Improving quality of depression care using organized systems of care: a review of the literature. Cost Effectiveness of a Pharmacy-Based Coaching Programme to Improve Adherence to Antidepressants Identification of primary care patients at risk of nonadherence to antidepressant treatment Improving patients' beliefs about antidepressants in primary care: a cluster-randomized controlled trial of the effect of a depression care program. Cost-effectiveness of systematic depression treatment among people with diabetes mellitus. Interventions for enhancing medication compliance/adherence with benefits in treatment outcomes A systematic review of the cost and cost-effectiveness of telehealth for patients suffering from chronic obstructive pulmonary disease Cost-effectiveness of systematic depression treatment for high utilizers of general medical care. A cluster randomized trial comparing two interventions to improve treatment of major depression in primary care. Economic impact of use of chlorhexidine-impregnated sponge dressing for prevention of central line-associated infections in the United States. Cost-effectiveness of a collaborative care program for primary care patients with persistent depression. Economic value of gemcitabine compared to cisplatin and etoposide in non-small cell lung cancer. Enhanced recovery after liver surgery. Cost Benefits of a Peer-Led Asthma Self-Management Program for Adolescents Improving antidepressant adherence and depression outcomes in primary care: the treatment initiation and participation (TIP) program. Cost-Effectiveness of a Program to Prevent Depression Relapse in Primary Care Is the Comparison between Exercise and Pharmacologic Treatment of Depression in the Clinical Practice Guideline of the American College of Physicians Evidence-Based? [Do depressed patients comply with treatments prescribed?: a cross-sectional study of adherence to the antidepressant treatment]. A randomized trial of relapse prevention of depression in primary care. Physical activity as a treatment for depression: the TREAD randomised trial protocol Cost-effectiveness of a psychoeducational relapse prevention program for depression in primary care. Cost-effectiveness of collaborative care for depression in a primary care veteran population. The feasibility of determining the effectiveness and cost-effectiveness of medication organisation devices compared with usual care for older people in a community setting: systematic review, stakeholder focus groups and feasibility randomised controlled trial.
OBJECTIVE To establish the need for a chronic disease management strategy for major depressive disorder ( MDD ) , discuss the challenges involved in implementing guideline -level treatment for MDD , and provide examples of successful implementation of collaborative care programs . DATA SOURCES A systematic literature search of MEDLINE and the US National Library of Medicine was performed . STUDY SELECTION We review ed clinical studies evaluating the effectiveness of collaborative care interventions for the treatment of depression in the primary care setting using the keywords collaborative care , depression , and MDD . This review includes 45 articles relevant to MDD and collaborative care published through May 2010 and excludes all non-English- language articles . RESULTS Collaborative care interventions include a greater role for nonmedical specialists and a supervising psychiatrist with the major goal of improving quality of depression care in primary care systems . Collaborative care programs restructure clinical practice to include a patient care strategy with specific goals and an implementation plan , support for self-management training , sustained patient follow-up , and decision support for medication changes . Key components associated with the most effective collaborative care programs were improvement in antidepressant adherence , use of depression case managers , and regular case load supervision by a psychiatrist . Across studies , primary care patients r and omized to collaborative care interventions  experienced enhanced treatment outcomes compared with those r and omized to usual care , with overall outcome differences approaching 30 % . CONCLUSIONS Collaborative care interventions may help to achieve successful , guideline -level treatment outcomes for primary care patients with MDD . Potential benefits of collaborative care strategies include reduced financial burden of illness , increased treatment adherence , and long-term improvement in depression symptoms and functional outcomes Introduction The efficacy of antidepressants in the treatment of depression has been convincingly demonstrated in r and omised trials . However , non-adherence to antidepressant treatment is common . Objective To evaluate , from a societal perspective , the cost effectiveness of a pharmacy-based intervention to improve adherence to antidepressant therapy in adult patients receiving treatment in primary care . Methods An economic evaluation was performed alongside a 6-month r and omised controlled trial in The Netherl and s. Patients who came to 19 pharmacies with a new prescription for a non-tricyclic antidepressant , i.e. those who had not received any prescription for an antidepressant in the past 6 months , were invited to participate . They were then r and omly allocated to education and coaching by the pharmacist or to usual care . The coaching programme consisted of three contacts with the pharmacist , with a mean duration of between 13 and 20 minutes , and a take-home video review ing important facts on depression and antidepressant treatment . The clinical outcome measures were adherence to antidepressant treatment measured using an electronic pill container ( eDEM ) and improvement in depressive symptoms measured using the Hopkins Symptom Checklist ( SCL ) . Re source use was measured by means of question naires . The uncertainty around differences in costs and cost effectiveness between the treatment groups was evaluated using bootstrapping . Results Seventy patients were r and omised to the intervention group and 81 to the usual care group ; of these , 40 in the intervention group and 48 in the control group completed all of the follow-up question naires . There were no significant differences in adherence , improvements in the SCL depression mean item score and costs over 6 months between the two treatment groups . Mean total costs ( 2002 values ) were € 3275 in the intervention group and € 2961 in the control group ( mean difference € 315 ; 95 % CI —1922 , 2416 ) . The incremental cost-effectiveness ratio associated with the pharmacist intervention was € 149 per 1 % improvement in adherence and € 2550 per point improvement in the SCL depression mean item score . Cost-effectiveness planes and acceptability curves indicated that the pharmacist intervention was not likely to be cost effective compared with usual care . Conclusion In patients starting treatment with antidepressants , there were no significant differences in adherence , severity of depression , costs and cost effectiveness between patients receiving coaching by a pharmacist and patients receiving usual care after 6 months . Considering the re sources needed to implement an intervention like this in clinical practice , based on these results , the continuation of usual care is recommended Introduction Poor adherence to antidepressant treatment is common , and results in increased disability and costs . Several factors are thought to influence patients ’ ability and willingness to adhere . So far , however , consensus is lacking regarding patient characteristics that predict nonadherence . The purpose of this study was to identify predictors of nonadherence to antidepressant treatment that can be ascertained at treatment start . Method The present study used data from a r and omized controlled trial with the main objective of study ing the effect of two different compliance-enhancing programs on treatment adherence  and treatment response in 1031 primary care patients with major depression . In this study , logistic regression analyses were performed to examine patient- and illness-related characteristics potentially associated with nonadherence . Results Nonadherence to antidepressant treatment  was predicted by age under 35 or over 64 years , presence of personality disorder , sensation-seeking personality traits , substance abuse , and absence of concomitant medications . Conclusion Certain patient- and illness-related characteristics may imply an increased risk of nonadherence to antidepressant treatment . Giving special attention to subjects with such characteristics may improve adherence OBJECTIVE Many depressed patients have negative beliefs about antidepressants , leading to poor adherence , unfavorable depression outcome , and low perceived well-being , role functioning , and quality of life . Interventions to ameliorate beliefs are therefore needed . METHOD In a cluster-r and omized controlled trial conducted from September 1999 to January 2001 , 2 interventions to improve management of major depressive disorder  in primary care were compared : ( 1 ) a depression care program ( DCP ) , providing enhanced patient education , stimulation of active participation of general practitioners and patients in the treatment process , discussion of benefits and costs of taking antidepressant medication , and systematic follow-up and ( 2 ) a systematic follow-up program ( SFP ) .  Thirty general practitioners were r and omly assigned , and 211 patients with current major depressive disorder ( diagnosed according to DSM-IV ) were included . All patients were prescribed a selective serotonin reuptake inhibitor .  Beliefs were assessed at baseline , at week 10 , and at week 26 . Differences in change of beliefs between DCP and SFP groups were analyzed . RESULTS Changes in patients ' beliefs were more favorable in the DCP condition at week 10 and week 26 , compared with SFP only ( beliefs concerning appropriate medication-taking , week 10 : effect size = 0.39 , p = .012 ; week 26 : effect size = 0.55 , p = .001 ; beliefs concerning harmfulness , week 10 : effect size = 0.45 , p = .011 ; week 26 : effect size = 0.62 , p = .002 ) . CONCLUSION The depression care program ameliorates beliefs about antidepressants in primary care patients with major depressive disorder . The study results encourage the implementation of a depression care program in order to improve beliefs about antidepressant medication in primary care patients diagnosed with major depressive disorder CONTEXT Depression co-occurring with diabetes mellitus is associated with higher health services costs , suggesting that more effective depression treatment might reduce use of other medical services . OBJECTIVE To evaluate the incremental cost and cost-effectiveness of a systematic depression treatment program among out patients with diabetes . DESIGN R and omized controlled trial comparing systematic depression treatment program with care as usual . SETTING Primary care clinics of group-model prepaid health plan . PATIENTS A 2-stage screening process identified 329 adults with diabetes and current depressive disorder . INTERVENTION Specialized nurses delivered a 12-month , stepped-care depression treatment program beginning with either problem-solving treatment psychotherapy or a structured antidepressant pharmacotherapy program . Subsequent treatment ( combining psychotherapy and medication , adjustments to medication , and specialty referral ) was adjusted according to clinical response . MAIN OUTCOME MEASURES Depressive symptoms were assessed by blinded telephone assessment s at 3 , 6 , 12 , and 24 months . Health service costs were assessed using health plan accounting records . RESULTS Over 24 months , patients assigned to the intervention accumulated a mean of 61 additional days free of depression ( 95 % confidence interval [ CI ] , 11 to 82 days ) and had outpatient health services costs that averaged $ 314 less ( 95 % CI , $ 1007 less to $ 379 more ) compared with patients continuing in usual care . When an additional day free of depression is valued at $ 10 , the net economic benefit of the intervention is $ 952 per patient treated ( 95 % CI , $ 244 to $ 1660 ) . CONCLUSIONS For adults with diabetes , systematic depression treatment significantly increases time free of depression and appears to have significant economic benefits from the health plan perspective . Depression screening and systematic depression treatment should become routine components of diabetes care Scientific background Poor compliance or adherence in  drug therapy  can cause increased morbidity , mortality and enormous costs in the healthcare system ( in Germany annually approximately 10 billion euros ) . Different methods are used for enhancing the compliance or adherence . Research questions The evaluation addresses the questions about existence , efficacy , cost-benefit relation as well as ethical-social and juridical implication s of strategies for enhancing compliance or adherence in drug therapy with concomitant improvements in treatment outcomes . Methods A systematic literature search was conducted in the medical , also health economic relevant , literature data bases in January 2007 , beginning from 2002 . Systematic review s on the basis of ( r and omised controlled trials ( RCT ) concerning interventions to enhance compliance or adherence with regard to treatment outcomes as well as systematic review s of health economic analyses were included in the evaluation . Additionally , it was also search ed for publications which primarily considered ethical-social and juridical aspects of these interventions for the German context . Results One systematic review with data for 57 RCT was included in the medical evaluation and one systematic review with data for six studies into the health economic evaluation . No publication primary concerning ethical-social or juridical implication s could be identified . A significant positive effect on the treatment outcome was reported for 22 evaluated interventions . For many interventions the results can be classified as reliable : counseling with providing an information leaflet and compliance diary chart followed by phone consultation for helicobacter pylori positive patients , repeated counseling for patients with acute asthma symptoms , telephone calls to establish the level of compliance and to make recommendations based on that for the therapy of cardiovascular diseases , calls of an automated telephone system with phone counseling in problem cases for diabetics , different family based interventions including repeated family counseling , education and " culturally modified family therapy " in patients with schizophrenia , repeated " compliance therapy " sessions for patients with acute psychosis . For other interventions the results should be viewed with more concern ( because of the poor method ical quality of the underlying studies ) . The effect size of the interventions can not be estimated from the available data . From the available data , no reliable results can be provided concerning the cost-benefit relation of these strategies . Discussion Many of the reported studies had a poor reporting and method ological quality . The reliability of the conclusions of the studies is restricted because of method ical shortcomings . Efficacy and cost estimates determined in the health economic studies are not transferable to the current situation in Germany . It has been discussed recently that the compliance or adherence enhancing interventions can restrict the autonomy and the privacy of the patients . Conclusions In drug therapy some compliance or adherence enhancing interventions with concomitant positive effect on the treatment outcome may be used . The cost-benefit relation of these interventions is to be estimated . Using these interventions the patient ’s autonomy and privacy are to be restricted as few as possible We conducted a systematic review of the evidence on the costs and cost-effectiveness of telehealth for patients with chronic obstructive pulmonary disease ( COPD ) . A literature search identified six relevant economic evaluations that were assessed according to the Consensus Health Economic Criteria list ( CHEC list ) . Three studies were from North America and three studies were from Europe . All studies reported the use of home monitoring devices that measured and transmitted different physical indicators to nurses who provided personalised feedback to patients during weekdays . The six studies involved a total of 559 COPD patients of whom 281 were r and omised to telehealth .  The review demonstrated a potential for cost savings . All six studies reported a lower average cost per patient with telehealth plus usual care compared with usual care alone . However , the quality of the economic evidence was poor . Five studies were evaluated as low quality and one study was evaluated as moderate quality , with CHEC list scores of 21–68 % . Caution is advised for healthcare decision-makers seeking large-scale implementation of telehealth in routine clinical practice . The clinical effectiveness of such implementations with follow-up exceeding 12 months has not yet been demonstrated BACKGROUND Exp and ing access to high- quality depression treatment will depend on the balance of incremental benefits and costs . We examine the incremental cost-effectiveness of an organized depression management program for high utilizers of medical care . METHODS Computerized records at 3 health maintenance organizations were used to identify adult patients with outpatient medical visit rates above the 85th percentile for 2 consecutive years . A 2-step screening process identified patients with current depressive disorders , who were not in active treatment . Eligible patients were r and omly assigned to continued usual care ( n = 189 ) or to an organized depression management program ( n = 218 ) . The program included patient education , antidepressant pharmacotherapy initiated in primary care ( when appropriate ) , systematic telephone monitoring of adherence and outcomes , and psychiatric consultation as needed . Clinical outcomes ( assessed using the Hamilton Depression Rating Scale on 4 occasions throughout 12 months ) were converted to measures of " depression-free days . " Health services utilization and costs were estimated using health plan-st and ardized cl aims . RESULTS The intervention program led to an adjusted increase of 47.7 depression-free days throughout 12 months ( 95 % confidence interval [ CI ] , 28.2 - 67.8 days ) . Estimated cost increases were $ 1008 per year ( 95 % CI , $ 534-$1383 ) for outpatient health services , $ 1974 per year for total health services costs ( 95 % CI , $ 848-$3171 ) , and $ 2475 for health services plus time-in-treatment costs ( 95 % CI , $ 880-$4138 ) . Including total health services and time-in-treatment costs , estimated incremental cost per depression-free day was $ 51.84 ( 95 % CI , $ 17.37-$108.47 ) . CONCLUSIONS Among high utilizers of medical care , systematic identification and treatment of depression produce significant and sustained improvements in clinical outcomes as well as significant increases in health services costs BACKGROUND Many patients with major depression are non-adherent to antidepressant medication and do not receive care according to current guidelines . There is increasing evidence that treatment of depression in primary care can be improved . Comparison between effective interventions may help to establish the active ingredients of such interventions . METHOD In a r and omized trial two interventions to improve treatment of major depression in primary care were compared ( 1 ) a depression care programme , targeting general practitioners ( GPs ) , patients , and systematic follow-up , and ( 2 ) a systematic follow-up programme .  