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This page contains references, abstracts, and, where available, links for recent research articles on collaborative care and its implementation. Please note that where links are provided, subscription to the journal may be required to access the article. Articles are organized by topic.
This bibliography will be updated periodically. Please email laurie.alexander@austin.utexas.edu with suggestions for additions. Overviews of Collaborative Care or Integrated Health Care Oxman, T.E., Dietrich, A.J., & Schulberg, H.C. (2005). Evidence-Based Models of Integrated Management of Depression in Primary Care. Psychiatric Clinics of North America, 28, 1061-1077. A variety of epidemiologic studies has demonstrated the high prevalence of depressive disorders in primary care. Indeed, by patient preference, the majority of treated depressive episodes are in primary care practices. This is particularly true for older persons. Accordingly, it is not surprising that primary care clinicians place a high priority on recognizing and treating their depressed patients. However, formidable obstacles impede appropriate treatment and the prevention of relapse or recurrence, including time pressures, the inclination of both clinicians and patients to focus on presenting symptoms and acute problems, the limits of reimbursement, and the lack of well-organized mental health systems capable of consulting about and treating patients in most primary care settings. Rollman, B.L., Weinreb, L., Korsen, N., & Schulberg, H.C. (2006). Implementation of guideline-based care for depression in primary care. Administration and Policy in Mental Health and Mental Health Services Research, 33(1), 43-53. Evidence-based
clinical practice guidelines for treating depression in primary
care settings were developed, in part, to ensure that health services
are provided in a consistent, high-quality, and cost-effective manner.
Yet for a variety of reasons, guideline-based primary care for depression
remains the exception rather than the rule. This work provides a
brief review of effective strategies used to customize and then
deliver evidence-based treatment for depression in primary care
settings; describes two representative case studies that illustrate
locally customized collaborative care strategies for treatment delivery;
and concludes with principles and implications for policy and practice
based on our practical experiences. Unützer, J.,
Schoenbaum, M., Druss, B.G., & Katon, W.J. (2006). Transforming
Mental Health Care at the Interface With General Medicine: Report
for the President's Commission. Psychiatric Services,
57, 3747. Patient and Staff Receptivity to Collaborative Care Gallo, J. J., Zubritsky, C., Maxwell, J., Nazar, M., Bogner, H. R., Quijano, L. M., et al. (2004). Primary care clinicians evaluate integrated and referral models of behavioral health care for older adults: Results from a multisite effectiveness trial (PRISM-E). Annals of Family Medicine, 2(4), 305-309. BACKGROUND:
Recent studies have shown that integrated behavioral health services
for older adults in primary care improve health outcomes. No study,
however, has asked the opinions of clinicians whose patients actually
experienced integrated rather than enhanced referral care for depression
and other conditions. METHOD: The Primary Care Research in Substance
Abuse and Mental Health for the Elderly (PRISM-E) study was a randomized
trial comparing integrated behavioral health care with enhanced
referral care in primary care settings across the United States.
Primary care clinicians at each participating site were asked whether
integrated or enhanced referral care was preferred across a variety
of components of care. Managers also completed questionnaires related
to the process of care at each site. CONCLUSIONS: Among primary
care clinicians who cared for patients that received integrated
care or enhanced referral care, integrated care was preferred for
many aspects of mental health care.
