Health Services Research and Development Service

Produced by the 

Center for Information Dissemination and Education Resources

VA Boston Healthcare System (152-C)

150 South Huntington Avenue, Building 9

Boston, MA 02130

Email: cider.boston@va.gov

http://www.hsrd.research.va.gov
Collaborative Care for 

Depression in the 

Primary Care Setting 

A Primer on VA’s Translating Initiatives for 

Depression into Effective Solutions 

(TIDES) Project

Health Services Research and Development Service
ii Collaborative Care for Depression in the Primary Care Setting

The Health Services Research and Development Service (HSR&D) 

is a program within the Veterans Health Administration’s Office of 

Research and Development. HSR&D provides expertise in health 

services research, a multidisciplinary field concerned with the effects 

of social factors, financing systems, organizational structures and 

processes, technology, and human behavior on health care access, 

quality, costs, and outcomes. HSR&D programs span the continuum 

of health care research and delivery, from basic research to the 

dissemination and implementation of research results into clinical 

practice to improve the health and care of veterans.

Collaborative Care for Depression in the Primary Care 

Setting. A Primer on VA’s Translating Initiatives for 

Depression into Effective Solutions (TIDES) Project.

Boston, MA: Center for Information Dissemination and 

Education Resources; Washington, DC: VA Health Services 

Research and Development Service, Office of Research and 

Development, Dept. of Veterans Affairs [2008].

p. i-vi, 1-22. cm.

Includes bibliographical references. Primer.

DNLM: 1. Patient Care Team. 2. Depressive Disorder –drug 

therapy, -therapy. 3. Treatment Outcome. 4. United States, 

Department of Veterans Affairs, Center for Information 

Dissemination and Education Resources. 

N 04.590.715
Health Services Research and Development Service iii

Acknowledgements and Contributions

We extend our thanks to the researchers and scientists who contributed material to this 

Primer, including: Lisa Rubenstein, MD, MSPH, HSR&D Center for the Study of Healthcare 

Provider Behavior, Sepulveda, CA and VA/HSR&D Mental Health Quality Enhancement 

Research Initiative; Elizabeth Yano, PhD, MSPH, HSR&D Center for the Study of Healthcare 

Provider Behavior, Sepulveda, CA; Edmund Chaney, PhD; HSR&D Northwest Center for 

Outcomes Research in Older Adults, Seattle, WA; Alex Young, MD, MSHS, VA Desert Pacific 

Mental Illness Research, Education, and Clinical Centers (MIRECCs); Richard Owen, MD, 

HSR&D Center for Mental Healthcare and Outcomes Research (CeMHOR), Little Rock, AR; 

Sabine Oishi, MSPH, MA, HSR&D Center for the Study of Healthcare Provider Behavior, 

Sepulveda, CA; and Jeffrey Smith, PhD candidate, CeMHOR.

Our appreciation to colleagues throughout VA for their input regarding the initial direction 

and focus of this Primer: Ira Katz, MD, PhD, VA Deputy Chief, Patient Care Services 

Officer for Mental Health; Karen Malebranche, RN, MSN, Col., USA Retired, [Executive 

Director, Operation Enduring Freedom/Operation Iraqi Freedom Office,] VA Office of the 

Under Secretary for Health; Mark Shelhorse, MD, Deputy Network Director for Clinical 

Operations/Chief Medical Officer, VA Mid-Atlantic Health Care Network; Col. Terry 

Washam, Reserve, Social Work Consultant for VA’s Office of Seamless Transition; and Toni 

Zeiss, PhD, Deputy Chief Consultant, Mental Health Strategic Healthcare Group, National 

MIRECC Education Group. 

And thanks to our reviewers for their thoughtful comments and suggestions: David Atkins, 

MD, MPH, Associate Director, VA/HSR&D Quality Enhancement Research Initiative; 

Martha Buffum, DNSc, RN, Associate Chief, Nursing Service for Research, VA Medical 

Center, San Francisco, CA; Thomas Craig, MD (Retired, VHA Office of Quality and 

Performance); April Gerlock, PhD, ARNP, VA Puget Sound Health Care System; Michael 

Miller, MD, PhD, Former Chief Medical Officer, VA New England Health Care System; 

Robert Petzel, MD, Network Director, VA Midwest Healthcare Network; and Edward Post, 

MD, PhD, FACP, Severe Mental Illness Treatment, Research and Evaluation Center, VA Ann 

Arbor Healthcare System.

Primer editing and development: Diane Hanks, MA, Writer/Editor, HSR&D Center for 

Information Dissemination and Education Resources (CIDER), VA Boston Healthcare 

System; Gerry McGlynn, MEd, Principal Investigator, CIDER; and Tom Brady, Publication 

Coordinator, CIDER.
iv Collaborative Care for Depression in the Primary Care Setting

Purpose of Primer series:

The Primer series is part of several research dissemination initiatives developed by VHA’s 

Office of Research and Development through its Health Services Research and Development 

Service (HSR&D). The purpose of the Primer series is to share evidence from health services 

research and to foster collaboration between researchers, policymakers, managers, and 

clinicians in an effort to improve the quality and cost-effectiveness of health care for veterans. 

Purpose of the “Collaborative Care for Depression in the 

Primary Care Setting: A Primer on VA’s Translating Initiatives 

for Depression into Effective Solutions (TIDES)” Project:

The purpose of this Primer is to provide information about collaborative care for depression, 

particularly in the primary care setting. The Primer discusses several collaborative care 

models, but specifically focuses on VA’s TIDES project—an evidence-based collaborative 

approach to depression management that has proven successful in the VA healthcare 

system. In addition, appendices provide a glossary of terms and a list of resources for further 

information about depression and treatment.

Suggested audience:

VA managers, policymakers, clinicians, front-line supervisors, researchers, nurse care 

managers, and staff involved in the delivery of care for depression, in particular healthcare 

providers working in primary care and mental health.

Suggested uses:

Individual study and education for professional staff and healthcare providers and healthcare 

teams involved in the management of depression, a tool for medical and health professional 

training programs addressing the treatment and management of depression, as well as other 

continuing medical education courses.

