an active health

care consumer. 

Even if the condition is detected and an

antidepressant is prescribed, most patients will stop

taking it before it has a chance to take effect, which

can range from a few days to several weeks. If the

clinician refers the patient to a VA mental health

clinic, chances are that the patient will not show up

for the first visit. Often, even if the patient

completes one primary care or mental health visit,

a second visit may not be available for a month or

two — too long a gap for an uncertain patient who

needs reassurance and reinforcement regarding

how long medications may take to work. Research

shows that a proactive, supportive team care

approach is necessary before the benefits of

depression treatment can be achieved.

TREATMENTS AND 

AVAILABLE THERAPIES

Experts agree on the key elements of

depression care that are outlined in the Agency for

Healthcare Research and Quality (AHRQ)1,2 and

VHA clinical guidelines for this condition. The

information in the guidelines has been augmented

by a variety of effectiveness studies on

implementing the guidelines. The following

treatment steps are based on both guidelines and

subsequent implementation research.

Clinical Assessment: Once symptoms of depression

are noticed, a systematic assessment by a trained

clinician to confirm a diagnosis of depression and

identify comorbidities is critical. Depressive

symptoms characterize a variety of syndromes in

addition to major depression, some of which do not

require major depression-type treatments, such as

grief reactions, adjustment reactions, and minor

depression. Some medical illnesses and medications

also can cause depression. In addition, depression or

depressive symptoms can be accompanied by, or signal

other major mental health comorbidities, most

commonly post-traumatic stress disorder (PTSD),

other anxiety disorders, substance use disorders, or

bipolar disorder. 

As the cycle illustrates, adverse events, physical

illness, and environmental circumstances, such as

social isolation, can affect the brain’s chemistry

(center of the cycle), which in turn alters a

person’s view of the world and affects behavior.

The effects of altered brain chemistry on thoughts

and behavior further perpetuate social withdrawal

and decrease physical activity, resulting in

difficulties at home and work that feed back and

worsen brain chemistry. 

Patient Education and Self-Management Support:

The first step in the recovery process is to help the

veteran understand the vicious cycle of depression. 

 Stressors

Medical illness,

work, family or

financial 

problems

 Behavior

Withdrawal,

decreased 

activities, 

decreased

productivity

Thoughts &

Feelings

Negative thoughts, low

self esteem, sadness,

hopelessness

Physical Factors

Pain, low energy,

poor concentrations,

poor sleep, alcohol

or drug use

Depression

Change in brain

chemicals & altered

perceptions

The Cycle of Depression
Clinical Treatment Choice: Breaking this cycle of

depression generally requires medication,

psychotherapy, or both. This choice should take

into account patient preferences and key symptoms.

The most evidence-based psychotherapies for this

condition are short-term, action-oriented

psychotherapies, such as cognitive-behavioral

therapy that optimally requires eight to twelve

visits. Medications are necessary for a minimum of

four to five months, and more typically for about

nine months, to achieve optimal results. The

length of initial antidepressant treatment is

dependent upon the speed with which depression

symptoms resolve; treatment should be continued

for at least four months after symptom resolution. 

If symptoms do not resolve within one to three

months of the initial antidepressant or

psychotherapy regimen, an active stepped-care

approach to changing or adding to current

treatment should be initiated. Even after

resolution, patients on antidepressants who have

had two or more prior episodes of major

depression should be continued on their

medication for at least two years. 

Both medications and psychotherapy act to

change the brain’s chemistry, helping patients make

additional positive behavioral and cognitive

changes. Research shows that patients’ stress and

physical symptoms improve as their brain

chemistry, cognition, and behavior move out of the

depressed state. Further detail on treatments is

available on a variety of websites including:

• VA TIDES - “Translating Initiatives for

Depression into Effective Solutions” at

www.va.gov/tides_waves/; 

• VA’s Office of Quality and Performance

(OQP), “Clinical Practice Guidelines for Major

Depressive Disorder” at www.oqp.med.va.gov/

cpg/MDD/MDD_Base.htm;

• RAND Health, “Overview of the Partners in

Care Study” at www.rand.org/health/

pic.products/overview.html;

• MacArthur, Research - Human and

Community Development “Initiative in

Depression and Primary Care” at

www.depression-primarycare.org

• AHRQ’s “National Quality Measures

Clearinghouse” at

www.qualitymeasures.ahrq.gov

Care Management Support: Because of the

propensity of depressed patients to drop out of

treatment, it is critical to support their adherence

through education about depression, as well as

problem solving and encouragement, especially

during the early weeks of treatment. Although

new classes of medication have made depression

easier to treat, in many cases adjustments to the

initial plan will be required to determine the

correct medication and dosage. This treatment

issue, combined with concerns about side-effects

and suicide risk among patients receiving

antidepressants, indicates that close monitoring is

imperative. Guidelines suggest three to six visits

either by telephone or in person with a trained

clinician over the first three months of treatment,

with visits concentrated in the first month.

