Steven K. Dobscha, MD; Kathryn Corson, PhD; David H. Hickam, MD, MPH; Nancy A. Perrin, PhD; Dale F. Kraemer, PhD; Martha S. Gerrity, MD, PhD
Disclaimer: The views expressed herein are those of the authors and do not necessarily reflect those of the U.S. Department of Veterans Affairs.
Acknowledgments: The authors thank Ginger Hanson, MS, for assistance with statistical analysis; Megan Crutchfield, BS, and Marsha W. Perkett, BA, for assistance with chart review; and the Portland Veterans Affairs Medical Center's primary care clinicians and staff whose participation made this study possible.
Grant Support: By the VA Health Services Research & Development Service (Project Mental Health Initiative [MHI 20-020]).
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Steven K. Dobscha, MD, Portland Veterans Affairs Medical Center, PO Box 1034 (P3MHDC), Portland, OR 97207; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Dobscha: Portland Veterans Affairs Medical Center, PO Box 1034 (P3MHDC), Portland, OR 97207.
Drs. Corson, Hickam, and Gerrity: Portland Veterans Affairs Medical Center, 3710 SW U.S. Veterans Hospital Road, Portland, OR 97239.
Dr. Perrin: Oregon Health & Science University, 3455 SW U.S. Veterans Hospital Road, Portland, OR 97239.
Dr. Kraemer: Oregon State University, 840 SW Gaines, MC GH212, Portland, OR 97239-2985.
Author Contributions: Conception and design: S.K. Dobscha, D.H. Hickam, D.F. Kraemer, M.S. Gerrity.
Analysis and interpretation of the data: S.K. Dobscha, K. Corson, D.H. Hickam, N.A. Perrin, D.F. Kraemer, M.S. Gerrity.
Drafting of the article: S.K. Dobscha, K. Corson, D.H. Hickam, D.F. Kraemer, M.S. Gerrity.
Critical revision of the article for important intellectual content: S.K. Dobscha, K. Corson, D.H. Hickam, N.A. Perrin, D.F. Kraemer, M.S. Gerrity.
Final approval of the article: S.K. Dobscha, K. Corson, D.H. Hickam, N.A. Perrin, D.F. Kraemer, M.S. Gerrity.
Provision of study materials or patients: S.K. Dobscha.
Statistical expertise: K. Corson, N.A. Perrin, D.F. Kraemer.
Obtaining of funding: S.K. Dobscha, D.H. Hickam, M.S. Gerrity.
Administrative, technical, or logistic support: K. Corson.
Collection and assembly of data: S.K. Dobscha, K. Corson.
Intensive collaborative interventions improve depression outcomes, but the benefit of less intensive interventions is not clear.
To determine whether decision support improves outcomes for patients with depression.
Clinician-level, cluster randomized, controlled trial.
5 primary care clinics of 1 Veterans Affairs medical center.
41 primary care clinicians, and 375 patients with depression (Patient Health Questionnaire [PHQ-9] depression scores of 10 to 25 or Hopkins Symptom Checklist-20 [SCL-20] scores ≥ 1.0).
The primary outcome was change in depression score (SCL-20) at 6 and 12 months. Secondary outcomes were health-related quality-of-life (36-item Short Form for Veterans [SF-36V] score), patient satisfaction, antidepressant use, and health care utilization.
Clinicians received depression education and were randomly assigned to depression decision support or usual care. The depression decision support team, which consisted of a psychiatrist and nurse, provided 1 early patient educational contact and depression monitoring with feedback to clinicians over 12 months.
Although SCL-20 depression scores improved in both groups, the intervention had no effect compared with usual care. The difference in slopes comparing intervention and control over 12 months was 0.20 (95% CI, −0.37 to 0.78; P = 0.49), which was neither clinically nor statistically significant. Changes in SF-36V scores also did not differ between groups. At 12 months, intervention patients reported greater satisfaction (P = 0.002) and were more likely to have had at least 1 mental health specialty appointment (41.1% vs. 27.2%; P = 0.025), to have received any antidepressant (79.3% vs. 69.3%; P = 0.041), and to have received antidepressants for 90 days or more (76.2% vs. 61.6%; P = 0.008).
Usual care clinicians received depression education and had on-site mental health support, which may have mitigated intervention effectiveness.
Decision support improved processes of care but not depression outcomes. More intensive care management or specialty treatment may be needed to improve depression outcomes.
Most successful disease management interventions for depression care have required intensive involvement of care managers or mental health specialists.
The authors randomly assigned 41 primary care physicians from 5 clinics to receive either depression decision support or usual care. Depression decision support was provided by a team that included a psychiatrist and a nurse care manager and involved an initial telephone contact, patient education, monthly record review, and sending a progress report to primary care physicians every 3 months. Depression severity improved equally in both groups over 12 months, despite evidence that intervention clinicians delivered more depression-related services.
Decision support improved processes of depression care but not outcomes.
Study flow chart.
PHQ-9 = Patient Health Questionnaire.
Table 1. Summary of Depression Decision Support Intervention and Usual Care Components
Table 2. Baseline Characteristics of Participating Clinicians
Table 3. Baseline Characteristics of Patients*
Unadjusted mean Hopkins Symptom Checklist-20 (SCL-20) depression severity scores over time.
Mean ± SE scores for the intervention group were 1.89 ± 0.05 at baseline, 1.54 ± 0.05 at 6 months, and 1.63 ± 0.06 at 12 months. Mean ± SE scores for the usual care group were 1.92 ± 0.05 at baseline, 1.58 ± 0.06 at 6 months, and 1.62 ± 0.06 at 12 months.
Unadjusted mean Patient Health Questionnaire-9 (PHQ-9) depression scores over time.
P = 0.019 for initial improvement from baseline (quadratic model), comparing intervention and usual care groups.
Table 4. Adjusted Proportions for Process-of-Care Variables
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Dobscha SK, Corson K, Hickam DH, Perrin NA, Kraemer DF, Gerrity MS. Depression Decision Support in Primary Care: A Cluster Randomized Trial. Ann Intern Med. ;145:477–487. doi: 10.7326/0003-4819-145-7-200610030-00005
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Published: Ann Intern Med. 2006;145(7):477-487.
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