Consensus recommendations for improving adherence, self-management, and outcomes in patients with depression

Abstract

Major depressive disorder (MDD) is often a chronic, recurrent, and debilitating disorder with a lifetime prevalence of 16.2% and a 12-month prevalence of 6.6% in the United States. The disorder is associated with high rates of comorbidity with other psychiatric disorders and general medical illnesses, lower rates of adherence to medication regimens, and poorer outcomes for chronic physical illness. While 51.6% of cases reporting MDD received health care treatment for the illness, only 21.7% of all MDD cases received minimal guideline-level treatment. Because the overwhelming majority of patients with depressive disorders are seen annually by their primary care physicians, the opportunity to diagnose and treat patients early in the course of their illness in the primary care setting is substantial, though largely unfulfilled by our current health care system. The goal of treatment is 2-fold: early and complete remission of symptoms of depression and eventual recovery to premorbid levels of functioning in response to acute-phase treatment, and prevention of relapse during the continuation phase or recurrence during the maintenance phase. However, only 25% to 50% of patients with MDD adhere to their antidepressant regimen for the length of time recommended by depression guidelines, and nearly 50% of depressed patients referred from primary care to specialty care treatment fail to complete the referral. Patients with chronic or treatment-resistant depression often require multiple trials using an algorithm-based approach involving more than one treatment strategy. Under conditions of usual care, 40% to 44% of patients with MDD treated with antidepressants in the primary care setting show a >or=50% improvement in depression scores at 4-month follow-up, compared with 70% to 75% of those treated using collaborative care models. This demonstrates the importance of factors other than antidepressant medication per se for achieving treatment effectiveness. Additional research is needed to evaluate longer-term outcomes of algorithm-based, stepped, collaborative care models that incorporate patient self-management in conjunction with usual care. Furthermore, the health care system must undergo major transformation to effectively treat depression, along with other chronic illnesses. The use of evidence-based treatment algorithms are discussed and recommendations are provided for patients and physicians based on collaborative care interventions that may be useful for improving the current management of depressive disorders.