Original Research

Improving Care for Depression in Organized Health Care Systems A Conference Report

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References

In the following article, we summarize the presentations given at a conference on improving care for depression in organized health care systems. The 68 conference participants included mental health services researchers, persons responsible for improving care for depression in large health care systems, representatives of the National Institute of Mental Health, and foundation representatives. The specific aims of the conference were to: (1) consider what depression interventions are ready for dissemination in large organized health care systems; (2) identify unanswered questions concerning their effectiveness and cost-effectiveness; and (3) identify critical next steps to accelerate dissemination. (J Fam Pract 2001; 50:530-31)

Framework

The organizing framework for the conference was provided by the Model for Improving Chronic Illness Care.1 This model identifies the need for health care systems change in 6 areas: (1) community resources and policies, including community programs and policies (eg, insurance benefits); (2) organization of care, including effective leadership for systems change and incentives for improved care; (3) self-management support consisting of a collaborative process between patients and providers to define problems, set priorities, establish goals, create treatment plans, and solve problems along the way2; (4) delivery system design, including clear delegation of roles and responsibilities from the physician to other professionals and systems for preventive services and active follow-up3-5; (5) decision support, including guidelines, reminders, provider education, and appropriate input from relevant medical specialties6,7; and (6) clinical information systems that provide timely information about patients with chronic conditions in support of guideline-based care.8,9 Comprehensive descriptions of the model are available elsewhere in the literature,14 and at the Web site of the Robert Wood Johnson Foundation National Program for Improving Chronic Illness Care (www.improvingchroniccare.org). Conference participants considered whether general approaches to improving chronic illness care were relevant to depression.

Presentations

Nine major randomized controlled trials evaluating delivery of depression treatments were presented at the conference. Barrett10,11 presented a trial evaluating antidepressant medications and Problem-Solving Therapy (PST) for patients with minor depression or dysthymia that showed benefits for medications but not for PST. Mynors-Wallis12 presented a comparison of pharmacologic treatment, PST, and their combination for major depression that found equal benefits of medications and PST, but no advantage to combined therapy. Miranda13 presented an evaluation of cognitive-behavioral therapy for low-income minority individuals, with and without social case management, that showed no added benefit of social case management. Katon14 presented a trial of a collaborative program for patients with major depression at risk for chronic depression that showed benefits relative to usual care. Wells15 presented a multisite evaluation of a program of nurse follow-up to improve pharmacologic management or cognitive-behavioral therapy by mental health specialists that found improvement in depression outcomes and reduced unemployment relative to usual care. Rost16 presented a trial of nurse case management for patients with major depression that found improved depression outcomes relative to usual care. Katzelnick17 presented a multicenter trial of step-wise case management of patients with high utilization and major depression that showed improved outcomes relative to usual care. Simon18 presented a trial comparing feedback on treatment adherence and outcomes to the primary care physician to a telephone case management program that found improved outcomes relative to usual care for case management but not for feedback alone. Hunkeler19 presented a trial of nurse telephone follow-up for patients with major depression that found improved outcomes relative to usual care.

Acknowledgments

This conference was supported by grants from the Robert Wood Johnson Foundation, the John A. Hartford Foundation, and the National Institute of Mental Health. We gratefully acknowledge Christian Helfrich for making conference arrangements.

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