Although primary care doctors usually prescribe antidepressants as the first line of treatment for patients who are suffering from depression, there is evidence that many patients prefer counseling. Models that support integrated psychotherapy and medication-based treatment strategies in primary care have the potential for relatively long-term patient benefits, according to a new study.
Cathy D. Sherbourne, Ph.D., and Kenneth B. Wells, M.D., M.P.H., of RAND, and their colleagues randomized 48 managed care primary care clinics to participate in either usual care (UC) or one of two quality improvement (QI) programs—QI-Meds, or QI-Therapy. The study was supported in part by the Agency for Healthcare Research and Quality (HS08349).
In the QI-Meds group, nurse specialists contacted the patients monthly for 6 or 12 months and helped primary care providers manage antidepressant medications. The nurse had a psychiatric expert available for consultation, and patients who preferred counseling were referred to psychotherapy options available to their practice (with regular co-pay levels). Patients in the QI-Therapy group could be referred to therapists, who provided individual or group cognitive behavioral therapy (CBT) for 12 to 16 sessions at a reduced copay. They also could receive medications from their regular primary care providers or see a non-study therapist with usual copayments. Clinics in the usual care group were mailed clinical practice guidelines on depression.
Both QI interventions reduced the likelihood of probable depression by 10-11 and 6-7 percentage points compared with usual care at 6 and 12 months, respectively. QI-Therapy patients had early (6 month) improvement in emotional well-being relative to UC patients, which was sustained over the full 2 years of the study. In contrast, there were no significant differences in emotional well-being levels between UC and QI-Meds patients during any time period.
QI-Therapy patients had fewer role limitations than QI-Meds patients at 6 months and 12 months, although patients in both intervention groups had fewer role limitations than those in usual care. Also, QI-Therapy patients had a 20 percent reduction in overall poor outcomes throughout the 2 years compared with UC patients, as well as reduced poor outcomes relative to QI-Meds patients of 19 percent at 18 months and 27 percent at 2 years.
See "Long-term effectiveness of disseminating quality improvement for depression in primary care," by Drs. Sherbourne and Wells, Naihua Duan, Ph.D., and others, in the July 2001 Archives of General Psychiatry 58, pp. 696-703.