Objective This study aimed to explore the views of stakeholders including patients, general practitioners (GPs) and mental health workers on the feasibility, acceptability and barriers to a collaborative care model for treatment of depression within the context of U.K. primary health care. Method We used semistructured interviews and focus groups with a purposive sample of 11 patients and 38 professionals from a wide selection of primary and secondary care mental health services, as well as framework analysis using a "constant comparative" approach to identify key concepts and themes. Results Regular contact for patients with depression is acceptable and valued by both patients and professionals. However, patients value support, whereas professionals focus on information. To be acceptable to patients, contacts about medication or psychosocial support must minimize the potential for patient disempowerment. The use of the telephone is convenient and lends anonymity, but established mental health workers think it will impair their judgments. While patients merely identified the need for skilled case managers, GPs preferred established professionals; however, these workers did not see themselves in this role. All involved were cautious about deploying new workers. Additional barriers included practical and organizational issues. Conclusions Although a telephone-delivered mix of medication support and low-intensity psychological intervention is generally acceptable, significant issues to be addressed include the values of the current mental health workforce, fears about new workers' experience and competence, the balance of face-to-face and telephone contacts and case manager education in nonspecific skills necessary to develop a therapeutic alliance, as well as the knowledge and skills required for education, medication support and behavioral activation. Qualitative research can add value to careful modeling of collaborative care prior to international implementation. Efficacy and Effectiveness of Collaborative Care Asarnow, J. R., Jaycox, L. H., Duan, N., LaBorde, A. P., Rea, M. M., Murray, P., et al. (2005). Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: A randomized controlled trial. Journal of the American Medical Association, 293, 311-319. Context: Depression is a common condition associated with significant morbidity in adolescents. Few depressed adolescents receive effective treatment for depression in primary care settings. Objective: To evaluate the effectiveness of a quality improvement intervention aimed at increasing access to evidence-based treatments for depression (particularly cognitive-behavior therapy and antidepressant medication), relative to usual care, among adolescents in primary care practices. Conclusions: A 6-month quality improvement intervention aimed at improving access to evidence-based depression treatments through primary care was significantly more effective than usual care for depressed adolescents from diverse primary care practices. The greater uptake of counseling vs medication under the intervention reinforces the importance of practice interventions that include resources to enable evidence-based psychotherapy for depressed adolescents.
Patient centeredness and equity are major quality goals, but little is known about how these goals are affected by efforts to improve the quality of care. The authors describe an approach to addressing these goals in a randomized trial of quality improvement for depressed primary care patients. METHODS: For four ethics goals (autonomy, distributive justice, beneficence, and avoiding harm), the authors identify intervention features, study measures, and hypotheses implemented in Partners in Care, a randomized trial of two quality improvement interventions, relative to usual care and summarize published findings pertinent to these outcomes. RESULTS: To implement an ethics framework, modifications were required in study design and in measures and analysis plans, particularly to address the autonomy and justice goals. Extra resources were needed for sample recruitment, for intervention and survey materials, and to fund an ethics coinvestigator. The interventions were associated with improvements in all four ethics areas. Patients who received the interventions were significantly more likely to receive the treatment they had indicated at baseline as their preferred treatment (autonomy goal). Intervention-associated benefits occurred more rapidly among sicker patients and extended to patients from ethnic minority groups, resulting in a reduction in ethnic-group disparities in health outcomes relative to usual care (distributive justice goal). The interventions were associated with improved quality of care and health outcomes (beneficence goal) and with reduced use of long-term minor tranquilizers (goal of avoiding harm). CONCLUSIONS: It is feasible to explicitly address ethics outcomes in quality improvement programs for depression, but substantial marginal resources may be required. Nevertheless, interventions so modified can increase a practice's ability to realize ethics goals.
Background: The response of ethnic minorities to mental health care is largely unstudied. Objective: To determine the effect of appropriate care for depression on ethnic minorities. Design: Observational analysis of the effects of evidence-based depression care over 6 months on clinical outcomes and employment status is examined for ethnic minorities and nonminorities. Selection into treatment is accounted for using instrumental variables techniques, with randomized assignment to the quality improvement intervention as the identifying instrument. Setting: Six managed care organizations across the United States. Patients: One thousand three hundred fifty-six depressed adults, including 601 white, 258 Latino, 56 African American, and 24 Asian or Native American patients. Conclusions: Evidence-based care for depression is equally effective in reducing depressive disorders for minority and nonminority patients. However, functional outcomes of care, such as continued employment, may be more limited for minority than nonminority patients. Because minority members are less likely to get appropriate care, efforts should be made to engage minority members in effective care for depression.
