JGIM
EDITORIALS
Life after Primary Care Depression Quality
Improvement Intervention
P
olicy analysts and researchers were dismayed to learn
almost 5 years ago that the impressive impact of acute
primary care depression interventions dissolved shortly
after interventions ended.
1
While disappointing, these
findings made a critical contribution to the recognition
that interventions to improve the treatment of chronic
diseases like depression not only needed to incorporate
chronic disease management principles but also poten-
tially needed to be delivered on an ongoing basis
to promote lasting improvements in symptoms and
functioning.
2
The study by Katon et al. suggests that for
at least 1 segment of the depressed patient population,
ongoing interventions may not be required to ensure
sustained symptom improvement.
3
Katon et al. demonstrate that an intervention that
improves antidepressant medication management over
3 months significantly improves depressive symptoms
2 years later in depressed patients who remain moderately
depressed after an 8-week trial of medication. Noting that
the intervention does not impact the group's use of
antidepressant medication after 6 months, the authors
postulate that getting patients on the right antidepressant
medication (drug and dose) early in their course of care: (1)
increases their rate of complete recovery, which then
reduces their susceptibility to relapse; or (2) improves
their skills to handle relapse. Importantly, these improve-
ments appear to add little or no financial burden to the
health care system, particularly as generic serotonin
reuptake inhibitors become more widely used.
This carefully designed and admirably executed study
illustrates the compelling logic Katon et al. have articu-
lated for using stepped care intervention (a sequence of
clinical guidelines for assigning staged treatment to
patients on the basis of observed outcomes) to improve
depression outcomes. In step 1, physicians successfully
start depressed primary care patients on antidepressant
medication. In step 2, consultation-liaison psychiatrists
make recommendations for medication adjustment for
20% (perhaps more in some systems) of patients who fail
to improve with initially prescribed medication. Because
step 2 intervention results in sustained symptom improve-
ment for moderately depressed patients only, patients who
remain severely depressed after step 1 care may need
referral to specialty care rather than consultation-liaison
intervention. The common sense underlying stepped care
intervention is all too uncommon in the allocation
resources to provide depression treatment in usual care
settings.
As good studies do, that of Katon et al. challenges
the field to address issues that remain before primary
care depression initiatives can and will be widely adopted.
One major challenge is the need to translate onsite
consultation-liaison intervention into telephone interven-
tion, because most primary care providers practice in
settings that do not employ onsite psychiatrists. A second
major challenge is to better understand how primary care
depression intervention needs to be tailored to improve
long-term functioning. A third challenge is to integrate the
results of this study into existing literature to define a
more tiered stepped care intervention in which depressed
patients who fail to improve in usual care are referred to
short-term primary care intervention, and in which short-
term intervention patients at risk for poor outcome are
referred to ongoing primary care intervention and/or
specialty care. As the song instructs us, it is only in
turning, turning that we come down right. Ð K
ATHRYN
R
OST
,P
H
D, University of Colorado Health Sciences Center,
Denver, Colo.
REFERENCES
1. Lin EHB, Simon GE, Katon WJ, et al. Can enhanced acute-phase
treatment of depression improve long-term outcomes? A report of
randomized trials in primary care. Am J Psychiatry. 1999;156:
643±5.
2. Rost K, Nutting P, Smith JL, Elliott CE, Dickinson M. Managing
depression as a chronic disease: A randomized trial of ongoing
primary care depression treatment. BMJ. 2002; (In Press).
3. Katon W, Russo J, Von Korff M, et al. Long-term effects of a
collaborative care intervention in persistently depressed primary
care patients. J Gen Intern Med. 2002;17:741±8.
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