Research shows that in order to provide successful

care management, primary care settings generally

require the involvement of a care manager, often a

nurse, who carries out initial assessment and

patient education, and then meets visit guidelines

through additional brief contacts interspersed with

the patient’s visits to their usual primary care

clinician. Research also shows that care manager

functions (i.e., assessment, support, and symptom

VA Practice Matters is a publication for VA decision makers and

practitioners that summarizes the results of important research

to help inform policy and to promote the application of

research for improved health care delivery and decision 

making within VA. It is produced by HSR&D’s Center 

for Information Dissemination and Education Resources

(CIDER) in collaboration with topic experts in the field. For

more information or to provide us with your suggestions,

please contact:

Center for Information Dissemination 

and Education Resources (152-M)

VA Boston Health Care System

150 South Huntington Avenue

Boston, MA 02130

Phone: (617) 278-4433 • FAX: (617) 278-4438

Email: geraldine.mcglynn@med.va.gov

VA Practice Matters is also available on the 

VA HSR&D internet at

www.hsrd.reasearch.va.gov/publications/practice_matters/

PRACTICEMatters 3
4 PRACTICEMatters

monitoring) can be successfully carried out by

telephone for patients who have telephones using

validated protocols and trained clinical staff.

Objective symptom monitoring through the

administration of depression symptom indices has

proven to be central to care management. These

indices produce scores that can be graphed to show

whether the patient is improving. Like blood

pressure or blood sugar readings, depression

symptom scores are used as the basis for proactive

management, monitoring, and treatment

adjustment. Current validated symptom indices

like the PHQ-93 are easy to use, reliable and valid,

and can be scored as part of CPRS. As care

managers review patient progress with mental

health specialists and primary care clinicians, these

scores become the basis for tracking and

communicating treatment progress.

Depression Treatment in Primary Care Settings:

Most depressed patients seek depression care first

in primary care settings. Extensive research shows

that depressed patients can be cared for very

successfully in these settings, if the primary care

environment has the capability to provide the kinds

of care outlined above, and when primary care

clinicians collaborate with mental health specialists

— one of the most important ingredients in

successful depression treatment in primary care.

This collaboration may incorporate ongoing

education of primary care clinicians, back-up or

supervision of primary care nurse care managers,

quality review of depression care in primary care,

and joint primary care and mental health specialty

care for more severe, complex, or difficult to treat

problems. 

An example of successful VA collaborative care

within the primary care setting is the TIDES

(Translating Initiatives for Depression into

Effective Solutions) project — a partnership of

researchers in Seattle and Los Angeles, and

network leaders and clinicians in VISNs 10, 16,

and 23. A key feature of this project is the

collaboration between primary care providers and

mental health specialists, with support from a

depression care manager, all working together to

assess and manage the care of depressed patients.

The implementation of TIDES at seven

demonstration clinics achieved successful clinical

outcomes. Primary care patients’ compliance with

medication and follow-up visits was outstanding.

Not surprisingly, depression severity scores and

functional status scores began showing substantial

sustained improvement after four to six weeks, and

early results of this ongoing project show even

more striking improvement after six months. The

project web site (www.va.gov/tides_waves/)

provides information for patients, clinicians, and

those wishing to implement collaborative care for

treatment of depression. 

Another example of successful VA collaborative

care is PROJECT IMPACT (www.impact.ucla.edu),

a multicenter randomized trial with 1,801

depressed older adults in eight cities around the

country, including two VA outpatient clinics. Like

TIDES, this project supported the care given by

patients’ regular primary care physicians. In the

IMPACT model, patients and their physicians had

access to a care manager in the primary care office

who could: educate patients about depression,

track symptoms and side effects, support treatment

with antidepressant medications, and/or provide a

brief form of psychotherapy or counseling for up

to 12 months. Patients assigned to IMPACT felt

better, were less depressed, had less impairment in

their day-to-day functioning, and experienced

greater improvements in quality of life than those

in usual care.

FUTURE DIRECTIONS IN 

VA DEPRESSION CARE 

Collaborative care models improve recognition

nd treatment of major depressive disorder in

rimary care settings, substantially improving the

ealth outcomes of affected veterans. The VA has

roven to be an outstanding environment for

mplementing collaborative care models. The type

f implementation research carried out in projects

ike TIDES and IMPACT fosters the adherence of

linical programs to the research evidence base by

Continued on page 5

a

p

h

p

i

o

l

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PRACTICEMatters 5

CLINICAL OPINION

There is growing awareness of the mismatch

between the needs of patients with chronic illness

and our acute care oriented delivery system.