Background: Panic disorder is a prevalent, often disabling condition among patients in the primary care setting. Although numerous studies have assessed the effectiveness of treatments for depression in primary care, few such studies have been conducted for panic disorder. Objective: To implement and test the effectiveness of a combined harmacotherapy and cognitive-behavioral intervention for panic disorder tailored to the primary care setting. Setting: Six primary care clinics associated with 3 university medical schools, serving an ethnically and socioeconomically diverse patient population. Conclusion: Delivery of evidence-based CBT and medication using the collaborative care model and a CBT-naïve, midlevel behavioral health specialist is feasible and significantly more effective than usual care for primary care panic disorder. Simon, G. E., Ludman, E. J., Unutzer, J., Bauer, M. S., Operskalski, B., & Rutter, C. (2005). Randomized trial of a population-based care program for people with bipolar disorder. Psychological Medicine, 35, 13-24. Background. Despite the availability of efficacious medications and psychotherapies, care of bipolar disorder in everyday practice is often deficient. This trial evaluated the effectiveness of a multi-component care management program in a population-based sample of people with bipolar disorder. Method. Four hundred and forty-one patients treated for bipolar disorder during the prior year were randomly assigned to continued usual care or usual care plus a systematic care management program including: initial assessment and care planning, monthly telephone monitoring including brief symptom assessment and medication monitoring, feedback to and coordination with the mental health treatment team, and a structured group psychoeducational program all provided by a nurse care manager. Conclusions. A systematic care program for bipolar disorder significantly reduces risk of mania over 12 months. Preliminary results suggest a growing effect on depression over time, but longer follow-up will be needed. Unutzer, J., Katon, W., Callahan, C. M., Williams, J. W., Hunkeler, E., Harpole, L., et al. (2002). Collaborative care management of late-life depression in the primary care setting: A randomized controlled trial. Journal of the American Medical Association, 288, 2836-2845. Context: Few depressed older adults receive effective treatment in primary care settings. Objective: To determine the effectiveness of the Improving MoodPromoting Access to Collaborative Treatment (IMPACT) collaborative care management program for late-life depression. Setting: Eighteen primary care clinics from 8 health care organizations in 5 states. Participants: A total of 1801 patients aged 60 years or older with major depression (17%), dysthymic disorder (30%), or both (53%). Intervention: Patients were randomly assigned to the IMPACT intervention (n = 906) or to usual care (n = 895). Intervention patients had access for up to 12 months to a depression care manager who was supervised by a psychiatrist and a primary care expert and who offered education, care management, and support of antidepressant management by the patient's primary care physician or a brief psychotherapy for depresssion, Problem Solving Treatment in Primary Care. Conclusion: The IMPACT collaborative care model appears to be feasible and significantly more effective than usual care for depression in a wide range of primary care practices. Barriers to Integrated Health Care Bachman, J., Pincus, H.A., Houtsinger, J.K., & Unutzer, J. (2006). Funding mechanisms for depression care management: Opportunities and challenges. General Hospital Psychiatry, 28, 278-288. Objective Inconsistent third-party reimbursement for depression care management is a significant economic barrier to the utilization and sustainability of the chronic illness care model in primary care practice settings. We review common mechanisms used to procure payment for depression care management services, discuss obstacles encountered and suggest future directions. Method We describe several extant models for funding depression care management services in use at the demonstration sites of the Robert Wood Johnson Foundation funded "Depression in Primary Care" project and similar programs. We derived this information from ongoing discussions with the sites' project directors and through an extensive electronic literature search on "care management, funding mechanisms and depression." Results Funding mechanisms include (a) practice-based care management on a fee-for-service basis, (b) practice-based care management under contract to health plans, (c) global capitation, (d) flexible infrastructure support for chronic care management, (e) health-plan-based care management, (f) third-party-based care management under contract to health plans and (g) hybrid models. Conclusions While substantial obstacles remain in the way of fully implementing these depression care management funding mechanisms (e.g., variations in care managers' credentials and work locations and third-party payer concerns about overutilization and transaction costs), several recent policy advances provide some optimism for the potential adoption of financial mechanisms to support and disseminate these evidence-based practices. Barry, C.L., & Frank, F.G. (2006). Commentary: An economic perspective on implementing evidence-based depression care. Administration