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In the following article, we summarize the presentations given at a conference on improving care for depression in organized health care systems. The 68 conference participants included mental health services researchers, persons responsible for improving care for depression in large health care systems, representatives of the National Institute of Mental Health, and foundation representatives. The specific aims of the conference were to: (1) consider what depression interventions are ready for dissemination in large organized health care systems; (2) identify unanswered questions concerning their effectiveness and cost-effectiveness; and (3) identify critical next steps to accelerate dissemination. (J Fam Pract 2001; 50:530-31)
Framework
The organizing framework for the conference was provided by the Model for Improving Chronic Illness Care.1 This model identifies the need for health care systems change in 6 areas: (1) community resources and policies, including community programs and policies (eg, insurance benefits); (2) organization of care, including effective leadership for systems change and incentives for improved care; (3) self-management support consisting of a collaborative process between patients and providers to define problems, set priorities, establish goals, create treatment plans, and solve problems along the way2; (4) delivery system design, including clear delegation of roles and responsibilities from the physician to other professionals and systems for preventive services and active follow-up3-5; (5) decision support, including guidelines, reminders, provider education, and appropriate input from relevant medical specialties6,7; and (6) clinical information systems that provide timely information about patients with chronic conditions in support of guideline-based care.8,9 Comprehensive descriptions of the model are available elsewhere in the literature,14 and at the Web site of the Robert Wood Johnson Foundation National Program for Improving Chronic Illness Care (www.improvingchroniccare.org). Conference participants considered whether general approaches to improving chronic illness care were relevant to depression.
Presentations
Nine major randomized controlled trials evaluating delivery of depression treatments were presented at the conference. Barrett10,11 presented a trial evaluating antidepressant medications and Problem-Solving Therapy (PST) for patients with minor depression or dysthymia that showed benefits for medications but not for PST. Mynors-Wallis12 presented a comparison of pharmacologic treatment, PST, and their combination for major depression that found equal benefits of medications and PST, but no advantage to combined therapy. Miranda13 presented an evaluation of cognitive-behavioral therapy for low-income minority individuals, with and without social case management, that showed no added benefit of social case management. Katon14 presented a trial of a collaborative program for patients with major depression at risk for chronic depression that showed benefits relative to usual care. Wells15 presented a multisite evaluation of a program of nurse follow-up to improve pharmacologic management or cognitive-behavioral therapy by mental health specialists that found improvement in depression outcomes and reduced unemployment relative to usual care. Rost16 presented a trial of nurse case management for patients with major depression that found improved depression outcomes relative to usual care. Katzelnick17 presented a multicenter trial of step-wise case management of patients with high utilization and major depression that showed improved outcomes relative to usual care. Simon18 presented a trial comparing feedback on treatment adherence and outcomes to the primary care physician to a telephone case management program that found improved outcomes relative to usual care for case management but not for feedback alone. Hunkeler19 presented a trial of nurse telephone follow-up for patients with major depression that found improved outcomes relative to usual care.
Acknowledgments
This conference was supported by grants from the Robert Wood Johnson Foundation, the John A. Hartford Foundation, and the National Institute of Mental Health. We gratefully acknowledge Christian Helfrich for making conference arrangements.
1. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996;74:511-44.
2. VonKorff M, Gruman J, Schaefer JK, Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med 1997;127:1097-102.
3. Perrin JM, Homer JM, Berwick DM, et al. Variations in rates of hospitalization of children in three urban communities. N Engl J Med 1984;313:295-300.
4. Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness. Managed Care Q 1996;4:12-25.
5. Calkins E, Boult C, Wagner EH, Pacala J. New ways to care for older people: building systems based on evidence. New York, NY: Springer; 1999.
6. McCulloch DK, Price MJ, Hindmarsh M, Wagner EH. A population-based approach to diabetes management in a primary care setting: early results and lessons learned. Effective Clin Pract 1998;1:12-22.
7. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines. JAMA 1995;273:1026-31.
8. Greenlick MR. The emergence of population-based medicine. HMO Pract 1995;9:120-22.
9. Wagner EH. Population-based management of diabetes care. Pat Educ Couns 1995;16:225-30.
10. Williams JW, Jr, Barrett J, Oxman T, et al. Treatment of dysthymia and minor depression in primary care: a randomized controlled trial in older adults. JAMA 2000;284:1519-26.