Thirty GPs were r and omized and 211 primary -care patients with current major depression were included . All patients were prescribed a selective serotonin reuptake inhibitor . Outcome measures included adherence to antidepressant medication , and depression outcome . RESULTS No significant differences in adherence rates and treatment outcome measures were demonstrated between interventions at week 10 or week 26 . Adherence rates were high and treatment outcome was favourable . CONCLUSIONS The depression care programme was not superior to the systematic follow-up programme . Systematic follow-up in depression treatment in primary care seems to be an intervention per se , having the potential to improve adherence and treatment outcome BACKGROUND The economic impact of adding chlorhexidine gluconate (CHG)-impregnated sponge dressing to st and ard care ( ie , chg-impregnated sponge dressing + skin preparation and transparent film dressing vs skin preparation and transparent film dressing ) for the prevention of central -line infections was evaluated . METHODS Clinical and economic data were obtained from peer- review ed published studies to populate the decision model . The efficacy of reducing  catheter-related bloodstream infection ( CR-BSI )  incidence with CHG-impregnated sponge dressing came from 2 recent r and omized controlled trials . One-way and two-way sensitivity analyses were performed on key clinical and economic parameters . RESULTS Based on model calculations , a hypothetical 400-bed hospital inserting 3,078 central venous catheters ( CVCs ) per year is expected to avoid an average of 35 CR-BSIs , 145 local infections , and 281 intensive care unit days annually with the systematic use of CHG-impregnated sponge dressing .  Potential hospital net cost savings ( mainly because of reduced CR-BSIs with use of the dressing ) would be $ 895,000 annually . Results were robust across a range of values in sensitivity analyses . CONCLUSION CHG-impregnated sponge dressing is a cost-effective CR-BSI prevention treatment option for patients requiring CVCs . The importance of these results should be considered in the context of federal government and insurance company policies that no longer permit enhanced reimbursement for CR-BSI OBJECTIVE The authors evaluated the incremental cost-effectiveness of stepped collaborative care for patients with persistent depressive symptoms after usual primary care management .  METHOD Primary care patients initiating antidepressant treatment completed a st and ardized telephone assessment 6 - 8 weeks after the initial prescription . Those with persistent major depression or significant subthreshold depressive symptoms were r and omly assigned to continued usual care or collaborative care . The collaborative care included systematic patient education , an initial visit with a consulting psychiatrist , 2 - 4 months of shared care by the psychiatrist and primary care physician , and monitoring of follow-up visits and adherence to medication regimen . Clinical outcomes were assessed through blinded telephone assessment s at 1 , 3 , and 6 months . Health services utilization and costs were assessed through health plan cl aims and accounting data . RESULTS Patients receiving collaborative care experienced a mean of 16.7 additional depression-free days over 6 months . The mean incremental cost of depression treatment in this program was $ 357 . The additional cost was attributable to greater expenditures for antidepressant prescriptions and outpatient visits . No off setting decrease in use of other health services was observed . The incremental cost-effectiveness was $ 21.44 per depression-free day . CONCLUSIONS A stepped collaborative care program for depressed primary care patients led to substantial increases in treatment effectiveness and moderate increases in costs . These findings are consistent with those of other r and omized trials . Improving outcomes of depression treatment in primary care requires investment of additional re sources , but the return on this investment is comparable to that of many other widely accepted medical interventions Although chemotherapy costs have not been highlighted traditionally , there is increasing pressure to demonstrate the value of new treatments within the health care budget . Pharmaceutical companies are assessing the economic value of their products before launch . Gemcitabine is a nucleoside analogue developed for use in solid tumours . The purpose of this model was to investigate the clinical outcomes and potential cost savings for gemcitabine used as monotherapy compared to cisplatin and etoposide combination therapy in late stage non-small cell lung cancer ( NSCLC ) , in a palliative ( as opposed to aggressive ) chemotherapy setting . Gemcitabine treatment data were taken from a large NSCLC study and data from retrospective chart review s identified through the National Oncology Data Base . The model population and effectiveness of the two regimens were judged to be similar , except for baseline performance status . If drug costs were not included , the probability distribution result ing from the simulation showed median cost savings per cycle ranging from $ US 1504 to $ US 7425 , with a medium value of $ US 2154 . The model suggested that gemcitabine would result in cost savings per cycle more than 90 % of the time . Outpatient versus inpatient drug administrations accounted for the majority of potential cost savings . Most of the remaining cost savings were attributable to the difference in febrile neutropenia and antiemetic use . This economic model showed susbstantial savings if gemcitabine was used instead of cisplatin and etoposide combination therapy in the United States ' community care setting . Some savings would