and Policy in Mental Health and Mental Health Services Research, 33(1), 21-25. Despite the development of cost-effective evidence-based models for treating depression in primary care, economic and organizational barriers often impede sustainability in routine clinical practice. Under the Depression in Primary Care: Linking Clinical and System Strategies program, the Robert Wood Johnson Foundation (RWJF) funded eight demonstration grants to implement clinical changes in depression care alongside changes in contractual relationships, payment methods and other economic arrangements. The preceding articles summarize the specific economic and organizational changes implemented under four of these demonstration projects. This commentary highlights certain elements that appear critical to successfully realign system incentives to support evidence-based depression care based in part on the experiences of these four sites. Feldman, M.D., Ong, M.K., Lee, D.L., & Perez-Stable, E.J. (2006). Realigning economic incentives for depression care at UCSF. Administration and Policy in Mental Health and Mental Health Services Research, 33(1), 34-38. Behavioral health carve-out arrangements create financial disincentives for primary care providers (PCPs) to treat depression. A novel collaboration between a primary care practice, a health insurer, and a managed behavioral health organization (MBHO) allows PCPs to receive reimbursement and schedule longer appointments to care for depressed patients. This article describes the details of the arrangement, and early results of this collaboration. Early results find that financial incentives are critical for implementation, but that time incentives do not appear to motivate PCPs. Sustainability of this model will require participation of multiple primary care practices, health insurers, and MBHOs. Frank, R. G., Huskamp, H. A., & Pincus, H.A. (2003). Aligning incentives in the treatment of depression in primary care with evidence-based practice. Psychiatric Services, 54(5), 682-687. Deficits in the quality of treatment of depression in the primary care sector have been documented in multiple studies. Several clinical models for improving primary care treatment of depression have been shown to be cost-effective in recent years but have not proved to be sustainable over time, partly because of barriers created by common organizational and financing arrangements such as managed behavioral health care carve-outs and risk-based provider payment mechanisms. These arrangements, which often distort relative costs that primary care physicians face when making treatment decisions for patients who have depression, can steer these decisions away from evidence-based practice. Various changes, such as in contractual relationships, payment methods for primary care physicians, and performance measurement, can be made in existing institutional arrangements to better align them with emerging clinical technologies and evidence-based practice. Grazier, K. L., Hegedus, A. M., & Carli, T. (2003). Integration of behavioral and physical health care for a Medicaid population through a public-public partnership. Psychiatric Services, 54(11), 1508-1512. This article documents a unique organizational, legal, and financial partnership between a state, a university, a Medicaid managed health care plan, and a county to provide integrated mental health, substance abuse, and primary and specialty health care services to Medicaid, low-income, and indigent consumers in Washtenaw county, Michigan. Major regulatory, financial, and clinical changes were required within and among the various partners hi the Washtenaw County Integrated Health Care Project. A new entity--the Washtenaw Community Health Organization--was created to implement the project. By sharing resources as well as financial risks, the state, the county, and the university have been able to provide ongoing integrated care to a vulnerable population of patients. Although resource intensive in conceptualization and implementation, the project can be viewed as a model for other states that face growing needy populations and decreasing Medicaid budgets. Grazier, K.L., & Klinkman, M.S. (2006). The economics of integrated depression care: The University of Michigan study. Administration and Policy in Mental Health and Mental Health Services Research, 33(1), 16-20. A goal of the Robert Wood Johnson Depression and Primary Care Initiative at the University of Michigan is to create and implement the clinical care and financial systems necessary to enable links between primary care and mental health specialty depression care. This paper describes the economic issues related to resources required, the mechanisms to distribute those resources, and the support that must be garnered from stakeholders. By systematic measurement and application, we assess the cost, price and selected consequences of these efforts. The study illustrates the need for both centralized and distributed capacity and support for innovative models of care. Hegel, M. T., Imming, J., Cyr-Provost, M., Noel, P. H., Arean, P. A., & Unutzer, J. (2002). Role of behavioral health professionals in a collaborative stepped care treatment model for depression in primary care: Project IMPACT. Families, Systems & Health, 20(3), 265-277. We describe a new collaborative stepped care treatment model for depression in primary care that was recently tested