11. Barrett J, Williams J, Oxman T, Frank E, Katon W, Williams M. The treatment effectiveness project: a comparison of the effectiveness of paroxetine, Problem-Solving Therapy (PST-PC), and placebo in the treatment of minor depression and dysthymia in primary care patients. Gen Hosp Psychiatry 1999;21:260-73.
12. Mynors-Wallis LM, Gath DH, Day A, Baker F. Randomized controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care. BMJ 2000;320:26-30.
13. Miranda J, Azocar F, Organista KC, Dwyer E, Areán P. Treatment of depression in disadvantaged medical patients. In press.
14. Katon W, Von Korff M, Lin EHB, et al. A randomized trial of stepped collaborative care for primary care patients with persistent symptoms of depression. Arch Gen Psychiatry 1999;56:1109-15.
15. Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA 2000;283:212-20
16. Rost KM, Nutting P, Smith J, Werner J, Duan N. Improving depression outcomes in community primary care practice: a randomized trial. J Gen Intern Med. In press.
17. Katzelnick DJ, Simon GE, Pearson SD, et al. Randomized trial of a depression management program in high utilizers of medical care. Arch Fam Med 2000;9:345-51.
18. Simon GE, Von Korff M, Rutter C, Wagner E. Randomized trial of monitoring, feedback and management of care by telephone to improve depression treatment in primary care. BMJ 2000;320:550-54.
19. Hunkeler EM, Meresman JF, Hargreaves WA, et al. Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. Arch Fam Med 2000;9:700-08.
In the following article, we summarize the presentations given at a conference on improving care for depression in organized health care systems. The 68 conference participants included mental health services researchers, persons responsible for improving care for depression in large health care systems, representatives of the National Institute of Mental Health, and foundation representatives. The specific aims of the conference were to: (1) consider what depression interventions are ready for dissemination in large organized health care systems; (2) identify unanswered questions concerning their effectiveness and cost-effectiveness; and (3) identify critical next steps to accelerate dissemination. (J Fam Pract 2001; 50:530-31)
Framework
The organizing framework for the conference was provided by the Model for Improving Chronic Illness Care.1 This model identifies the need for health care systems change in 6 areas: (1) community resources and policies, including community programs and policies (eg, insurance benefits); (2) organization of care, including effective leadership for systems change and incentives for improved care; (3) self-management support consisting of a collaborative process between patients and providers to define problems, set priorities, establish goals, create treatment plans, and solve problems along the way2; (4) delivery system design, including clear delegation of roles and responsibilities from the physician to other professionals and systems for preventive services and active follow-up3-5; (5) decision support, including guidelines, reminders, provider education, and appropriate input from relevant medical specialties6,7; and (6) clinical information systems that provide timely information about patients with chronic conditions in support of guideline-based care.8,9 Comprehensive descriptions of the model are available elsewhere in the literature,14 and at the Web site of the Robert Wood Johnson Foundation National Program for Improving Chronic Illness Care (www.improvingchroniccare.org). Conference participants considered whether general approaches to improving chronic illness care were relevant to depression.
Presentations
Nine major randomized controlled trials evaluating delivery of depression treatments were presented at the conference. Barrett10,11 presented a trial evaluating antidepressant medications and Problem-Solving Therapy (PST) for patients with minor depression or dysthymia that showed benefits for medications but not for PST. Mynors-Wallis12 presented a comparison of pharmacologic treatment, PST, and their combination for major depression that found equal benefits of medications and PST, but no advantage to combined therapy. Miranda13 presented an evaluation of cognitive-behavioral therapy for low-income minority individuals, with and without social case management, that showed no added benefit of social case management. Katon14 presented a trial of a collaborative program for patients with major depression at risk for chronic depression that showed benefits relative to usual care. Wells15 presented a multisite evaluation of a program of nurse follow-up to improve pharmacologic management or cognitive-behavioral therapy by mental health specialists that found improvement in depression outcomes and reduced unemployment relative to usual care. Rost16 presented a trial of nurse case management for patients with major depression that found improved depression outcomes relative to usual care. Katzelnick17 presented a multicenter trial of step-wise case management of patients with high utilization and major depression that showed improved outcomes relative to usual care. Simon18 presented a trial comparing feedback on treatment adherence and outcomes to the primary care physician to a telephone case management program that found improved outcomes relative to usual care for case management but not for feedback alone. Hunkeler19 presented a trial of nurse telephone follow-up for patients with major depression that found improved outcomes relative to usual care.