July 2008
Health Services Research and Development Service v

Table of Contents

Acknowledgements iii

Purpose iv

Preface 1

Introduction 3

What are the elements of effective depression treatment in the primary care setting? 5

What is the evidence that collaborative care improves outcomes for 

depressed patients? 5

What is the TIDES care model? 7

How does TIDES work? 9

Is TIDES collaborative care effective and cost-effective? 9

What organizational changes are required to implement the TIDES 

approach to mental health care in primary care settings? 10

What can VISNs (Veterans Integrated Service Networks) do to promote 

evidence-based models for treating depression in primary care settings? 14

Conclusion 15

References 16

Appendices

Appendix A: Glossary 18

Appendix B: Suggested Reading Materials 19

Appendix C: Resources 22
vi Collaborative Care for Depression in the Primary Care Setting
Health Services Research and Development Service 1

Preface: Implementing collaborative care for 

depression into the primary care setting

This Primer is intended to help practices and facilities who are interested in implementing 

new collaborative models for caring for veterans with depression. Depression is a major 

problem for veterans seen in primary care. About one out of every three veterans visiting 

primary care have some symptoms of depression; one in five have serious symptoms that 

suggest the need for further evaluation for major depression; and one in eight to ten have 

major depression requiring treatment with psychotherapy or antidepressants. Without 

treatment, symptoms of depressive disorders can last for an extended period of time and 

can cause significant disability.Most VA patients with depression are cared for principally 

in primary care clinics, thus collaboration between primary care and mental health care 

providers is essential to enhancing treatment for depression and improving outcomes.

VA/HSR&D’s Mental Health Quality Enhancement Research Initiative (MH-QUERI) works 

to improve the quality of care and health outcomes of veterans with major depressive disorder and schizophrenia—two highly prevalent conditions among veterans. Mental Health 

QUERI has been a key part of VA’s efforts to incorporate collaborative care for depression in 

the primary care setting through its Translating Initiatives for Depression into Effective Solutions (TIDES) project. The TIDES project was designed to:

•	 adapt depression collaborative care models to VA settings through Evidence-Based

Quality Improvement for Depression (EBQID);

•	 implement VA depression collaborative care models in selected medical centers;

•	 support and evaluate the implementation of collaborative care for depression; and

•	 prepare quality improvement methods and materials to support implementation

throughout the VA.

A key feature of TIDES is collaboration between primary care providers and mental health 

specialists, supported by a depression care manager. The care manager, under supervision of 

a mental health specialist, assists the primary care provider in the assessment and ongoing 

management of depressed patients. 

This Primer discusses details of the TIDES model, in addition to other successful collaborative care models for depression treatment, to assist clinicians and managers who are interested in implementing these successful models in their setting. VA is at the forefront of this 

important work. Researchers within VA are working in collaboration with VA leaders toward 

a systematic integration of collaborative care for depression into the primary care setting. 

Together we can provide the best possible care to veterans living with this chronic mental 

illness.

David Atkins, MD, MPH

Associate Director, Quality Enhancement Research Initiative (QUERI)

Health Services Research and Development Service

Department of Veterans Affairs

About one out 

of every three 

veterans visiting 

primary care have 

some symptoms 

of depression; 

one in five have 

serious symptoms 

that suggest the 

need for further 

evaluation for major 

depression; and one 

in eight to ten have 

major depression 

requiring treatment 

with psychotherapy 

or antidepressants. 
2 Collaborative Care for Depression in the Primary Care Setting
Health Services Research and Development Service 3

Introduction

Major depression is currently the leading cause of disability in the United States, and by 

2020 it is projected to be the leading cause of disability worldwide. The annual societal costs 

of depression are currently estimated at $66 billion, which includes costs for providing 

treatment for the condition and lack of productivity. Nationally, fewer than one-fourth of 

persons experiencing an episode of depression during a 12-month period receive appropriate 

treatment.1

 Moreover, depression is the second most prevalent, chronic, disabling, and costly 

illness in VA healthcare settings and also is prevalent among veterans with other chronic 

mental and physical illnesses. Approximately 7% of VA patients meet criteria for major 

depression, and veterans with depression account for 14.3% of total VA healthcare costs.2

Most patients with depression are detected in primary care settings, with studies showing 

that about 20% of primary care patients screen positive for depressive symptoms. About half 

of these patients are being treated for mental health issues within the VA healthcare system.3

In 2002, VA’s National Registry for Depression—a comprehensive database of patients with 

diagnosed depressive disorders in VHA primary care and mental health specialty settings—

showed that while 56% of veterans had the majority of their depression visits in specialty 

settings, 44% had their depression visits in primary care.4

As treatments for mental disorders have become more effective and acceptable to patients, 

the case for screening and early recognition of these disorders is strengthened, particularly in 

the primary care setting. Not only can early treatment improve depression outcomes, it raises 

the possibility of preventing the development of other mental and substance use disorders 

which so often are co-occuring.5

 However, treatments shown to be effective in research 

are not automatically successful in actual practice. For example, the assessment process 

by which patients with possible depression are evaluated takes time and training. Just as a 

diagnosis of diabetes cannot be made without a visit to the lab for a blood-draw, a diagnosis 

of depression depends on an analogous “test” involving the administration of a diagnostic 

instrument and a tailored medical and social history. In addition, once treatment is initiated, 

symptom improvement is usually not immediate, and initial courses of antidepressants are 

often accompanied by temporary side effects. Sufficient monitoring is required to support 

medication tolerance and compliance. Also, depression treatment can require adjustment of 

dosages and multiple medication trials that may require specialty mental health consultation. 

Studies show that collaborative models for depression care delivery can bridge the 

gap between treatment efficacy reported in carefully controlled research trials and the 

effectiveness actually achieved in typical primary care practice. One type of collaborative care 

model—the model on which VA’s TIDES Project is based—links primary care and mental 

health via a depression care manager. The care manager assesses and educates patients, and 

follows up with patients and providers between primary care visits to optimize treatment. 

TIDES can also be combined with another collaborative care model involving co-located 

mental health providers. 6

In co-located models, a mental health specialist has an office and sees patients in the primary 

care setting (or via telehealth when supporting a patient at a location without an on-site 

Approximately 

7% of VA patients 

meet criteria for 

major depression, 

and veterans with 

depression account 

for 14.3% of total VA 

healthcare costs.
4 Collaborative Care for Depression in the Primary Care Setting

mental health provider). The co-located model has been used most extensively at the White 

River Junction VA. It emphasizes changing how mental health and primary care interact, and 

provides methods for doing so. Blending co-location with TIDES allows both the flexibility 

and improved efficiency offered by structured care management, while strengthening the 

overall program by better integrating mental health and primary care.

