Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care

Abstract

Objective: To test the effectiveness of two programmes to improve the treatment of acute depression in primary care.

Design: Randomised trial.

Setting: Primary care clinics in Seattle.

Patients: 613 patients starting antidepressant treatment.

Intervention: Patients were randomly assigned to continued usual care or one of two interventions: feedback only and feedback plus care management. Feedback only comprised feedback and algorithm based recommendations to doctors on the basis of data from computerised records of pharmacy and visits. Feedback plus care management included systematic follow up by telephone, sophisticated treatment recommendations, and practice support by a care manager.

Main outcome measures: Blinded interviews by telephone 3 and 6 months after the initial prescription included a 20 item depression scale from the Hopkins symptom checklist and the structured clinical interview for the current DSM-IV depression module. Visits, antidepressant prescriptions, and overall use of health care were assessed from computerised records.

Results: Compared with usual care, feedback only had no significant effect on treatment received or patient outcomes. Patients receiving feedback plus care management had a higher probability of both receiving at least moderate doses of antidepressants (odds ratio 1.99, 95% confidence interval 1.23 to 3.22) and a 50% improvement in depression scores on the symptom checklist (2.22, 1.31 to 3.75), lower mean depression scores on the symptom checklist at follow up, and a lower probability of major depression at follow up (0.46, 0.24 to 0.86). The incremental cost of feedback plus care management was about $80 ( pound50) per patient.

Conclusions: Monitoring and feedback to doctors yielded no significant benefits for patients in primary care starting antidepressant treatment. A programme of systematic follow up and care management by telephone, however, significantly improved outcomes at modest cost.

Figure 1

Antidepressant use in six months after initial prescription for patients taking antidepressants for at least 90 days by dosage level and receiving usual care (n=196), feedback only (n=221), and care management (n=196)

Figure 2

Course of scores over time on depression scale of symptom checklist in patients receiving usual care (n=196), feedback only (n=221), and care management (n=196)

Figure 3

Categorical outcomes for depression (50% decrease in depression scores on symptom checklist and major depression by structured clinical interview for DSM-IV) since baseline assessment at three and six month blinded outcome assessments in patients receiving usual care (n=196), feedback only (n=221), and care management (n=196)