Acknowledgments
This conference was supported by grants from the Robert Wood Johnson Foundation, the John A. Hartford Foundation, and the National Institute of Mental Health. We gratefully acknowledge Christian Helfrich for making conference arrangements.
In the following article, we summarize the presentations given at a conference on improving care for depression in organized health care systems. The 68 conference participants included mental health services researchers, persons responsible for improving care for depression in large health care systems, representatives of the National Institute of Mental Health, and foundation representatives. The specific aims of the conference were to: (1) consider what depression interventions are ready for dissemination in large organized health care systems; (2) identify unanswered questions concerning their effectiveness and cost-effectiveness; and (3) identify critical next steps to accelerate dissemination. (J Fam Pract 2001; 50:530-31)
Framework
The organizing framework for the conference was provided by the Model for Improving Chronic Illness Care.1 This model identifies the need for health care systems change in 6 areas: (1) community resources and policies, including community programs and policies (eg, insurance benefits); (2) organization of care, including effective leadership for systems change and incentives for improved care; (3) self-management support consisting of a collaborative process between patients and providers to define problems, set priorities, establish goals, create treatment plans, and solve problems along the way2; (4) delivery system design, including clear delegation of roles and responsibilities from the physician to other professionals and systems for preventive services and active follow-up3-5; (5) decision support, including guidelines, reminders, provider education, and appropriate input from relevant medical specialties6,7; and (6) clinical information systems that provide timely information about patients with chronic conditions in support of guideline-based care.8,9 Comprehensive descriptions of the model are available elsewhere in the literature,14 and at the Web site of the Robert Wood Johnson Foundation National Program for Improving Chronic Illness Care (www.improvingchroniccare.org). Conference participants considered whether general approaches to improving chronic illness care were relevant to depression.
Presentations
Nine major randomized controlled trials evaluating delivery of depression treatments were presented at the conference. Barrett10,11 presented a trial evaluating antidepressant medications and Problem-Solving Therapy (PST) for patients with minor depression or dysthymia that showed benefits for medications but not for PST. Mynors-Wallis12 presented a comparison of pharmacologic treatment, PST, and their combination for major depression that found equal benefits of medications and PST, but no advantage to combined therapy. Miranda13 presented an evaluation of cognitive-behavioral therapy for low-income minority individuals, with and without social case management, that showed no added benefit of social case management. Katon14 presented a trial of a collaborative program for patients with major depression at risk for chronic depression that showed benefits relative to usual care. Wells15 presented a multisite evaluation of a program of nurse follow-up to improve pharmacologic management or cognitive-behavioral therapy by mental health specialists that found improvement in depression outcomes and reduced unemployment relative to usual care. Rost16 presented a trial of nurse case management for patients with major depression that found improved depression outcomes relative to usual care. Katzelnick17 presented a multicenter trial of step-wise case management of patients with high utilization and major depression that showed improved outcomes relative to usual care. Simon18 presented a trial comparing feedback on treatment adherence and outcomes to the primary care physician to a telephone case management program that found improved outcomes relative to usual care for case management but not for feedback alone. Hunkeler19 presented a trial of nurse telephone follow-up for patients with major depression that found improved outcomes relative to usual care.
Acknowledgments
This conference was supported by grants from the Robert Wood Johnson Foundation, the John A. Hartford Foundation, and the National Institute of Mental Health. We gratefully acknowledge Christian Helfrich for making conference arrangements.
1. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996;74:511-44.
2. VonKorff M, Gruman J, Schaefer JK, Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med 1997;127:1097-102.
3. Perrin JM, Homer JM, Berwick DM, et al. Variations in rates of hospitalization of children in three urban communities. N Engl J Med 1984;313:295-300.
4. Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness. Managed Care Q 1996;4:12-25.
5. Calkins E, Boult C, Wagner EH, Pacala J. New ways to care for older people: building systems based on evidence. New York, NY: Springer; 1999.
6. McCulloch DK, Price MJ, Hindmarsh M, Wagner EH. A population-based approach to diabetes management in a primary care setting: early results and lessons learned. Effective Clin Pract 1998;1:12-22.
7. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines. JAMA 1995;273:1026-31.
8. Greenlick MR. The emergence of population-based medicine. HMO Pract 1995;9:120-22.
9. Wagner EH. Population-based management of diabetes care. Pat Educ Couns 1995;16:225-30.
10. Williams JW, Jr, Barrett J, Oxman T, et al. Treatment of dysthymia and minor depression in primary care: a randomized controlled trial in older adults. JAMA 2000;284:1519-26.