This Primer focuses on VA’s Translating Initiatives for Depression into Effective Solutions 

(TIDES) Project—an evidence-based collaborative approach to depression management that 

has proven successful in the VA healthcare system. TIDES is similar in concept to another 

model also being implemented in VA—the Behavioral Health Laboratory (BHL) model, 

which will be discussed later in this Primer.7

Most patients with 

depression are 

detected in primary 

care settings, with 

studies showing 

that about 20% 

of primary care 

patients screen 

positive for 

major depression 

symptoms.
Health Services Research and Development Service 5

What are the elements of effective depression 

treatment in the primary care setting? 

Effective models of care for depression involve collaboration between mental health and 

primary care specialists with support for: 

•	 assessment and triage,

•	 patient education and activation, and

•	 proactive follow-up of patients with depressive symptoms.

Evidence-based depression guidelines, including those of VHA, recognize that collaborative 

care is effective and cost-effective for improving symptoms of depression and promoting 

treatment adherence. Multiple studies have demonstrated the effectiveness of collaborative 

care in improving treatment and outcomes for primary care patients with depression. Nurse 

care management and collaborative care can improve the detection of suicidal ideation and 

reduce suicidal ideation or attempts.8,9

What is the evidence that collaborative care improves 

outcomes for depressed patients? 

Meta-analysis of more than 35 randomized trials shows that collaborative care models are 

effective.10 This type of depression care improves quality of care and outcomes for men and 

women of all ages, from diverse ethnic backgrounds, and in a broad range of rural and urban 

practice settings, including VA and managed care settings. 

Studies also show that clinical outcomes remain improved for two to five years after 

participation in care management11 . Cost-effectiveness studies demonstrate that 

collaborative care can be cost-effective or cost-saving in diverse settings, including VA.12,13,21

A long-term cost analysis for the Improving Mood: Promoting Access to Collaborative 

Treatment (IMPACT) model shows a $3,300 cost-savings in overall healthcare costs over a 

4-year follow-up period of elderly patients who received care management for depression 

for 12 months. While overall costs were up a little in year 1, there were substantial savings 

in later years. At 4 years, costs in every category examined (and the total) were lower in 

the intervention group than in the group treated in primary care with usual care.13 Recent 

studies also show that total costs for care for elderly diabetic patients with depression under 

depression care management may be less than those for usual care after one year.12 

Studies of collaborative care have varied in how care was structured or delivered. While 

most studies used registered nurses as care managers, others employed social workers, 

psychologists, or pharmacists who received special training to provide depression care 

support. Collaborative care models also vary in their decision support methods (e.g., paper 

and pencil versus computer), their training styles and intensity, and the degree to which care 

managers assume care for more complex patients. While the specifics of these models vary, 

VHA and other 

evidence-based 

depression 

guidelines 

recognize the 

effectiveness and 

cost-effectiveness 

of collaborative 

care with regard to 

improving symptoms 

of depression 

and treatment 

adherence.
6 Collaborative Care for Depression in the Primary Care Setting

they consistently show improvement in satisfaction with care, recovery from depression, and, 

in some cases, possible reduction in deaths.14

Key collaborative care model studies, projects, and initiatives 

Several of the studies and projects contributing to the literature on collaborative care are of 

particular relevance to the VA and are highlighted below.

•	 VA’s Behavioral Health Laboratory

•	 MacArthur Initiative on Depression and Primary Care

•	 Partners in Care

•	 Improving Mood-Promoting Access to Collaborative Treatment Program (IMPACT)

•	 Prevention of Suicide in Primary Care Elderly: Collaborative Trial

•	 Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISMe)

•	 VA’s Translating Initiatives for Depression into Effective Solutions (TIDES)

VA’s Behavioral Health Laboratory (BHL) project is a flexible and dynamic clinical service 

designed to help manage the behavioral health needs of patients seen in primary care. The 

core of the BHL is a brief, structured interview that provides primary care providers with 

comprehensive assessments of veterans’ mental health and substance abuse symptoms, along 

with the option of structured follow-up assessments, as needed or requested. The program 

was designed to be: 

•	 cross-cutting, in that it provides support for depression, alcohol, and anxiety problems;

and

•	 multi-modal, for example, assessments can be conducted by telephone or in-person

and can be conducted at individual clinics or medical centers.

The BHL also was designed to provide targeted interventions, such as early intervention, 

disease management, and referral management.24

The MacArthur Initiative on Depression and Primary Care is based on the Three Component 

Model (3CMTM)—a specific clinical model for depression that incorporates tools, routines, 

and a team approach to patient care. The three components include: 1) training the primary 

care clinician and practice to deliver collaborative care, 2) depression care managers, and 

3) collaborating mental health specialists. Telephone support for the patient from a care 

manager is a central element, as is a close relationship between the primary care clinician 

and mental health specialists that includes informal psychiatric advice from a psychiatrist, as 

needed.25

The Partners in Care project involved six managed care organizations and 48 of their 

practices in a randomized trial of two care manager-based interventions. One arm of the 

study emphasized nurse care management, with emphasis on follow-up of antidepressant 

treatment in primary care (enhanced medication). In the other arm, nurse care managers 

provided assessment and early education to depressed patients, but then referred them 
Health Services Research and Development Service 7

directly to group cognitive behavioral therapy without an intervening mental health specialty 

visit if appropriate (enhanced therapy). Compared to a group receiving usual care, both 

groups significantly improved treatment adherence and reported reduced symptoms; the 

largest impact was on ethnic minority patients.15, 16 In studies carried out over the succeeding 

nine years, positive effects of the psychotherapy-enhanced intervention (but not the 

antidepressant-enhanced group) were seen at two,17 five,18 and nine years.19,20

The Improving Mood-Promoting Access to Collaborative Treatment (IMPACT) project is a 

collaborative care program for late-life depression that includes four essential elements: 1) a 

depression care manager, 2) a designated psychiatrist, 3) collaborative care, and 4) stepped 

care. The IMPACT program was tested in the largest treatment trial for late-life depression 

to date. It included 18 diverse primary care clinics within eight health care organizations 

across the United States, including one VA. At one year, about half of the patients receiving 

IMPACT care reported a reduction in depression symptoms of at least 50%, compared with 

only a 19% reduction for those in usual care. While physical functioning steadily declined in 

usual care patients, it improved in patients receiving IMPACT care.26

The Primary Care Research in Substance Abuse and Mental Health for the Elderly (PRISMe) 

study was carried out in a multi-site trial including VA sites21 to foster collaboration between 

mental health and primary care in taking care of a range of mental disorders in the elderly. 