be realized even if the location of treatment for both regimens was mostly outpatient . Assessment of the product 's economic value before launch has assisted in our underst and ing of the potential areas of cost savings for gemcitabine and has guided us in the design of prospect i ve r and omized studies which included pharmacoeconomic endpoints INTRODUCTION In a majority of cases , enhanced recovery after surgery program ( ERP ) leads to a reduced rate of postoperative complications and shortened hospital stays following digestive surgery . The program 's preoperative , perioperative and postoperative measures are implemented by the members of a motivated multidisciplinary team . Having shown its merits in digestive surgery , ERP would be particularly useful in liver surgery due to the elevated rates of morbidity and mortality this type of operation continues to entail . The objective of this review was to evaluate the efficacy of ERP  in liver surgery . METHOD This is a systematic narrative review of the literature on the efficacy of ERP  in liver surgery by laparotomy or laparoscopy . RESULTS Notwithst and ing a number of studies ( n=30 : 5 r and omized trials , 14 cohort studies and 11 meta-analyses ) less sizable than with regard to digestive surgery in general and colorectal surgery in particular , analysis of the literature confirms that in liver surgery , ERP is associated with an overall decrease in complications by 30 to 60 % , but without improvement in the rates of hospital readmission and postoperative mortality . All of the studies report a reduction in average length of stay ( ALOS ) by 2.3 days and in functional recovery , a more objective indicator than ALOS , by 2.5 days . As of now , the economic impact of the ERP programs in liver surgery is neither positive nor negative , the above-mentioned savings being counterbalanced by heightened costs for material and equipment . Laparoscopic surgery is independently associated with better outcomes in terms of complications , functional recovery and ALOS ; that is why it is important to incorporate this surgical approach in ERP as often as possible . Given a lack of robust evidence , Prehabilitation , which is a preoperative optimization process leading to improved functional reserve , has yet to be assigned a place in ERP programs pertaining to liver surgery . Possible roadblocks to application of an ERP program can be overcome through coordination by a team leader , a motivated multidisciplinary team , training courses and dedicated teaching sessions . CONCLUSION ERP is a care improvement process that has a major play to play in organization of liver surgery , and its large-scale application is to be recommended Objective . Frequent use of health-care services associated with pediatric asthma places substantial economic burden on families and society . The purpose of this study is to examine the cost-saving effects of a peer-led program through reduction in health-care utilization in comparison to an adult-led program . Methods . R and omly assigned adolescents ( 13–17 years ) participated in either  peer-led  ( n = 59 ) or adult-led  ( n = 53 )  asthma self-management program .  Health-care utilization data were collected at baseline and at 3- , 6- , and 9-months post-intervention . Negative binomial regression models were conducted to examine the effects of the peer-led program on health-care utilization . Net cost savings were estimated based on the differences in program costs and health-care utilization costs between groups . Results . Significant group differences were found in acute office visits and school clinic visits after controlling for race and socioeconomic status . The incidence rate of acute office visits was 80–82 % less for the peer-led group during follow-ups . The peer-led group was four to five times more likely to use school clinics due to asthma than the adult-led group during follow-ups . The non research cost of peer-led program per participant was lower than the adult-led program , $ 64 versus $ 99 , respectively . The net cost saving from the reduction in acute office visits and the lower program costs of the peer-led program was estimated $ 51.8 per person for a 3-month period . Conclusions . An asthma self-management program using peer leaders can potentially yield health-care cost savings through the reduction in acute office visits in comparison to a traditional program led by health-care professionals OBJECTIVE To test the impact of a novel psychosocial intervention to improve antidepressant adherence and depression outcomes among older adults prescribed pharmacotherapy by their primary care physician ( PCP ) . DESIGN A r and omized controlled pilot study was conducted to examine the usefulness of the Treatment Initiation and Participation ( TIP ) program as an intervention to improve antidepressant adherence and depression outcomes . SETTING The study was conducted at two primary care clinics in New York city : one clinic served geriatric adults and the second clinic served a diverse group of mixed aged adults . PARTICIPANTS The sample consisted of adults aged 60 years and older with major depression who were recommended antidepressant therapy by their PCPs . INTERVENTION All participants were prescribed antidepressant therapy and r and omly assigned to either the intervention ( TIP ) or the treatment as usual ( TAU ) group . The TIP intervention identifies and targets psychological barriers to depression care , especially stigma , as well as fears and misconceptions of depression and its treatment . TIP participants are encouraged to develop a treatment goal and create an adherence strategy . MEASUREMENT Study participants were assessed at entry , 6 , 12 , and 24 weeks later . Adherence was measured based on self-report with chart verification . Depression severity was measured using the Hamilton Depression Rating Scale . RESULTS Participants in TIP were significantly more adherent to their antidepressant pharmacotherapy at all assessment time points and had a significantly greater decrease in depressive symptoms than older adults who received TAU . CONCLUSION The results provide support for the usefulness of TIP as a brief intervention to improve adherence to depression medication treatment provided in primary care setting Objective . Evaluate the incremental cost-effectiveness of a  depression relapse prevention program in primary care