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Can Depression Treatment in Primary Care Reduce Disability?
A Stepped Care Approach
Elizabeth H. B. Lin, MD, MPH;
Michael VonKorff, ScD;
Joan Russo, PhD;
Wayne Katon, MD;
Greg E. Simon, MD, MPH;
Jürgen Unützer, MD, MPH;
Terry Bush, PhD;
Edward Walker, MD;
Evette Ludman, PhD
Arch Fam Med. 2000;9:1052-1058.
Objective To assess effects of stepped collaborative care depression intervention on disability.
Design Randomized controlled trial.
Setting Four primary care clinics of a large health maintenance organization.
Patients Two hundred twenty-eight patients with either 4 or more persistent major depressive symptoms or a score of 1.5 or greater on the Hopkins Symptom Checklist. Depression items were randomized to stepped care intervention or usual care 6 to 8 weeks after initiating antidepressant medication.
Intervention Augmented treatment of persistently depressed patients by an on-site psychiatrist collaborating with primary care physicians. Treatment included patient education, adjustment of pharmacotherapy, and proactive monitoring of outcomes.
Main Outcome Measures Baseline, 1-, 3-, and 6-month assessments of the Sheehan Disability Scale and the social function and role limitation subscales of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36).
Results Patients who received the depression intervention experienced less interference in their family, work, and social activities than patients receiving usual primary care (Sheehan Disability Scale, z = 2.23; P = .025). Patients receiving intervention also reported a trend toward more improvement in SF-36–defined social functioning than patients receiving usual care (z = 1.63, P = .10), but there was no significant difference in role performance (z = 0.07, P = .94).
Conclusions Significant disability accompanied depression in this persistently depressed group. The stepped care intervention resulted in small to moderate functional improvements for these primary care patients.
From the Center for Health Studies, Group Health Cooperative of Puget Sound, Seattle, Wash (Drs Lin, VonKorff, Russo, Katon, Simon, and Walker); the Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle (Drs Lin, VonKorff, Simon, Bush, and Ludman); and the Neuropsychiatric Institute, University of California, Los Angeles (Dr Unützer).
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