The study resulted in substantial new knowledge about the collaboration process. 

The Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT) was a 

practice-based randomized controlled trial to test whether a collaborative care intervention 

for depression could modify risk for death. Depression care managers (social workers, nurses 

or master’s level psychologists) worked with primary care physicians to provide algorithmbased care in 20 primary care practices. The risk for death was reduced in patients with 

major depression who received collaborative care.14 In addition, collaborative care reduced 

suicidal ideation and produced larger and faster improvements in symptoms than usual care.

VA’s Translating Initiatives for Depression into Effective Solutions (TIDES) project is an effort 

to bring evidence-based, depression collaborative care models into routine care in the VA. 

The project provided three demonstration VISNs with information and tools from previous 

high-quality collaborative care studies, and assisted them in adapting the published models 

to VA outpatient practices. The resulting collaborative care methods are integrated into 

VA Employee Education System training packages, Office of Information & Technology 

development, and standard VA policies and procedures. The program is thus intended 

to continue to evolve through the ongoing activities of VA program participants, and in 

response to new developments in the mental health and primary care evidence bases upon 

which it rests. 

What is the TIDES Care Model? 

TIDES is an evidence-based quality improvement program that aims to improve depression 

outcomes across the VA primary care patient population. The program builds on the 

evidence supporting nurse care management for depression.11, 12, 13

TIDES’ goals are to 

improve treatment 

adherence, promote 

symptom resolution, 

and prevent patient 

relapse.
8 Collaborative Care for Depression in the Primary Care Setting

TIDES’ goals are to improve treatment adherence, promote symptom resolution, and prevent 

patient relapse. TIDES continues to gather and evaluate new evidence about what works and 

does not work for improving depression outcomes. Through its Collaboration Workgroup14

(a national group of participating mental health specialists, nurse care managers, and 

primary care clinician leaders) and its link to VA’s Mental Health Quality Enhancement 

Research Initiative (MH-QUERI), TIDES incorporates new evidence from the literature and 

from field investigation. A key TIDES objective is to capitalize on the VA’s computerized 

patient record system (CPRS), to improve adherence to effective collaborative care within 

participating VISNs.

TIDES uses a population-based and patient-centered approach to care to increase the 

number of veterans with depression who receive optimal depression care in primary 

care. TIDES does this by educating primary care clinicians and by giving them access to 

comprehensive assessment by a trained nurse care manager. 

The comprehensive assessment is critical to identifying those patients who can benefit 

from nurse care management. Although one in every three veterans visiting primary care 

has some symptoms of depression, only two-thirds of them meet criteria for possible 

major depression (persistent depressed mood and/or loss of pleasure); the remainder 

may be experiencing grief, stress, adjustment, or other transient problems affecting their 

mood. Others may have a distinct mental health problem, such as substance abuse or posttraumatic stress disorder. Of those patients with possible major depression, only one-half to 

three-quarters have depression that requires antidepressants or psychotherapy. In addition, 

some depressed patients in primary care are complex, with suicidality (e.g., suicide attempt, 

suicidal ideation), substance abuse, psychosis, post-traumatic stress disorder (PTSD), and/or 

anxiety disorders, which require more specialized care. 

TIDES is designed to assess patients with symptoms of depression—and to distinguish 

from among this group those with major depression, dysthymia (less severe, persistent 

depression), and other psychiatric disorders, including suicidality. [Patients already known 

to be suicidal or otherwise in acute danger should be not referred to TIDES]. The TIDES 

program follows patients with major depression or dysthymia for six months after their 

assessment, and assures that all referred patients receive care according to their needs and 

preferences. 

TIDES also works to bring primary care providers and mental health specialists together. 

Patients with major depression who do not need mental health specialty care (e.g., due to 

major psychiatric comorbidities, suicidality, or patient preference) are followed in primary 

care with support from mental health specialists and RN Depression Care Managers. Mental 

health specialists gain efficiency by working through the care manager to monitor and adjust 

treatment for an entire panel of 100 to 150 patients, using the initial and ongoing assessment 

of depression symptoms and treatment adherence to identify and address problems as they 

occur.

TIDES also works 

to bring primary 

care providers 

and mental health 

specialists together.
Health Services Research and Development Service 9

Developed by MH-QUERI, TIDES was designed to increase appropriate and effective mental 

health specialty care for veterans with major depressive disorder by:

•	 adapting and implementing depression collaborative care models to VA settings

through evidence-based quality improvement for depression (EBQID),

•	 participating in the intervention,

•	 supporting and evaluating depression collaborative care implementation, and

•	 preparing EBQID methods and materials for dissemination to support further

implementation throughout the VA healthcare system. 

How does TIDES work?

Collaborative care begins when the primary care physician refers veterans with symptoms of 

depression to the Depression Care Manager, using the CPRS (computerized patient record 

system) electronic consultation mechanism. If the primary care physician considers the 

patient to be a psychiatric emergency, or if the patient is in active treatment with a mental 

health specialist, the patient would not be referred to the Depression Care Manager. 

Upon receiving the consult, the Depression Care Manager contacts the patient by telephone 

for an assessment and education session, and then mails appropriate education materials to 

the veteran. The assessment focuses on diagnosing major depression, measuring symptom 

severity and past depression history, and assessing any mental health comorbidities (i.e., 

anxiety disorder, substance abuse, suicidality, or PTSD). The Depression Care Manager also 

identifies the patient’s preferences and questions about depression treatment. 

The Depression Care Manager communicates the assessment to the primary care physician, 

who reviews the suggestions and initiates either a referral or medications, if needed. The 

Depression Care Manager also communicates weekly with a mental health specialist 

supervisor to review problematic cases and confers with TIDES faculty consultants (working 

through MH-QUERI) who have extensive expertise in evidence-based care for depression. 