Material s and Methods . Primary care patients initiating antidepressant treatment completed a st and ardized telephone assessment 6–8 weeks later . Those recovered from the current episode but at high risk for relapse ( based on history of recurrent depression or dysthymia ) were offered r and omization to usual care or a relapse prevention intervention . The intervention included systematic patient education , two psychoeducational visits with a depression prevention specialist , shared decision-making regarding maintenance pharmacotherapy , and telephone and mail monitoring of medication adherence and depressive symptoms . Outcomes in both groups were assessed via blinded telephone assessment s at 3 , 6 , 9 , and 12 months and health plan cl aims and accounting data . Results . Intervention patients experienced 13.9 additional depression-free days during a 12-month period ( 95 % CI , −1.5 to 29.3 ) . Incremental costs of the intervention were $ 273 ( 95 % CI , $ 102 to $ 418 ) for depression treatment costs only and $ 160 ( 95 % CI , −$173 to $ 512 ) for total outpatient costs . Incremental cost-effectiveness ratio was $ 24 per depression-free day ( 95 % CI , −$59 to $ 496 ) for depression treatment costs only and $ 14 per depression-free day ( 95 % CI , −$35 to $ 248 ) for total outpatient costs . Conclusions . A program to prevent depression relapse in primary care yields modest increases in days free of depression and modest increases in treatment costs . These modest differences reflect high rates of treatment in usual care . Along with other recent studies , these findings suggest that improved care of depression in primary care is a prudent investment of health care re sources Major depression disorder is most commonly treated with antidepressants . However , due to their side effects clinicians seek non-pharmacologic options , and one of these is exercise . The literature on the benefits of exercise for depression is extensive . Nevertheless , two recent review s focusing on antidepressants vs. other therapies as a basis for clinical practice guidelines recommended mainly antidepressants , excluding exercise as a viable choice for treatment of depression . The aim of this perspective is to analyze the literature exploring the reasons for this discrepancy . Two categories of publications were examined : r and omized controlled trials ( RCTs ) and meta-analyses or systematic review s. Based on this re assessment , RCTs comparing exercise to antidepressants reported that exercise and antidepressants were equally effective . RCTs comparing exercise combined with antidepressants to antidepressants only reported a significant improvement in depression following exercise as an adjunctive treatment . Almost all the review s examining exercise vs. other treatments of depression , including antidepressants , support the use of exercise in the treatment of depression , at least as an adjunctive therapy . The two review s examining pharmacologic vs. non-pharmacologic therapies as a basis for clinical practice guidelines examined limited evidence on exercise vs. antidepressants . In addition , it is possible that academics and health care practitioners are skeptical of viewing exercise as medicine . Maybe , there is a reluctance to accept that changes in lifestyle as opposed to pharmacological treatment can alter biological mechanisms . Longitudinal studies are needed for assessing the effectiveness of exercise in real clinical setting s , as well as studies exploring dose-response relationship between exercise and depression INTRODUCTION . Compliance with antidepressant treatment is a very relevant factor in the outcome of depressive disorders . Poor compliance has been associated with worse outcome , increased rate of relapses and greater cost . This study has aim ed to describe adherence to antidepressant treatment in a sample of primary care patients with a diagnosis of depression in 2007 . METHODS . R and omized sampling was made of patients with depression and antidepressant treatment attended in two primary care teams . Their medical records were review ed to obtain the total number of prescriptions given to patients and the total number of prescriptions dispensed in the pharmacies . The difference between prescriptions written and collected was calculated . A difference of ± 2 was considered as good compliance . Results are shown as percentages . Comparisons were made with the chi-square , Student ’s T and ANOVA tests , where appropriate . RESULTS . The simple was made up of 212 patients . Mean age was 63.2 years ( SD 15.27 ) . In the sample , 66.5 % were treated with only one antidepressant and 24.1 % with two . The percentage of non-compliance was 33.96 % ( 95 % CI : 25.35–40.57 ) . Treatment-adherent patients have a lower percentage of long-term treatment with other drugs . The percentage of treatment-adherent women was higher than non-adherent ( p=0.015 ) . No differences were found in compliance among patients treated in the mental health center . CONCLUSIONS . One third of patients on antidepressant drug treatment were non-compliers because the drugs were not picked up properly from the pharmacies . We need to develop strategies to improve the therapeutic adherence of patients BACKGROUND Despite high rates of relapse and recurrence , few primary care patients with recurrent or chronic depression are receiving continuation and maintenance-phase treatment . We hypothesized that a relapse prevention intervention would improve adherence to antidepressant medication and improve depression outcomes in high-risk patients compared with usual primary care . METHODS Three hundred eighty-six patients with recurrent major depression or dysthymia who had largely recovered after 8 weeks of antidepressant treatment by their primary care physicians were r and omized to a relapse prevention program ( n = 194 ) or usual primary care ( n = 192 ) . Patients in the intervention group received 2 primary care visits with a depression specialist and 3 telephone visits over a 1-year period aim ed at enhancing adherence to antidepressant medication , recognition of prodromal symptoms , monitoring of symptoms , and development of a written relapse prevention plan . Follow-up assessment s were completed at 3 , 6 , 9 , and 12 months by a telephone survey team blinded to r and omization status . RESULTS Those in the intervention group had significantly greater