in Project IMPACT, a multi-site, randomized, controlled study with older adults. We present in particular detail the role of the central figure in this model, the Depression Clinical Specialist, a behavioral health professional trained to coordinate the delivery of a flexible, multicomponent intervention that includes antidepressant medications and brief psychotherapy (Problem-Solving Treatment for Primary Care). We describe the training program for these specialists and present two patient case studies demonstrating the stepped care model in practice. Finally, we discuss the issues involved in implementing the model and review recent changes in training and reimbursement practices for behavioral health professionals, suggesting the viability of the model for the future. Kilbourne, A. M., Rollman, B. L., & Schulberg, H. C. (2002). A clinical framework for depression treatment in primary care. Psychiatric Annals, 32(9), 545-553. Presents a clinical framework for depression treatment in primary care. The authors address daunting systems issues that thwart integration. Appropriately designed information and delivery systems, fiscally aligned treatment incentives, and support from community organizations and other stakeholders are some of the key components necessary to make their model work. The model will be tested during the next several years through demonstration projects. Ultimately, the paradigm must be relevant to "real world" practice so that depression care is available and consistent across diverse treatment settings. Kilbourne, A.M., McGinnis, G.F., Belnap, B.H., Klinkman, M., & Thomas, M. (2006). The role of clinical information technology in depression care management. Administration and Policy in Mental Health and Mental Health Services Research, 33(1), 54-64. We examine the literature on the growing application of clinical information technology in managing depression care and highlight lessons learned from Robert Wood Johnson Foundation's national program "Depression in Primary Care-Incentives Demonstrations." Several program sites are implementing depression care registries. Key issues discussed about implementing registries include using a simple yet functional format, designing registries to track multiple conditions versus depression alone (i.e., patient-centric versus disease-centric registries) and avoiding violations of patient privacy with the advent of more advanced information technologies (e.g., web-based formats). Finally, we discuss some implications of clinical information technology for healthcare practices and policy makers. Kilbourne, A. M., Schulberg, H. C., & Post, E. P. (2004). Translating evidence-based depression management services to community-based primary care practices. Milbank Quarterly, 82(4), 631-659. Randomized controlled trials have demonstrated the efficacy and cost-effectiveness of using treatment models for major depression in primary care settings. Nonetheless, translating these models into enduring changes in routine primary care has proved difficult. Various health system and organizational barriers prevent the integration of these models into primary care settings. This article discusses barriers to introducing and sustaining evidence-based depression management services in community-based primary care practices and suggests organizational and financial solutions based on the Robert Wood Johnson Foundation Depression in Primary Care Program. It focuses on strategies to improve depression care in medical settings based on adaptations of the chronic care model and discusses the challenges of implementing evidence-based depression care given the structural, financial, and cultural separation between mental health and general medical care. Labby, D., Spofford, M., Robison, J., & Ralston, R. (2006). The economics of depression in primary care: Defragmentation in the Oregon Medicaid market. Administration and Policy in Mental Health and Mental Health Services Research, 33(1), 39-42. The Oregon Medicaid program legislatively separates the administration of physical health and mental health services, even though behavioral and physical health conditions significantly impact each other. To overcome this barrier and enhance integrated care, CareOregon, a large Medicaid only health plan partnered with two of its largest provider groups to pilot two different models of integration. In one, an "ownership" model, behavioral health specialists were employed by Federally Qualified Health Center primary care clinics and functioned in a common care model with other providers. In the other, a "loaned" model, behavioral specialists were placed in primary care clinics by community mental health centers and continued to function in a specialty mental health model. The qualitative effects of these two models are discussed. Pincus, H.A., Hough, L., & Houtsinger, J.K. (2003). Emerging models of depression care: Multi-level ('6 P') strategies. International Journal of Methods in Psychiatric Research, 12(1), 54-63. Depression is a prevalent, often chronic condition that has enormous personal, social, and financial consequences. Although technologies for treating depression have advanced notably over the past 20 years, many people continue to suffer needlessly, due in part to the lack of evidence-based treatment applied in primary care settings. Substantial public and private efforts have been devoted to encouraging individuals