For each patient’s treatment plan (i.e., watchful waiting, drug therapy, or referral to a mental 

health specialist), the Depression Care Manager provides follow-up and assistance for the 

veteran, periodically assessing symptom severity, medication adherence and side-effects, as 

well as relapse prevention. 

Is TIDES collaborative care effective and cost-effective? 

The implementation of TIDES at seven demonstration clinics in VISNs 10, 16, and 23 

achieved the clinical outcomes predicted by the evidence-based quality improvement (EBQI) 

collaborative care model. Among the first 1000 patients cared for in TIDES, implementation 

of the model enabled eight out of 10 depressed patients to be treated effectively in primary 

care. Primary care patients achieved very high levels of compliance with medication (85%) 

and follow-up visits (95%). Depression severity scores and functional status scores began 

TIDES results show 

that most depressed 

patients without 

major comorbidities 

can be effectively 

treated in primary 

care.
10 Collaborative Care for Depression in the Primary Care Setting

showing improvement after four to six weeks, and recovery at six months was 70% among 

primary care patients and 50% among the more severely ill veterans referred to mental health 

specialty treatment. Final publications discussing these outcomes are forthcoming.3 

Although long-term outcomes are not yet available, estimates can be projected from 

these short-term successes based on studies that have used similar collaborative care 

approaches.15-18, 19 These projections suggest outcomes will remain improved for at least two 

years, including improvements in treatment adherence, recovery, social and role functioning, 

financial status, and patient satisfaction. Because the TIDES model is similar to other models 

showing long-term cost-effectiveness,12,13 TIDES may be expected to reduce system costs by: 

•	 reducing relapse rates,

•	 reducing the use of sub-therapeutic or ineffective antidepressant regimens,

•	 providing better patient self-management through education and psychotherapy, and

•	 promoting better patient overall health due to improved adherence to other treatments,

better health habits, and less stress. 10

TIDES results show that most depressed patients without major comorbidities can be 

effectively treated in primary care with mental health specialist back-up and supervision, 

with the most severe cases needing to be followed in specialty settings. Based on these and 

other results, MH-QUERI began a TIDES follow-up project, “Expanding and Testing VA 

Collaborative Care Models for Depression” (ReTIDES).

What organizational changes are required to implement 

the TIDES approach to mental health care in primary 

care settings? 

Although they may improve quality and costs, new care models for depression can 

be difficult to implement, partly because they require organizational change. A recent 

randomized trial assessed a specific approach to help healthcare systems design and 

implement evidence-based care models for depression. 

Investigators compared evidence-based quality improvement (EBQI) depression care to 

usual depression care for 567 patients (369 EBQI and 198 usual care) with major depression 

at six Kaiser Permanente and three VA primary care practices. Primary care practices in the 

EBQI group received:

•	 manuals,

•	 key senior leader goals for depression care,

•	 depression care model tool kit, and

•	 articles on effective care models for improving depression care or changing provider

behavior. 

The successful 

implementation 

of a collaborative 

care model 

for depression 

in primary 

care requires 

organizational effort 

and coordinated 

collaboration.
Health Services Research and Development Service 11

Outcomes were measured at six and 12 months among randomly selected patients. The EBQI 

approach had perceptible but modest effects on practice performance: Patients in EBQI 

practices showed a trend toward more appropriate treatment, more satisfaction with their 

participation in care, and better social functioning than those in usual care.22

The successful implementation of a collaborative care model for depression in primary care 

requires organizational effort and coordinated collaboration. Ongoing clinical and research 

partnerships are critical to ensuring long-term sustainability. Clinicians and care managers 

need to be educated about depression care, collaborative care, and information technology 

(IT) support. Depression care managers need to be instructed in the use of CPRS and VistA® 

(Veterans Health Information Systems and Technology Architecture) tools that can support 

their role as care managers, and in the clinical management of complex mental health issues, 

such as suicidality.

Several key elements are needed to successfully implement a collaborative care model: 

•	 effective collaborations,

•	 effective depression care managers, and

•	 appropriate use of information technology.

Building Effective Collaborations 

Collaboration between the care manager, primary care provider, mental health specialist, and 

patient is the key to clinical success; however, implementation of this team approach requires 

participation of individuals at various levels within the healthcare system. Collaboration 

and buy-in starts at the highest leadership levels and must take resources and priorities into 

account. A clear understanding between service lines regarding roles and responsibilities 

helps keep the project on track throughout its various implementation stages. 

The TIDES project has produced tools to help anticipate the roles of different levels of 

the system. The TIDES Project Charter and Deliverables illustrates all of the clinical, 

administrative, and support services required to successfully implement TIDES. The 

Intervention Design Preference Questionnaire (IDPQ) identifies network and medical center 

leaders’ preferences for initial design specifications for how the program will be implemented 

and with what resources. Ratings of the importance and feasibility of each possible program 

component and implementation option are useful starting points for a discussion among 

decision-makers. A sample of the TIDES Project Charter and Deliverables, and the 

Intervention Design Preference Questionnaire are available on a VA intranet site called 

SharePoint (http://vha22web6/sites/Research/HSRD/ClinicalPart/default.aspx). First-time 

users can learn to navigate the site by clicking on “What is SharePoint?”, and “Where can I 

find the Site Map?”

Key positions for successful clinical collaboration among the care provider team include: 

1) A primary care leader (or champion) who ensures collaboration between primary care 

and specialty mental health. The primary care leader monitors program productivity and 

outcomes. He or she ensures the education of mental health specialists and primary care 
12 Collaborative Care for Depression in the Primary Care Setting

providers in the TIDES care model. PowerPoint slide presentations have been developed for 

provider education and can be found on the SharePoint site. 

2) A mental health leader who ensures collaboration with primary care, as well as clinical 

supervision of care managers by mental health services. He or she provides the initial 

education and orientation of new staff, and provides clinical updates for mental health 

specialists and primary care physicians regarding depression care policies. 

3) A nursing leader who ensures integration of care managers into nursing service, as well 

as primary care and mental health. The nursing leader administratively supervises care 

managers and solicits DCM performance feedback from mental health and primary care. 

Effective Depression Care Managers 

Depression care management can be achieved with nurses, social workers or pharmacists in 

the role of depression care manager. Below, nurse depression care managers and alternative 

approaches are discussed in greater detail. 

