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Am Fam Physician. 2007;75(7):1078

Background: Depression is one of the leading causes of disability in the world and affects 5 to 10 percent of the population. Current management of depression often does not meet evidence-based standards. Recent strategies to improve treatment of depression have included collaborative care, which is a structured approach to chronic disease management that has a greater role for nonmedical specialists. The model ranges from phone interventions that encourage medication compliance to intensive follow-up that includes a form of structured psychological intervention. Previous studies have found that collaborative care is effective in the treatment of depression, but reviews of these studies have shown limitations in their designs. Gilbody and associates evaluated the published literature on collaborative care for depression and assessed the short- and long-term benefits.

The Study: The authors searched multiple literature databases for studies that evaluated collaborative care for depression. In addition, the reference lists for each of the articles identified were reviewed for studies that fit the inclusion criteria. To be included in the review, the studies had to be randomized trials of collaborative care compared with standard care. Collaborative care was defined as a multifaceted intervention that had three distinct professionals working together in a primary care setting. This included a case manager, a primary care professional, and a mental health specialist. Two of the three components had to be present in the study to meet inclusion criteria. Outcome measures were analyzed at a short-term interval (six months) and at long-term intervals (12, 18, and 24 months and five years).

Results: The authors included 37 randomized studies that had 12,355 participants receiving care for depression. Analysis showed that collaborative care had significantly better outcomes at all intervals, from six months to five years. The best effect of collaborative care was dependent on improved medication compliance and regularly scheduled supervision with a case manager who specialized in mental health issues. Even brief interventions such as phone calls were effective. Psychotherapy was not found to be associated with improvement of outcomes, but studies that included all three components of collaborative care had better outcomes than those with just two components.

Conclusion: The authors conclude that the collaborative care model for managing depression in primary care offices has better short- and long-term outcomes than standard care. They add that there is strong evidence that the collaborative care model is effective, and future research should be aimed at how to integrate this model into the health care system.

editor's note: The time for debating the benefit of collaborative care in the management of depression has passed. After this study, the debate should move from the effectiveness of collaborative care to how to implement treatment programs. Even small programs that had phone follow-up to educate and encourage medication compliance were found to improve outcomes in depression treatment. Two editorials about this issue stated that future research should focus on which implementation strategies provide the best short- and long-term outcomes.1,2 As we continue to care for patients with depression, physicians need to work with systems to help provide collaborative care.—k.e.m.

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