Reflections on the 10th anniversary of the AHCPR's guideline for the treatment of depression in primary care.

As regular readers of JGIM are aware, 6–10% of patients who present to primary care physicians' (PCPs') offices meet Diagnostic and Statistical Manual criteria for major depression, and a similar number have either minor depression or dysthymia. By 2020, depression is expected to be the second leading cause of worldwide global health disability, following cardiovascular disease.1 Yet it could assume the dubious # 1 position as our understanding of its impact on other medical conditions increases. Given that the majority of depressed individuals receive treatment for their mood symptoms in primary care settings if at all, JGIM has an established tradition of informing PCPs of the latest developments in the field2 that continues in this issue. Following the 1993 release of the landmark Agency for Health Care Policy and Research (AHCPR) Clinical Practice Guideline that summarized the then available evidence base for best treatment practices,3 attention over the following years turned toward identifying successful methods for its implementation in routine practice. Consequently, we have data from several well-designed effectiveness trials to support “collaborative care” strategies as a means to enhance quality of treatment.4–8 Collaborative care is based on Wagner's Chronic Care Model.9 It holds that outcomes can be improved by organized systems for treating patients with chronic medical conditions that include active, sustained follow-up by a nonphysician “care manager” who adheres to guideline-based treatment protocols and works under the supervision of a PCP, with specialty back-up when necessary. These care managers support patients with the time and frequency of contacts necessary to familiarize them with their illness and its treatment options, teach self-management techniques, promote patient and provider adherence with guideline-based treatment, proactively monitor response to therapy, provide timely reminders of care, and facilitate specialty referral when appropriate.10 A method for effectively implementing guideline-based care for depression having been identified, attention has shifted toward identifying financially viable iterations of collaborative care that are sustainable outside the setting of a clinical trial. Accordingly, investigators are presently evaluating the impact of: (1) “risk stratification,”“watchful-waiting,” and “stepped care” strategies to focus costly care manager resources on the most impaired individuals; and (2) care managers who handle clusters of related chronic conditions (e.g., depression, anxiety, and alcohol use disorders) rather than a single condition, as is typical in clinical trials. The Robert Wood Johnson Foundation is also supporting a national program aimed at realigning financial incentives in a manner that will support implementation of the Chronic Care Model within a variety of health plans and involving patients covered by traditional indemnity insurance, managed care, and Medicaid.11 Health services researchers are supporting these efforts by supplementing their traditional assessment batteries of symptom burden with measures for work productivity, absenteeism, and employment turnover. The report of Pyne et al. in this issue of the Journal is a fine example of this trend.12 As we reflect on the tremendous progress in the field made over the past 10 years, let us also take this opportunity to speculate on what depression treatment in primary care could be on the Guideline's 20th anniversary. First, the weight of evidence supporting the “business case” for effective depression treatment should encourage enlightened payors to provide financial incentives to PCPs and health plans for delivering quality treatment founded on evidence-based process measures of care and clinical outcomes. Second, reports, such as those pertaining to HIV13 and vascular disease14 in this issue of JGIM, will continue to quantify the adverse impact of depression on comorbid medical illness. They will provide the impetus for numerous clinical trials that focus on the clinical and economic effects of treating comorbid depression among patients with such chronic and highly prevalent medical conditions as ischemic heart disease, diabetes, end-stage renal disease, and cancer; following high-cost surgical procedures such as coronary artery bypass graft and organ transplant; and in the post-partum and end-of-life stages. Third, the immense rise of the Internet will support greater levels of patient empowerment in medical decision making and increased reliance on self-management strategies in chronic disease care. Therefore, PCPs and care managers will need to be computer literate to educate patients in the use of appropriate resource materials and then electronically monitor clinical outcomes using Health Insurance Portability and Accountability Act–compliant and secure web- and/or e-mail-based patient self-reports (e.g., PHQ-9)15 and patient registries that facilitate proactive treatment. Fourth, as electronic medical record systems gain widespread use as a means for reducing medical errors,16 PCPs will use systematic electronic screening of patients at elevated risk for depression (e.g., those with poorly controlled diabetes, those with unexplained medical symptoms,17 and high utilizers of health care services). Fifth, the stigma of depression and racial disparities in care will decrease as the accumulated impact of the pharmaceutical industry's direct-to-consumer marketing efforts increases patients' awareness and acceptance of their condition.18 Sixth, given Big Pharma's record of innovation, PCPs will prescribe entirely new classes of antidepressants that are as effective, simple to dose, and safe as presently available medications. Seventh, typical primary care for depression will remain inadequate for individuals who lack insurance. Nevertheless, we remain optimistic that meaningful health care reform will occur in the United States before the baby boom generation begins to retire in large numbers and well before 2013. Finally, it is safe to predict that as our understanding of the impact of depression and its treatment continues to grow, JGIM will continue to inform its readership of the latest developments in the field far beyond the 20th anniversary of the AHCPR's Guidelines.