adherence to adequate dosage of antidepressant medication for 90 days or more within the first and second 6-month periods and were significantly more likely to refill medication prescriptions during the 12-month follow-up compared with usual care controls . Intervention patients had significantly fewer depressive symptoms , but not fewer episodes of relapse/recurrence over the 12-month follow-up period . CONCLUSIONS A relapse prevention program targeted to primary care patients with a high risk of relapse/recurrence who had largely recovered after antidepressant treatment significantly improved antidepressant adherence and depressive symptom outcomes Background Depression is one of the most common reasons for consulting a General Practitioner ( GP ) within the UK . Whilst antidepressants have been shown to be clinical ly effective , many patients and healthcare professionals would like to access other forms of treatment as an alternative or adjunct to drug therapy for depression . A recent systematic review presented some evidence that physical activity could offer one such option , although further investigation is needed to test its effectiveness within the context of the National Health Service . The aim of this paper is to describe the protocol for a r and omised , controlled trial ( RCT ) design ed to evaluate an intervention developed to increase physical activity as a treatment for depression within primary care . Methods / design The TREAD study is a pragmatic , multi-centre , two-arm RCT which targets patients presenting with a new episode of depression . Patients were approached if they were aged 18 - 69 , had recently consulted their GP for depression and , where appropriate , had been taking antidepressants for less than one month . Only those patients with a confirmed diagnosis of a depressive episode as assessed by the Clinical Interview Schedule-Revised ( CIS-R ) , a Beck Depression Inventory ( BDI ) score of at least 14 and informed written consent were included in the study . Eligible patients were individually r and omised to one of two treatment groups ;  usual GP care or usual GP care plus facilitated physical activity . The primary outcome of the trial is clinical symptoms of depression assessed using the BDI four months after r and omisation . A number of secondary outcomes are also measured at the 4- , 8- and 12-month follow-up points including quality of life , attitude to and involvement in physical activity and antidepressant use/adherence . Outcomes will be analysed on an intention-to-treat ( ITT ) basis and will use linear and logistic regression models to compare treatments . Discussion The results of the trial will provide information about the effectiveness of  physical activity  as a treatment for depression . Given the current prevalence of depression and its associated economic burden , it is hoped that TREAD will provide a timely contribution to the evidence on treatment options for patients , clinicians and policy-makers . Trial registration : IS RCT N BACKGROUND Major depression is a prevalent mental disorder with a high risk of relapses and recurrences , which are associated with considerable burden for patients and high costs for society . Despite these negative consequences , only few studies have focused on interventions aim ed at the prevention of recurrences in primary care patients with depression . AIMS OF THE STUDY To assess the cost-effectiveness of a psychoeducational prevention program ( PEP ) aim ed at improving the long-term outcome of depression in primary care . METHODS Recruitment took place in the northern part of the Netherl and s , patients were referred by general practitioners . In total 267 patients were included in the study and r and omly assigned to usual care ( UC ) or UC with one of three forms of PEP ; PEP alone , psychiatric consultation followed by PEP ( psychiatrist-enhanced PEP ) , and cognitive behavioral therapy followed by PEP ( CBT-enhanced PEP ) .  Costs and health outcomes were registered at three month intervals during the 36 months follow-up of the study . Primary outcome measure was the proportion of depression-free time . RESULTS Mean total costs during the 36 months of the study were 8200 euros in the UC group , 9816 euros in the PEP group , 9844 euros in the psychiatrist-enhanced PEP group , and 9254 euros in the CBT-enhanced PEP group . Costs of productivity losses , hospital admissions , contacts with regional institutions for mental healthcare , and medication use contributed substantially to the total costs in each group . Results of the primary outcome measure were less positive for PEP than for UC , but slightly better in the enhanced PEP groups . If decision-makers are willing to pay up to 300 euros for an additional proportion of depression-free time , UC is most likely to be the optimal intervention . For higher willingness to pay , CBT-enhanced PEP seems most efficient . DISCUSSION The basic PEP intervention was not cost-effective in comparison with UC . The economic impact of productivity losses associated with depression , and the importance of including these costs in economic studies , was illustrated by the findings of this study . Due to the drop-out of patients during the 36 months follow-up period , economic analyses had to account for missing data , which may complicate the interpretation of the results . Although Quality -Adjusted Life Years ( QALYs ) could not be assessed for all the patients , the results of analyses focusing on QALYs supported the overall conclusion that PEP is not cost-effective . IMPLICATION S FOR HEALTH CARE PROVISION AND POLICIES : Results indicated that PEP should not be implemented in the Dutch healthcare system . Furthermore , is seems highly unlikely that PEP could be cost-effective in other ( comparable ) European healthcare systems . IMPLICATION S FOR FURTHER RESEARCH The relatively positive economic results for CBT-enhanced PEP imply that UC enriched with CBT ( but without PEP ) might be cost-effective in preventing relapses in primary care patients with depression . The actual consequences of CBT for relapse prevention will have to be studied in further detail , both from a clinical and economic point of view OBJECTIVE This study examined the incremental cost-effectiveness of a collaborative care intervention for depression compared with consult-liaison care . METHODS A total of 354 patients in a Department of