Randomized Trial of a Depression Management Program in High Utilizers of Medical Care
David J. Katzelnick, MD;
Gregory E. Simon, MD;
Steven D. Pearson, MD;
Willard G. Manning, PhD;
Cindy P. Helstad, PhD;
Henry J. Henk, MS;
Stanley M. Cole, MD;
Elizabeth H. B. Lin, MD;
Leslie H. Taylor, MD;
Kenneth A. Kobak, PhD
Arch Fam Med. 2000;9:345-351.
Background High utilizers of nonpsychiatric health care services have disproportionally high rates of undiagnosed or undertreated depression.
Objective To determine the impact of offering a systematic primary care–based depression treatment program to depressed "high utilizers" not in active treatment.
Design Randomized clinical trial.
Setting One hundred sixty-three primary care practices in 3 health maintenance organizations located in different geographic regions of the United States.
Patients A group of 1465 health maintenance organization members were identified as depressed high utilizers using a 2-stage telephone screening process. Eligibility criteria were met by 410 patients and 407 agreed to enroll: 218 in the depression management program (DMP) practices and 189 in the usual care (UC) group.
Intervention The DMP included patient education materials, physician education programs, telephone-based treatment coordination, and antidepressant pharmacotherapy initiated and managed by patients' primary care physicians.
Main Outcome Measures Depression severity was measured using the Hamilton Depression Rating Scale (Ham-D) and functional status using the Medical Outcomes Study 20-item short form (SF-20) subscales. Outpatient visit and hospitalization rates were measured using the health plan's encounter data.
Results Based on an intent-to-treat analysis, at least 3 antidepressant prescriptions were filled in the first 6 months by 151 (69.3%) of 218 of DMP patients vs 35 (18.5%) of 189 in UC (P<.001). Improvements in Ham-D scores were significantly greater in the intervention group at 6 weeks (P=.04), 3 months (P=.02), 6 months (P<.001), and 12 months (P<.001). At 12 months, DMP intervention patients were more improved than UC patients on the mental health, social functioning, and general health perceptions scales of the SF-20 (P<.05 for all).
Conclusion In depressed high utilizers not already in active treatment, a systematic primary care–based treatment program can substantially increase adequate antidepressant treatment, decrease depression severity, and improve general health status compared with usual care.
From the Dean Foundation for Health, Research, and Education, Middleton, Wis (Drs Katzelnick, Helstad, Taylor, and Kobak and Mr Henk); the Department of Ambulatory Care and Prevention, Harvard Pilgrim Health Care and Harvard Medical School, Boston, Mass (Drs Pearson and Cole); the Center for Health Studies, Group Health Cooperative of Puget Sound, Seattle, Wash (Drs Simon and Lin); and the Department of Health Studies, University of Chicago, Chicago, Ill (Dr Manning).
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