Nurse Depression Care Managers: Nurses have been studied most frequently as care 

managers and are well-equipped for the role. Their backgrounds in physical health, 

medication management, patient education, and their collaboration with physicians and/

or nurse practitioners give them broad expertise. Care managers with mental health 

backgrounds require less training in mental health issues, but they must be comfortable with 

a management as opposed to a therapy role in their patients’ care. Experienced primary care 

nurses can be equally effective, but require more mental health training and supervision 

during start-up. 

Effective depression care managers must be proficient at:

•	 working with primary care and mental health specialist clinicians,

•	 following patients with varying levels of depression-related symptoms, and

•	 educating patients toward self-management.

Care managers work within primary care, mental health, and nursing, thereby filling the gaps 

that exist between these services. 

The target population for Depression Care Managers consists of patients in primary care 

with newly identified symptoms of depression, who do not have symptoms indicating a 

psychiatric emergency, and who have a telephone. Even depressed patients who do not fit 

these criteria benefit through enhanced access to mental health services, greater depression 

awareness in primary care, and proactive policy and educational development.

A great strength of nurse care managers is the patient education emphasis they bring to 

their roles. Care managers teach patients about depression, its symptoms, treatments, and 

treatment side effects, during the initial and follow-up assessments. They also engage patients 

in self-help activities to help them become activated and involved in their own care. Patient 

education and self-help are critical to sustaining benefits over time. 
Health Services Research and Development Service 13

Social Workers or Pharmacists as Care Managers: There is less research on social workers 

or pharmacists as depression care managers, although clearly, adding the skills of each of 

these disciplines to the team can be very valuable. Social workers will require more training 

and support in medication monitoring and use than will nurses or pharmacists. On the 

other hand, pharmacists will require more training in mental health-specific issues (e.g., 

role of therapy) and may or may not have training in patient education/activation outside of 

medication use.

Information Technology 

The information technology (IT) support needs for collaborative care among primary care 

providers and specialists are similar for depression care and for other chronic conditions 

(e.g., diabetes). An expert panel convened as part of an ongoing MH-QUERI project—

Creating HealtheVet Informatics Applications for Collaborative Care (CHIACC)—cited the 

following important elements of effective IT support: 

•	 the ability to track a panel of patients with specific disorders and identify next steps in

clinical care for each patient in the panel.

•	 decision support at point-of-care for medication dosing and other clinical treatment

decisions.

•	 context-specific prompts to help providers track and prioritize tasks during the clinical

encounter.

•	 the ability of patients to enter patient-reported data (e.g., symptoms).

•	 a comprehensive treatment plan that is available through the medical record to all

members of the treatment team, including the patient and family caregiver(s);

•	 secure messaging among team members.

•	 the ability to summarize in real-time the quality of depression care at the patient,

provider, and practice levels. 

VA VistA is currently one of the best electronic medical records (EMR) available. However, 

supporting collaborative care will require enhancing what is currently a documentationoriented system to allow sophisticated methods of combining and displaying information 

across patients and care teams. 

Different depression collaborative care models (3CM, IMPACT, BHL, and TIDES) have 

taken somewhat different paths to improving IT support, depending on the care model and 

the environment in which it was implemented. The most important distinctions include: 

•	 whether the IT system is stand-alone or integrated within a more comprehensive EMR;

•	 who the intended users are, what degree of decision support is available; and

•	 whether provision is made for patients directly interacting with the system.

The TIDES approach has been to work to enhance existing features of VistA. Enhancement 

modules have been developed and are available to interested VA practices. However, these 

enhancements are limited by the underlying structure of VistA. Conversely, IMPACT 
14 Collaborative Care for Depression in the Primary Care Setting

and BHL have developed stand-alone software that facilitates input and organization of 

information, at the cost of not being part of the comprehensive electronic medical record. 

Just as VA is undertaking comprehensive MyHealtheVet development to enhance the 

ability of veterans and involved family and caretakers to be full partners in their care, 

further enhancements of the EMR will be necessary to combine the strengths of the current 

depression collaborative care IT approaches.

What can VISNs do to promote evidence-based models for 

treating depression in primary care settings? 

Research has shown that collaboration between primary care clinicians and mental health 

specialists is necessary for better depression care outcomes. Institutionalizing primary care/

mental health collaboration across participating clinics within individual VISNs may benefit 

from creating a VISN leadership group that includes, for example: 

•	 lead nurse manager

•	 depression care manager

•	 lead mental health specialists

•	 primary care physicians and

•	 representation from one or more individual medical center leaders.

The Leadership Group might meet monthly by conference call to develop strategic 

plans, oversee implementation of collaborative care principles, and identify and resolve 

implementation barriers. The VISN-level Lead Care Manager is chosen to oversee and 

standardize care management procedures for depression care managers working at 

participating VISN clinics. 

The collaborative care model can be implemented in Plan-Do-See-Act (PDSA)23 cycles 

within the VISN, which might start with a single medical center and clinician and rapidly 

cycle to include all medical centers and all clinicians over a one- or two-year period. All 

patients referred to care management could be entered into a database suitable for generating 

clinical reports, and the evaluation data managed by a designated ‘data monitor.’ These data 

could guide quality improvement (QI) decisions for modifications to be implemented in 

subsequent PDSA cycles until the implementation is fully achieved with optimal patient 

outcomes.

Steps for implementing TIDES at the VISN level

The initial steps VISNs might take in implementing TIDES include the following: 

Step 1: Preparation. Identify one mental health, one primary care, one nursing, and 

one administrative leader within the VISN who can take leadership roles in designing 

Research has shown 

that collaboration 

between primary 

care clinicians 

and mental health 

specialists is 

necessary for better 

depression care 

outcomes.
Health Services Research and Development Service 15

and implementing the model. This group identifies funding sources for the program and 

convenes a larger group (e.g., 10 leaders from sites within the VISN) as a steering committee 

for it. 

Step 2: Design. With support from experts, the steering committee reviews the evidence 

base to determine and develop a summary of basic program features. The committee also 

identifies one to three demonstration locations and initiates PDSA cycles beginning with one 

and increasing to two or three clinicians per site to test and refine the program in these sites. 