to seek care, improving recognition and diagnosis by primary care physicians, and implementing evidence-based treatment practices. From these efforts have come new models of care as well as an awareness of the critical barriers impeding clinical, organizational, economic, and policy implementation of effective care strategies. In this paper, we describe these clinical and systems barriers and consider the perspectives of various stakeholder groups; present emerging clinical models for providing evidence-based care as well as economic strategies for overcoming barriers to their implementation; and propose community-based approaches that will need to be tested. To achieve maximum benefits from current knowledge, we will need to implement a multi-level strategy employing focused efforts involving patients, providers, practice settings, health plans, purchasers (public and private), and populations (or communities): the '6 P' strategy. Pincus, H.A., Pechura, C.M., & Elinson, L. (2001). Depression in primary care: Linking clinical and systems strategies. General Hospital Psychiatry, 23(6), 311-318. Depression is a serious, often chronic disease that can be managed effectively with a chronic care model in primary care settings. Depressed persons are likely to be seen by a primary care physician, but their condition often goes unrecognized and untreated. There are effective treatment models that consist of efficacious psychotherapeutic and pharmacological interventions, use of evidence-based guidelines for primary care treatment of depression, development of explicit plans and protocols, reorganization of practice, longitudinal follow-up, patient self-management, decision-making support, access to community resources and leadership commitment. Moving these models into everyday practice requires overcoming both clinical and system barriers. Barriers consist of issues surrounding patients, providers, practices, plans, and purchasers. An understanding of these barriers at each level helps to provide a framework for the changes required to overcome them. The Robert Wood Johnson Foundation National Program on Depression in Primary Care will seek to apply simultaneously both clinical and system strategies in a new five-year initiative to overcome these barriers. Pincus, H.A., Pechura, C., Keyser, D., Bachman, J., & Houtsinger, J.K. (2006). Depression in primary care: Learning lessons in a national quality improvement program. Administration and Policy in Mental Health and Mental Health Services Research, 33(1), 2-15. In this introduction, we describe the overall context and rationale for the Depression in Primary Care program and the design and implementation of its key components, especially emphasizing its unique combined clinical and economic/systems framework. We also discuss some of the new challenges and opportunities that may impact the program's evolution and the state of behavioral health care more generally. We conclude with some thoughts on potential future scenarios and strategies for improving the quality of behavioral health care, including the treatment of depression in primary care. Thomas, M.R., Waxmonsky, J.A., McGinnis, G.F., & Barry, C.L. (2006). Realigning clinical and economic incentives to support depression management within a Medicaid population: The Colorado Access experience. Administration and Policy in Mental Health and Mental Health Services Research, 33(1), 26-33. The authors describe their experiences in developing an economically sustainable depression care management program within Colorado Access, a non-profit Medicaid health plan. They describe high rates of mental health issues, medical comorbidities, and psychosocial barriers to care within the plan;s Medicaid population. They discuss how the company redirected resources to incorporate depression care management into an intensive care management program focused on high-cost members with multiple chronic medical conditions. This strategy allowed Colorado Access to cost effectively care manage a targeted group of high-cost Medicaid recipients across multiple primary care physician (PCP) practices without requiring changes in provider workflow. Business Case for Collaborative Care Araya, R., Flynn, Rojas, G., Fritsch, R., & Simon, G. (2006). Cost-Effectiveness of a Primary Care Treatment Program for Depression in Low-Income Women in Santiago, Chile. American Journal of Psychiatry, 163, 1379-1387. OBJECTIVE: The authors compared the incremental cost-effectiveness of a stepped-care, multicomponent program with usual care for the treatment of depressed women in primary care in Santiago, Chile. METHOD: A cost-effectiveness study was conducted of a previous randomized controlled trial involving 240 eligible women with DSM-IV major depression who were selected from a consecutive sample of adult women attending primary care clinics. The patients were randomly allocated to usual care or a multicomponent stepped-care program led by a nonmedical health care worker. Depression-free days and health care costs derived from local sources were assessed after 3 and 6 months. A health service perspective was used in the economic analysis. RESULTS: Complete data were determined for 80% of the randomly assigned patients. After we adjusted for initial severity, women receiving the stepped-care program had a mean of 50 additional depression-free days over 6 months relative to patients allocated to