11. Barrett J, Williams J, Oxman T, Frank E, Katon W, Williams M. The treatment effectiveness project: a comparison of the effectiveness of paroxetine, Problem-Solving Therapy (PST-PC), and placebo in the treatment of minor depression and dysthymia in primary care patients. Gen Hosp Psychiatry 1999;21:260-73.
12. Mynors-Wallis LM, Gath DH, Day A, Baker F. Randomized controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care. BMJ 2000;320:26-30.
13. Miranda J, Azocar F, Organista KC, Dwyer E, Areán P. Treatment of depression in disadvantaged medical patients. In press.
14. Katon W, Von Korff M, Lin EHB, et al. A randomized trial of stepped collaborative care for primary care patients with persistent symptoms of depression. Arch Gen Psychiatry 1999;56:1109-15.
15. Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA 2000;283:212-20
16. Rost KM, Nutting P, Smith J, Werner J, Duan N. Improving depression outcomes in community primary care practice: a randomized trial. J Gen Intern Med. In press.
17. Katzelnick DJ, Simon GE, Pearson SD, et al. Randomized trial of a depression management program in high utilizers of medical care. Arch Fam Med 2000;9:345-51.
18. Simon GE, Von Korff M, Rutter C, Wagner E. Randomized trial of monitoring, feedback and management of care by telephone to improve depression treatment in primary care. BMJ 2000;320:550-54.
19. Hunkeler EM, Meresman JF, Hargreaves WA, et al. Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. Arch Fam Med 2000;9:700-08.
1. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q 1996;74:511-44.
2. VonKorff M, Gruman J, Schaefer JK, Curry SJ, Wagner EH. Collaborative management of chronic illness. Ann Intern Med 1997;127:1097-102.
3. Perrin JM, Homer JM, Berwick DM, et al. Variations in rates of hospitalization of children in three urban communities. N Engl J Med 1984;313:295-300.
4. Wagner EH, Austin BT, Von Korff M. Improving outcomes in chronic illness. Managed Care Q 1996;4:12-25.
5. Calkins E, Boult C, Wagner EH, Pacala J. New ways to care for older people: building systems based on evidence. New York, NY: Springer; 1999.
6. McCulloch DK, Price MJ, Hindmarsh M, Wagner EH. A population-based approach to diabetes management in a primary care setting: early results and lessons learned. Effective Clin Pract 1998;1:12-22.
7. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines. JAMA 1995;273:1026-31.
8. Greenlick MR. The emergence of population-based medicine. HMO Pract 1995;9:120-22.
9. Wagner EH. Population-based management of diabetes care. Pat Educ Couns 1995;16:225-30.
10. Williams JW, Jr, Barrett J, Oxman T, et al. Treatment of dysthymia and minor depression in primary care: a randomized controlled trial in older adults. JAMA 2000;284:1519-26.
11. Barrett J, Williams J, Oxman T, Frank E, Katon W, Williams M. The treatment effectiveness project: a comparison of the effectiveness of paroxetine, Problem-Solving Therapy (PST-PC), and placebo in the treatment of minor depression and dysthymia in primary care patients. Gen Hosp Psychiatry 1999;21:260-73.
12. Mynors-Wallis LM, Gath DH, Day A, Baker F. Randomized controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care. BMJ 2000;320:26-30.
13. Miranda J, Azocar F, Organista KC, Dwyer E, Areán P. Treatment of depression in disadvantaged medical patients. In press.
14. Katon W, Von Korff M, Lin EHB, et al. A randomized trial of stepped collaborative care for primary care patients with persistent symptoms of depression. Arch Gen Psychiatry 1999;56:1109-15.
15. Wells KB, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA 2000;283:212-20
16. Rost KM, Nutting P, Smith J, Werner J, Duan N. Improving depression outcomes in community primary care practice: a randomized trial. J Gen Intern Med. In press.
17. Katzelnick DJ, Simon GE, Pearson SD, et al. Randomized trial of a depression management program in high utilizers of medical care. Arch Fam Med 2000;9:345-51.
18. Simon GE, Von Korff M, Rutter C, Wagner E. Randomized trial of monitoring, feedback and management of care by telephone to improve depression treatment in primary care. BMJ 2000;320:550-54.
19. Hunkeler EM, Meresman JF, Hargreaves WA, et al. Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. Arch Fam Med 2000;9:700-08.