Attention to the information technology features is critical in this phase, and should involve 

local information technology staff including computer applications coordinators. 

Step 3: Full implementation and spread. When initial PDSA cycles have stabilized with a 

few clinicians, intensive efforts should be undertaken to ensure penetration throughout the 

primary care clinicians at the site. Moreover, the percentage of referring clinicians should 

be tracked regularly. This will require marketing by care managers and program leaders 

(champions). Spread to additional sites can begin with the initiation of regular (e.g. weekly) 

across-site conference calls to identify problems and begin the process of cross-training and 

problem-solving. 

Step 4: Identify and institute the full range of data monitoring, policy changes, and 

program support required to maintain the program over time.

Conclusion 

Major depression is currently the leading cause of disability in the United States, and by 

2020 it is projected to be the leading cause of disability worldwide. Moreover, depression is 

the second most prevalent, chronic, disabling, and costly illness in VA healthcare settings, 

and also is prevalent among veterans with other chronic mental and physical illnesses. Most 

VA patients with depression are cared for principally in primary care clinics. Collaboration 

between primary care and mental health, including screening and assessment to identify the 

condition, symptom monitoring to guide treatment, and brief care management are essential 

to effective treatment and improved outcomes. 

This Primer offers evidence of the success of collaborative care for depression in the primary 

care setting, particularly through VA’s Translating Initiatives for Depression into Effective 

Solutions (TIDES) project. VA is working to further this effort through VA’s Mental Health/

Primary Care Integration Initiative, which began in 2006 and aims to implement improved 

mental health care models, including TIDES, in all 22 VISNs.
16 Collaborative Care for Depression in the Primary Care Setting

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18 Collaborative Care for Depression in the Primary Care Setting

Appendix A: Glossary

Champion (or primary care leader): A technique used as a translation intervention that involves enlisting esteemed peers to encourage the desired behavior. Clinical champions often 

are active promoters of a best practice.

Collaborative Care for Depression: An evidence-based collaborative approach to depression 

management that creates linkages across primary care and mental health via a depression 

care manager, or other healthcare professional, who facilitates treatment between patients 

and providers.

Depression Care Manager: The depression care manager assesses and educates patients with 

depression, and follows up with patients and providers between primary care visits to optimize treatment effectiveness.

Dissemination: An active effort to communicate tailored information to target audiences with 

the goal of engagement and information use. Dissemination is an integral part of the process 

of implementing an evidence-based intervention.

Evaluation: The rigorous, systematic analysis of the degree to which targeted implementation 

goals have been met, consisting of two types:

•	 Summative evaluation: a systematic assessment of the degree to which the finding or

product affected outcomes, the degree to which desired outcomes have been achieved, 

and/or an assessment of cost-effectiveness.

•	 Formative evaluation: an analysis of discrepancies between the implementation plan

and its realization, and the monitoring of progress indicators. 

Evidence: Best practice findings and/or consensus of national experts. The source, scientific 

basis, and thus credibility/generalizability of evidence can vary and is referred to in terms of 

its strength. 

Evidence-Based Best Practice: Evidence-based findings regarding an appropriate diagnostic 

approach, therapeutic treatment/regimen, or delivery system. Findings should be well established to be “best practice.” 

Facilitation: A technique used as a translation intervention that involves actively promoting adoption of best practice recommendations. Facilitation roles can be both internal and 

external to the setting of change.

Guideline: Comprehensive evidence- or expert opinion-based guide to appropriate care for a 

particular condition.

Implementation: Efforts designed to get best practice findings and related products into use 

via effective change strategies. Implementation typically follows dissemination; multiple 

strategies tend to be more effective, and successful implementation includes the identification of facilitating factors as well as barriers.
Health Services Research and Development Service 19

Intervention: A single method or technique to facilitate change and, thereby, adoption of best 

practice recommendations. Interventions can be categorized as social interaction/norm/behavioral, knowledge/educational, or functional/organizational. 

Major Depressive Disorder: A mood disorder characterized by the occurrence of one or more 

major depressive episodes and the absence of any history of manic, mixed, or hypomanic 

episodes. Major depression may be diagnosed when five or more symptoms of depression are 

present for at least two weeks. These symptoms include feeling sad, hopeless, worthless, or 

pessimistic, and can lead to social and occupational dysfunction. 

Appendix B: Suggested reading materials

What reading materials are available to provide more information on mental health care 

for depression?

Depression has been the subject of numerous publications, from entire books and journals 

devoted to the topic to individual articles and literature reviews. The list below provides a 

comprehensive, but by no means complete, guide to a variety of published articles and journals on depression, including collaborative care. 

Books 

1. How You Can Survive When They’re Depressed by Ann Sheffield (Harmony Books, 1998). 

Ms. Sheffield describes, stage by stage, how individuals with depression affect others around 

them. 

2. More Than Moody by Harold Koplewicz, M.D. (G.P. Putnam’s, 2002). 

The author, a leading child psychiatrist, provides advice on treating depression in the young, 

drawing on anecdotes from his practice. 

3. The Peace of Mind Prescription by Dennis Charney, M.D., and Charles Nemeroff, M.D. 

(Houghton-Mifflin, 2004). 

Physician authors dispel some of depression’s mysteries and provide extensive evaluations of 

various drugs and therapies. 

4. Undercurrents: A Therapist’s Reckoning With Her Own Depression by Martha Manning 

(HarperCollins, 1994). 

Martha Manning, a practicing clinical psychologist, was struck by major depression. This 

book describes her experience with this illness. 

5. Against Depression by Peter D. Kramer (Viking, 2005). 

Dr. Peter Kramer, the author of “Listening to Prozac,” provides news from top research scientists about the causes of depression and treatment.

6. Beating Depression: The Journey to Hope by Maga Jackson-Triche, Kenneth Wells and 

Katherine Minnium. (UCLA, NPI Health Services Research Center, 2002).

The authors discuss treatment options and practical coping skills.
20 Collaborative Care for Depression in the Primary Care Setting

Articles

Barbui C and Tansella M. Identification and management of depression in primary care 

settings: A meta-review of the evidence. Epidemiol Psychiatr Soc October-December 

2006;12(6):702-706.

Bower P, Gilbody S, Richards D, et al. Collaborative care for depression in primary care. 