Patients with chronic illness and their loved ones

must respond daily to the demands of the illness,

the treatment, and the disruptions and

uncertainties of a fluctuating course with a

modicum of skill and confidence. These demands

are challenging enough when one has energy and

perceives the world accurately. But the challenges

of coping with their illness often overwhelm the

patient with depression, who, even if diagnosed

and treated, may be incapable of sustaining

treatment without more intensive follow-up and

support than most medical practices can provide.

The usual intermittent interactions with health

care to deal with urgent problems don’t help much. 

However, evidence is now overwhelming that

the rate of recovery from major depression will

increase by 50% or more if practice is redesigned

to: 1) assure effective treatment, and 2) provide

ongoing surveillance and support. This issue of

Practice Matters nicely summarizes the research,

much of it done within the VA, that has clarified

the critical features of effective depression care: 

• Intensive monitoring of symptoms (using

standardized measures like the PHQ-9),

medication adherence, and experience of

treatment;

• Ongoing support of the patient’s selfmanagement skill and confidence; and

• Adjustment of therapy if the clinical response is

inadequate.

Providing care with these features requires

access to and integration of resources and expertise

not often resident in primary care-nurse care

managers, psychiatrists, and psychotherapists.

Integration that makes sense to both patients and

health care professionals is the more daunting task.

Edward H. Wagner MD, MPH

MacColl Institute for Healthcare Innovation

Center for Health Studies

Group Health Cooperative

• Primary care clinicians should be aware of the

high incidence of depression in their patients

and should be prepared to assess severity,

deliver first-line treatment, and make use of

collaborative care resources.

• Mental health care directors should be aware of

the critical role their services can play in

reducing disability and distress in the primary

care population through collaborative care

arrangements.

• Health care practice directors should develop

systems for supporting and encouraging

collaborative care for depression.

• Practice systems should devote resources to the

treatment of depression and other mental

health disorders to achieve parity with other

less stigmatized chronic conditions.

KEY RECOMMENDATIONS 

FUTURE DIRECTIONS IN 

VA DEPRESSION CARE 

Continued from page 4

bridging the gap between literature and existing

clinical and administrative procedures. It is

expected that programs developed through action

research partnerships like these will endure past

the formal project demonstration period and

provide veterans with cost-effective, targeted care

for a wide range of often under-diagnosed, undertreated problems, including common mental health

problems like depression. 
6 PRACTICEMatters

AUTHORS 

This issue of VA Practice Matters on Collaborative

Treatment for Depression was written by Lisa

Rubenstein, MD, MSPH, Director of HSR&D’s

Center for the Study of Healthcare Provider

Behavior, Sepulveda, CA; Edmund F. Chaney,

PhD, HSR&D’s Northwest Center for Outcomes

Research in Older Adults, Seattle, WA; John

Williams, Jr., MD, MHS, Center for Health

Services Research in Primary Care, Durham, NC;

and Martha Gerrity, MD, PhD, HSR&D’s Center

for Outcomes Research in Older Adults, Portland,

OR. The authors of this article are members of

the VA HSR&D Mental Health Quality

Enhancement and Research Initiative (QUERI)

Executive Committee (www.hsrd.research.

va.gov/research/queri/), and are dedicated to the

ongoing improvement of mental health outcomes

among veterans through researcher-clinicianveteran partnerships. 

ACKNOWLEDGEMENTS

Mark Shelhorse, MD, Acting Chief of the

Mental Health Strategic Health Care Group, and

Joe Francis, MD, Associate Director of HSR&D,

QUERI, reviewed the issue and provided

comments. Geraldine McGlynn, MEd, and Diane

Hanks, MA, with HSR&D’s Center for

Information Dissemination and Education

Resources (CIDER), edited this issue.

REFERENCES

1. Clinical Practice Guideline: Quick Reference Guide for Clinicians.

Agency for Health Care Policy and Research, 1993; Publication No.

93-0552.

2. Schulberg HC, Katon W, et al. Treating major depression in

primary care practice: An update of the Agency for Health Care Policy

and Research Practice Guidelines. Arch Gen Psychiatry

1998;55(12):1121-1127.

3. Kroenke K, Spitzer RL, William JB. The PHQ-9: Validity of a

brief depression severity measure. J Gen Intern Med 2001;Sept

16(9):606-13.