usual care. The stepped-care program was marginally more expensive than usual care (an extra 216 Chilean pesos per depression-free day). There was a 90% probability that the incremental cost of obtaining an extra depression-free day with the intervention would not exceed 300 pesos ($1.04 U.S.). CONCLUSIONS: The stepped-care program was significantly more effective and marginally more expensive than usual care for the treatment of depressed women in primary care. Small investments to improve depression appear to yield larger gains in poorer environments. Simple and inexpensive treatment programs tested in developing countries might provide good study models for developed countries. Dickinson, L. M., Rost, K., & Nutting, P. A. (2005). RCT of a clinical care manager intervention for major depression in primary care: 2-year costs for patients with physical vs psychological complaints. Annals of Family Medicine, 3(1), 15-22. Purpose: Depression clinical care management for primary care patients results in sustained improvement in clinical outcomes with diminishing costs over time. Clinical benefits, however, are concentrated primarily in patients who report to their primary care clinicians psychological rather than exclusively physical symptoms. This study proposes to determine whether the intervention affects outpatient costs differentially when comparing patients who have psychological with patients who have physical complaints. Methods: We undertook a group-randomized controlled trial (RCT) of depression comparing intervention with usual care in 12 primary care practices. Intervention practices encouraged depressed patients to engage in active treatment, using nurses to provide regularly scheduled clinical care management for 24 months. Conclusions: Depression intervention for a 2-year period produced observable clinical benefit with decreased outpatient costs for depressed patients who complain of psychological symptoms. It produced limited clinical benefit with increased costs, however, for depressed patients who complain exclusively of physical symptoms, suggesting the need for developing new intervention approaches for this group. Gilbody S, Bower P, & Whitty P. (2006). Costs and consequences of enhanced primary care for depression: Systematic review of randomized economic evaluations. British Journal Of Psychiatry, 189, 297-308. BACKGROUND: A number of enhancement strategies have been proposed to improve the quality and outcome of care for depression in primary care settings. Decision-makers are likely to need to know whether these interventions are cost-effective in routine primary care settings. METHOD: We conducted a systematic review of all full economic evaluations (cost-effectiveness and cost-utility analyses) accompanying randomised controlled trials of enhanced primary care for depression. Costs were standardised to UKpounds/US dollars and incremental cost-effectiveness ratios (ICERs) were visually summarised using a permutation matrix. RESULTS: We identified 11 full economic evaluations (4757 patients). A near-uniform finding was that the interventions based upon collaborative care/case management resulted in improved outcomes but were also associated with greater costs. When considering primary care depression treatment costs alone, ICER estimates ranged from pound7 ($13, no confidence interval given) to pound13 ($24,95% CI -105 to 148) per additional depression-free day. Educational interventions alone were associated with increased cost and no clinical benefit. CONCLUSIONS: Improved outcomes through depression management programmes using a collaborative care/case management approach can be expected, but are associated with increased cost and will require investment. Katon, W. J., Roy-Byrne, P., Russo, J., & Cowley, D. (2002). Cost-effectiveness and cost offset of a collaborative care intervention for primary care patients with panic disorder. Archives of General Psychiatry, 59, 1098-1104. Background: A collaborative care (CC) intervention for patients with panic disorder that provided increased patient education and integrated a psychiatrist into primary care was associated with improved symptomatic and functional outcomes. This report evaluates the incremental cost-effectiveness and potential cost offset of a CC treatment program for primary care patients with panic disorder from the perspective of the payer. Conclusion: A CC intervention for patients with panic disorder was associated with significantly more anxiety-free days, no significant differences in total outpatient costs, and a distribution of the cost-effectiveness ratio based on total outpatient costs that suggests a 70% probability that the intervention was dominant, compared with usual care. Schoenbaum, M., Miranda, J., & Sherbourne, C. (2004). Cost-effectiveness of interventions for depressed Latinos. Journal of Mental Health Policy & Economics, 7(2), 69-76. Context: Depression is a leading cause of disability worldwide, but treatment rates are low, particularly for minority patients. Objective: To estimate societal cost-effectiveness of two interventions to improve care for depression in primary care, examining Latino and white patients separately. Methods: The study involved 46 clinics in 6 non-academic, managed care organizations; 181 primary care providers; and 398 Latino and 778 White patients with current depression. Conclusions: Latinos benefit from improved care for depression, and the cost is less than that for white patients. Diverse patients are likely to benefit from improving care for depression in primary care. Schoenbaum, M., Unützer, J., & Sherbourne, C. (2001). Cost-effectiveness of practice-initiated quality improvement for depression: Results of a randomized controlled trial. Journal of the American Medical Association, 286, 1325-1330. Examined societal cost-effectiveness and impact on patients' employment over a 2-yr period of implementation of the Partners In Care (PIC) interventions for depression, relative to usual care, in diverse managed care practices. 