Making sense of a complex intervention: Systematic review and meta-regression. Br J 

Psychiatry December 2006;189:484-493.

Campbell D, Felker B, Lui C, Yano E, Kirchner J, Chan D, Rubenstein L, and Chaney E. 

Prevalence of depression-PTSD comorbidity: Implications for clinical practice guidelines and 

primary care-based interventions. J Gen Intern Med June 2007;22(6):711-718.

Chew-Graham C, Lovell K, Roberts C, et al. A randomized controlled trial to test the feasibility 

of a collaborative care model for the management of depression in older people. Br J Gen Pract

May 2007;57(538):364-370.

Collins R and Escobar J. Dialogues on depression management: The primary care and specialist 

perspectives. Manag Care October 2006;15(10 Suppl):3-9.

Dobscha S, Leibowitz R, Flores J, Doak M, and Gerrity M. Primary care provider preferences 

for working with a collaborative support team. Implement Sci May 30, 2007;2(1):16.

Fickel J, Parker L, Yano E and Kirchner J. Primary care – mental health collaboration: 

An example of assessing usual practice and potential barriers. J Interprof Care March 

2007;21(2):207-216.

Fortney J, Pyne J, Edlund M, et al. A randomized trial of telemedicine-based collaborative care 

for depression. J Gen Intern Med August 2007;22(8):1086-93.

Gaynes B, Rush A, Trivedi, M, et al. Major depression symptoms in primary care 

and psychiatric care settings: A cross-sectional analysis. Ann Fam Med March-April 

2007;5(2):126-134.

Gelenberg A, Kocsis, J, McCullough J, et al. The state of knowledge of chronic depression. Prim 

Care Companion J Clin Psychiatry 2006;8(2):60-65.

Gilbody S, Bower P, Fletcher J, et al. Collaborative care for depression: A cumulative 

meta-analysis and review of longer-term outcomes. Arch Intern Med November 27, 

2006;166(21):2314:21.

Hyman Rapaport M. Translating the evidence of atypical depression into clinical practice. 

J Clin Psychiatry 2007;68(Suppl 3):31-36.

Ijff M, Huijbregts K, van Marwijk H, et al. Cost-effectiveness of collaborative care including 

PST and an antidepressant treatment algorithm for the treatment of major depressive disorder 

in primary care: A randomized clinical trial. BMC Health Serv Res March 2007;1(7):34. 

Kates N and Mach M. Chronic disease management for depression in primary care: A 

summary of the current literature and implications for practice. Can J Psychiatry February 

2007;52(2):77-85.

Katon W and Unutzer J. Collaborative care models for depression: Time to move from 

evidence to practice. Arch Intern Med November 27, 2006;166(21):2304-2306.
Health Services Research and Development Service 21

Katon W, Lin E, and Kroenke K. The association of depression and anxiety with medical 

symptom burden in patients with chronic medical illness. Gen Hosp Psychiatry March-April 

2007;29(2):147-155.

Klein D, Shankman S, and Rose S. Dysthymic disorder and double depression: Prediction of 

10-year course trajectories and outcomes. J Psychiatr Res Apr 2008;42(5):408-15. Epub Apr 26, 

2007. 

Koran L, Aboujaoude E, and Gamel N. Duloxetine treatment of dysthymia and double 

depression: An open-label trial. J Clin Psychiatry May 2007;68(5):761-765.

Ludman E, Simon G, Tutty S, and Von Korff M. A randomized trial of telephone psychotherapy 

and pharmacotherapy for depression: Continuation and durability of effects. J Consult Clin 

Psychol April 2007;75(2):257-266.

Mischeoulon D. Update and critique of natural remedies as antidepressant treatments. 

Psychiatr Clin North Am March 2007;30(1):51-68. 

Scanlan J. Comments on “A note on the partnership between psychiatry and primary care.”

Am J Psychiatry March 2007;164(3):528.

Sherman S, Fotiades J, Rubenstein L, et al. Teaching systems-based practice to primary care 

physicians to foster routine implementation of evidence-based depression care. Acad Med 

February 2007;82(2):168-175.

Turvey C, Willyard D, Hickman D, Klein D, and Kukoyi O. Telehealth screen for depression in 

a chronic illness care management program. Telemed J E Health February 2007;13(1):51-56.

Wolf N and Hopko D. Psychosocial and pharmacological interventions for depressed adults 

in primary care: A critical review. Clin Psychol Rev January 2008;28(1):131-61. Epub April 29, 

2007.

Appendix C: Resources

What resources are available for those interested in learning about depression and/or treatment for depression?

Visit the following websites for more information about depression and various treatments for 

this chronic and common mental illness. 

American Psychiatric Association: www.psych.org/ .

Center for Mental Health Services: http://mentalhealth.samhsa.gov/ .

Depression and Bipolar Support Alliance: www.dbsalliance.org/ .

National Institute of Mental Health: www.nimh.nih.gov/ .

National Mental Health Association: www.nmha.org/ .

To learn more about TIDES, visit the TIDES intranet website at vaww.gla.med.va.gov/tides 

(not available from outside VA). The website provides links to TIDES tools and training.
22 Collaborative Care for Depression in the Primary Care Setting

Collaborative Care for Depression in the Primary Care Setting. 

A Primer on VA’s Translating Initiatives for Depression into Effective 

Solutions (TIDES) Project is available in electronic and print formats. 

Additional copies may be obtained from the sources listed below.

Electronic copies (PDF format) can be downloaded from the 

VA HSR&D web site. Point your browser to:

 http://www.hsrd.research.va.gov/publications/primer/

Print copies may be requested from:

CIDER

VA Boston Healthcare System (152-C)

150 South Huntington Avenue, Building 9

Boston, MA 02130

Email: cider.boston@va.gov 

Other Primers in the series include:

Primary Care in VA

Health Technology Assessment in VA

Using Outcomes to Improve Healthcare Decision Making

Program Evaluation for Managers

Risk Adjustment: A Tool for Leveling the Playing Field

Clinical Practice Guidelines

Organizational Change

Informed Consent For Human Subjects Research
Health Services Research and Development Service

Produced by the 

Center for Information Dissemination and Education Resources

VA Boston Healthcare System (152-C)

150 South Huntington Avenue, Building 9

Boston, MA 02130

Email: cider.boston@va.gov

http://www.hsrd.research.va.gov