Interventions that improve the quality of depression care: where do we go from here?

For a myriad of reasons, the diagnosis and treatment of depression in primary care is becoming an increasingly important topic. One only needs to look back over the last several issues of this journal to note that the number of articles pertaining to mental health care has grown.1–9 The emphasis placed on this subject is no accident; according to the World Health Organization, major depression worldwide is the fourth leading cause of disability and soon is expected to be second only to heart disease.10 Within primary care, the prevalence of major depression is estimated at between 6% and 10%.11 However, despite increasing attention to this topic, the current state of care for patients with depression is suboptimal. Physician education is a traditional mechanism believed to improve the quality of care. However, formal evaluation of physician education has often demonstrated that education alone is unsuccessful at changing outcome.12 In this issue of the Journal, Meredith et al.8 describe a quality improvement initiative whereby practices were randomized to a core quality improvement initiative alone, or to receive additional resources to care for their depressed patients in the form of assistance with medication management or more affordable access to psychotherapy. Physician education was provided to all practice clinicians that participated in the quality improvement initiative. The authors conclude that the quality improvement program provided sustained (18-month) improvement in clinician treatment knowledge across all three arms. However, review of the various subgroups demonstrates that knowledge was gained primarily for those who received the augmented intervention (assistance with medication management or psychotherapy access). This group had greater participation in educational sessions, which may have led to improved depression knowledge. Additionally, although the study reports an elevation in the overall depression knowledge score, the increase is primarily a result of improved performance on the subgroup of questions on the role of psychotherapy. This suggests that although education was beneficial, it was limited primarily to the area in which primary care physicians typically have the largest knowledge deficit. Finally, it is not known whether or not the knowledge change itself led to improved patient outcomes. Physicians' reports of use of mental health specialists and preauthorization for selective serotonin reuptake inhibitor antidepressants did not change. Perhaps due to the failure of more traditional quality improvement efforts to improve the quality of depression care, more rigorous, structured interventions have been designed.13–15 These models have included collaborative management between primary care and mental health care, and integrating mental health care professionals into the primary care clinics. Organized treatment protocols, systematic monitoring of treatment, and structured follow-up programs are used to meet the goal of improved concordance with evidence-based guidelines and, ultimately, improved depression outcomes. The barrier of the stigma of going to a mental health clinic is removed by integrating mental health care professionals into the primary care clinics. This design also allows the primary care provider to retain some involvement in the patient's depression management. However, despite overall improvement of depression outcomes for those cared for in collaborative treatment models, approximately 25% to 30% of patients still fail to improve. The article by Walker et al.9 strives to understand if there are differences in response to a collaborative stepped care model based upon severity of depression, and if patient factors predict failure to respond. In this study, the authors hypothesized that depression severity would predict outcome, and patients were thus stratified by depression severity prior to randomization. As they anticipated, intervention patients in the lower severity group were significantly more likely to improve over time. The more severely depressed group did not experience greater improvement than the usual care group. This was in spite of more intensive pharmacotherapy and appropriate antidepressant dosing. However, these patients were more likely to have comorbid panic disorder, loneliness, and childhood emotional abuse. Interestingly, they were more likely than the control group to improve over the first 3 months of the study, while the active intervention was ongoing. However, the difference in response between the intervention and usual care groups disappeared at 6 months, when psychiatry visits were no longer occurring. This suggests that more severely depressed patients with other comorbid illness may require more intensive, continued support and psychotherapy, as appropriate medication management alone was not sufficient. This hypothesis needs to be further tested, but implies that more explicit stepped collaborative care algorithms that match intensity and longevity with severity may prove to be the next step in improving the effectiveness and cost-effectiveness of depression therapy. The findings of these two studies, among others, demonstrate methods by which the treatment of depression can be improved in primary care. Moreover, they bring to light the tremendous difficulties inherent in caring for all patients who develop depression and the reason why we need to consider alternative models for caring for depressed patients. Quality care for depression requires making the diagnosis, educating the patient about the disease process, incorporating patient preferences into the treatment plan, providing adequate pharmacotherapy trials and dosing regimens, monitoring for side-effects and progress, and collaborating with mental health care providers. Additionally, it requires matching the length and complexity of treatment with the severity of depression. For some patients, this will require provision for continued monitoring and maintenance treatment, as in any other chronic disease; for others it will require vigilance for the possibility of recurrence. Reaching the goal of improved depression outcomes in primary care will require more than physician education. Collaborative care models between primary care and mental health care that utilize systematic monitoring and tracking suggest a potential design for providing effective depression care in the primary care arena. The next challenge will be to determine the economic feasibility of such a model across a multitude of practice settings.