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Depression Management Programs
Allen J. Dietrich, MD
Arch Fam Med. 2000;9:689-670.
The report by Katzelnick et al1 and recent reports from Wells et al2 and Simon et al3 add to our knowledge of effective ways to help our patients who suffer from major depression. Congratulations to the ARCHIVES for bringing this news to family physicians. Several questions come to mind.
Careful monitoring by telephone using a specific symptom monitoring tool seems to be a common element of these programs.1-3 Katzelnick et al have served family physicians well in demonstrating this finding among high-utilizing patients seen in 3 health maintenance organizations. Outside of capitated settings, is this approach financially feasible?
Pfizer Inc (New York, NY) sponsored the research and sertraline provided first-line therapy, with a psychiatric consultation recommended for nonresponders. Cognitive behavioral therapy and some other specific psychotherapies are recognized as effective treatments for patients with mild or moderate major depression. Were patients given an initial choice between medication and psychotherapy and, if so, how many chose psychotherapy and what were their outcomes?
One depression instrument that seems especially useful is the Patient Health Questionnaire (PHQ),4 which functions as both a formal diagnostic tool and also allows for quantitative monitoring of patient's symptoms over time. An electronic copy of this form and scoring instructions are available through the MacArthur Foundation Initiative on Depression and Primary Care Web site (http://www.depression-primarycare.org).
Department of Community and Family Medicine
Dartmouth Medical School
HB7250
Hanover, NH 03755
REFERENCES
1. Katzelnick D, Simon G, Pearson S, et al. Randomized trial of a depression management program in high utilizers of medical care. Arch Fam Med. 2000;9:345-351.
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2. Wells K, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA. 2000;283:212-220.
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3. Simon G, VonKorff M, Rutter C, Wagner E. Randomised trial of monitoring, feedback and management of care by telephone to improve treatment of depression in primary care. BMJ. 2000;320:550-554.
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4. Spitzer R, Kroenke K, Williams J, et al. Validation and utility of a self-report version of PRIME-MD: the PHQ Primary Care Study. JAMA. 1999;282:1737-1744.
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David Katzelnick, MD;
Gregory Simon, MD;
Steven Pearson, MD;
Willard Manning, PhD;
Kenneth Kobak, PhD
In reply
We agree with Dr Dietrich that systematic monitoring of depression symptom severity is a key element in successful depression treatment programs. He raises the question of the generalizability of telephone-based monitoring outside of capitated medical groups. In our study,1 1 of the 3 sites (the Dean Health Plan) had providers who were not paid through capitation. Some of the sites in the study by Wells et al2 were also not capitated. We believe that telephone monitoring as part of an organized depression management program can be successful in multiple types of care systems. The Robert Wood Johnson Depression Breakthrough Series is implementing a similar depression management program in 23 clinical sites around the United States. Reimbursement for telephone follow-up care, especially in fee-for-service systems, is an issue that must be resolved before this model is widely disseminated. Designing a monitoring system that is cost-effective is a challenge that will require the use of automated technology such as interactive voice response3 and the Internet.
In our study, formal psychotherapy was not offered to patients as a frontline treatment. Based on the limited availability of formal psychotherapy in many settings, we chose to create a primary care–based intervention in which antidepressant therapy would be used first, with psychotherapy reserved for patients who did not respond to treatment. Psychiatric consultation with the primary care physician was automatic when patients failed to improve significantly early in the course of treatment. Patients referred to mental health specialty care had access to the full range of psychotherapy.
Dean Foundation for Health, Research, and Education
2711 Allen Blvd
Middleton, WI 53562
REFERENCES
1. Katzelnick D, Simon G, Pearson S, et al. Randomized trial of a depression management program in high utilizers of medical care. Arch Fam Med. 2000;9:345-351.
FREE FULL TEXT
2. Wells K, Sherbourne C, Schoenbaum M, et al. Impact of diseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA. 2000;283:212-220.
FREE FULL TEXT
3. Kobak K, Taylor L, Dottl SL, et al. A computer-administered interview to identify mental disorders. JAMA. 1997;278:905-910.
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