Clinical Question: Does a collaborative approach to care benefit patients with depression who fail to respond to antidepressant therapy or who are at risk for recurrence?

Setting: Population-based

Study Design: Randomized controlled trial (nonblinded)

Synopsis: Of 88,000 patients who visited four offices of a large health maintenance organization, researchers identified all patients who had received a new antidepressant medication (n = 2,699). Eight weeks later, the patients were contacted to determine whether they had four or more residual major depressive symptoms (“persistent” depression, n = 159), or were having recurrent depression (two or more previous episodes) or dysthymia (“relapse prevention,” n = 69). Patients were randomized to receive usual care by their primary care physician or a “stepped collaborative care intervention.”Allocation concealment was not mentioned. The intervention focused on patients, physicians, and process of care.

Patients received a book and companion videotape outlining depression and its treatment. Patients were seen by a psychiatrist for two sessions and were called between visits to review their progress. The psychiatrist worked with the primary care physician and patient to adjust medication dosages or referred some patients (12 percent) for psychotherapy.

In patients with moderate depression, the collaborative approach was associated with continued improvement in symptoms over the 28 months of the study (mean symptom checklist score: 0.9/4.0 versus 1.2/4.0) as well as in disability scores (3.09/10 versus 3.58/10, P = 0.004). In patients with severe depression, the intervention had no effect on symptoms or level of disability. Overall costs for health care were, on average, about 8 percent lower in the intervention group, although depression treatment costs were higher.

Bottom Line: In patients with moderate depression that is unresponsive to initial drug therapy, a multiple-intervention approach using patient education and psychiatric therapy can result in symptom improvement and decreased disability at a lower overall health care cost. (Level of Evidence: 1c)