1356 patients aged 18 yrs and older with depression enrolled in the study: 443 in usual care, 424 in quality improvement (QI)-meds, and 489 in QI-therapy practices. Interventions costs, health care costs, costs per quality-adjusted life year (QALY), days with depression burden, and employment outcomes were measured. Compared to usual care, average health care costs increased $419 in QI-meds and $485 in QI-therapy. Patients had 25 and 47 fewer days with depression burden and were employed 17.9 and 20.9 more days during the study period. The authors conclude that practice-initiated, locally implemented programs that encourage guideline-concordant care for depression can substantially reduce the individual suffering and economic consequences of depression. QI-therapy may have a better overall value in terms of cost per QALY than QI-meds, suggesting that there may be a particular value to improving access to structured psychotherapy for depressed primary care patients. Simon, G. E., Katon, W. J., Von Korff, M., Unutzer, J., Lin, E. H. B., Walker, E. A. (2001). Cost-effectiveness of a collaborative care program for primary care patients with persistent depression. American Journal of Psychiatry, 158, 1638-1644. OBJECTIVE: The authors evaluated the incremental cost-effectiveness of stepped collaborative care for patients with persistent depressive symptoms after usual primary care management. METHOD: Primary care patients initiating antidepressant treatment completed a standardized telephone assessment 68 weeks after the initial prescription. Those with persistent major depression or significant subthreshold depressive symptoms were randomly assigned to continued usual care or collaborative care. RESULTS: Patients receiving collaborative care experienced a mean of 16.7 additional depression-free days over 6 months. The mean incremental cost of depression treatment in this program was $357. The additional cost was attributable to greater expenditures for antidepressant prescriptions and outpatient visits. No offsetting decrease in use of other health services was observed. The incremental cost-effectiveness was $21.44 per depression-free day. CONCLUSIONS: A stepped collaborative care program for depressed primary care patients led to substantial increases in treatment effectiveness and moderate increases in costs. These findings are consistent with those of other randomized trials. Improving outcomes of depression treatment in primary care requires investment of additional resources, but the return on this investment is comparable to that of many other widely accepted medical interventions. Wang, P.S., Patrick, A., Avorn, J., Azocar, F., Ludman, E., McCulloch, J., Simon, G., & Kessler, R. (2006). The costs and benefits of enhanced depression care to employers. Archives of General Psychiatry, 63, 1345-1353. Context Although outreach and enhanced treatment interventions improve depression outcomes, uptake has been poor in part because purchasers lack information on their return on investment. Objective To estimate the costs and benefits of enhanced depression care for workers from the societal and employer-purchaser perspectives. Design Cost-effectiveness and cost-benefit analyses using state-transition Markov models. Simulated movements between health states were based on probabilities drawn from the clinical literature. Participants Hypothetical cohort of 40-year-old workers. Intervention Enhanced depression care consisting of a depression screen and care management for those depressed vs usual care. Main Outcome Measures Our base-case cost-effectiveness analysis was from the societal perspective; costs and quality-adjusted life-years were used to compute the incremental cost-effectiveness of the intervention relative to usual care. A secondary cost-benefit analysis from the employer's perspective tracked monetary costs and monetary benefits accruing to employers during a 5-year time horizon. Results From the societal perspective, screening and depression care management for workers result in an incremental cost-effectiveness ratio of $19 976 per quality-adjusted life-year relative to usual care. These results are consistent with recent primary care effectiveness trials and within the range for medical interventions usually covered by employer-sponsored insurance. From the employer's perspective, enhanced depression care yields a net cumulative benefit of $2895 after 5 years. In 1-way and probabilistic sensitivity analyses, these findings were robust to a variety of assumptions. Conclusion If these results can be replicated in effectiveness trials directly assessing effects on work outcomes, they suggest that enhanced treatment quality programs for depression are cost-beneficial to purchasers. Grant
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