Veterans Affairs ( VA ) primary care clinic who met the criteria for major depression or dysthymia were r and omly assigned to one of the two care models . Under the collaborative care model , a mental health team provided a treatment plan to primary care providers , telephoned patients to encourage adherence , review ed treatment results , and suggested modifications . Outcomes were assessed at three and nine months by telephone interviews . Health care use and costs were also assessed . RESULTS A significantly greater number of collaborative care patients were treated for depression and given prescriptions for antidepressants . The collaborative care patients experienced an average of 14.6 additional depression-free days over the nine months . The mean incremental cost of the intervention per patient was $ 237 US dollars for depression treatment and $ 519 US dollars for total outpatient costs . A majority of the additional expenditures were accounted for by the intervention . The incremental cost-effectiveness ratio was $ 24 US dollars per depression-free day for depression treatment costs and $ 33 US dollars for total outpatient cost . CONCLUSIONS Better coordination and communication under collaborative care was associated with a greater number of patients being treated for depression and with moderate increases in days free of depression and in treatment cost . Additional re sources are needed for effective collaborative care models for depression treatment in primary care BACKGROUND Medication organisation devices ( MODs ) provide compartments for a patient 's medication to be organised into the days of the week and the recommended times the medication should be taken . AIM To define the optimal trial design for testing the clinical effectiveness and cost-effectiveness of MODs . DESIGN The feasibility study comprised a systematic review and focus groups to inform a r and omised controlled trial ( RCT ) design . The result ing features were tested on a small scale , using a 2 × 2 factorial design to compare MODs with usual packaging and to compare weekly with monthly supply . The study design was then evaluated . SETTING Potential participants were identified by medical practice s. PARTICIPANTS Aged over 75 years , prescribed at least three solid oral dosage form medications , unintentionally non-adherent and self-medicating . Participants were excluded if deemed by their health-care team to be unsuitable . INTERVENTIONS One of three MODs widely used in routine clinical practice supplied either weekly or monthly . OBJECTIVES To identify the most effective method of participant recruitment , to estimate the prevalence of intentional and unintentional non-adherence in an older population , to provide a point estimate of the effect size of MODs relative to usual care and to determine the feasibility and acceptability of trial participation . METHODS The systematic review included MOD studies of any design reporting medication adherence , health and social outcomes , re source utilisation or dispensing or administration errors . Focus groups with patients , carers and health-care professionals supplemented the systematic review to inform the RCT design . The result ing design was implemented and then evaluated through question naires and group discussion s with participants and health-care professionals involved in trial delivery . RESULTS Studies on MODs are largely of poor quality . The relationship between adherence and health outcomes is unclear . Of the limited studies reporting health outcomes , some reported a positive relationship while some reported increased hospitalisations associated with MODs . The pre-trial focus groups endorsed the planned study design , but suggested a minimum recruitment age of 50 - 60 years . A total of 35.4 % of patients completing the baseline question naire were excluded because they already used a MOD . Active recruitment yielded a higher consent rate , but passive recruitment was more cost-effective . The prevalence of intentional non-adherence was 24.7 % [ n = 71 , 95 % confidence interval ( CI ) 19.7 % to 29.6 % ] of participants . Of the remaining 76 participants , 46.1 % ( 95 % CI 34.8 % to 57.3 % ) were unintentionally non-adherent . There was no indication of a difference in adherence between the study arms . Participants reported a high level of satisfaction with the design . Five adverse/serious adverse events were identified in the MOD study arms and none was identified in the control arms . There was no discernible difference in health economic outcomes between the four study arms ; the mean intervention cost was £ 20 per month greater for MOD monthly relative to usual supply monthly . CONCLUSIONS MOD provision to unintentionally non-adherent older people may cause medication-related adverse events . The primary outcome for a definitive MOD trial should be health outcomes . Such a trial should recruit patients by postal invitation and recruit younger patients . FUTURE WORK A study examining the association between MOD initiation and adverse effects is necessary and a strategy to safely introduce MODs should be explored . A definitive study testing the clinical effectiveness and cost-effectiveness of MODs is also required . STUDY REGISTRATION Current Controlled Trials IS RCT N 30626972 and UKCRN 12739 . FUNDING This project was funded by National Institute for Health Research ( NIHR ) Health Technology Assessment Programme and will be published in full in Health Technology Assessment ; Vol . 20 , No. 50 . See the NIHR Journals Library website for further project information
Depression frequently causes unemployment , absenteeism , and presenteeism , which results in significantly reduced productivity .
Improving patients ' compliance with their antidepressant medication results in improved outcomes and prolongs remission from depression , increasing work productivity , and thus reducing overall costs .
The implementation of remote enhanced-care programs may improve compliance and reduce overall costs .
In conclusion , depression is a common disorder with a high economic impact .
Enhanced-care programs may lower costs associated with depression and improve patients ' lives
This systematic review examines the economic and human costs of depression and the potential savings associated with improvement in patient adherence to treatment with antidepressants through the use of enhanced-care programs .