BACKGROUND/RATIONALE:
Most depression treatment takes place in primary care, where the condition continues to be under-detected and under-treated. A collaborative care model derived from chronic illness management theory has been successful in improving care in other managed care settings.

OBJECTIVE(S):
This effectiveness study adapted collaborative care to the VA primary care setting ("collaborative care") and compared it with consult-liaison care ("CL care").

METHODS:
Patients within a VA primary care clinic were randomly assigned by firm to the two interventions.
In collaborative care, existing staff resources were reorganized to form a multidisciplinary mental health specialist team. The team developed a treatment plan based on an initial assessment and suggested the plan to the primary care provider. Primary care providers' treatment efforts were then supported by brief Social Work telephone calls designed to support adherence and monitor symptomatology. Treatment results were systematically reviewed and suggestions for treatment modification were fed back to the primary providers. In CL care, the primary care providers were informed of the diagnosis and study clinicians facilitated referrals to Psychiatry residents in-clinic as requested. Mailed and in-clinic surveys and provider referral were used to recruit 168 collaborative care and 186 CL care patients who met criteria for major depression and/or dysthymia based on structured interview. Patients were excluded only if they required immediate inpatient care, had a pending mental health specialty clinic appointment, or had primary alcohol abuse. Outcome data on the SCL-20 depression symptomatology measure, Veterans SF-36, and Sheehan Disability Scale were collected at baseline, 3 and 9 months. VA utilization and costs of care were analyzed.

FINDINGS/RESULTS:
Collaborative care resulted in significantly greater improvement in depressive symptomatology from baseline to 3 months (collaborative care changed from 1.96 to 1.63 versus CL care 1.83 to 1.67, p< .05), with CL care catching up by 9 months (1.56 versus 1.58, ns). Collaborative care resulted in statistically and clinically significant greater improvement in SF-36 Mental Component scores (33.7 to 39.0 versus 35.3 to 37.5, p< .05) from baseline to 9 months and in significantly greater improvement on the Sheehan at 3 months. SF-36 Physical Component scores did not change significantly. Collaborative care significantly increased the proportion of patients given prescriptions and engaging in cognitive behavioral therapy. Total costs of inpatient and outpatient care were significantly higher in the collaborative care group. While cost of depression-related inpatient care was not higher, cost of depression-related outpatient care was significantly higher in the collaborative care group.

IMPACT:
After our research involvement was completed, our clinic continued to do systematic depression screening and evaluation and support close primary care - mental health collaboration. Current research is evaluating if collaborative care can be implemented and be effective in VA primary care clinics with different resources.

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External Links for this Project

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PUBLICATIONS:

Journal Articles

1. Kanter JW, Epler AJ, Chaney EF, Liu CF, Heagerty P, Lin P, Felker B, Hedrick SC. Comparison of 3 Depression Screening Methods and Provider Referral in a Veterans Affairs Primary Care Clinic. Primary care companion to the Journal of clinical psychiatry. 2003 Dec 1; 5(6):245-250. [view]
2. Liu CF, Hedrick SC, Chaney EF, Heagerty P, Felker B, Hasenberg N, Fihn S, Katon W. Cost-effectiveness of collaborative care for depression in a primary care veteran population. Psychiatric services (Washington, D.C.). 2003 May 1; 54(5):698-704. [view]
3. Hedrick SC, Chaney EF, Felker B, Liu CF, Hasenberg N, Heagerty P, Buchanan J, Bagala R, Greenberg D, Paden G, Fihn SD, Katon W. Effectiveness of collaborative care depression treatment in Veterans' Affairs primary care. Journal of general internal medicine. 2003 Jan 1; 18(1):9-16. [view]
4. Felker BL, Hedrick SC, Chaney EF, Liu CF, Heagerty P, Caples H, Lin P, Katon W. Identifying Depressed Patients With a High Risk of Comorbid Anxiety in Primary Care. Primary care companion to the Journal of clinical psychiatry. 2003 Jun 1; 5(3):104-110. [view]
5. Fischer EP, Marder SR, Smith GR, Owen RR, Rubenstein L, Hedrick SC, Curran GM. Quality Enhancement Research Initiative in Mental Health. Medical care. 2000 Jun 1; 38(6 Suppl 1):I70-81. [view]
6. Lin P, Campbell DG, Chaney EF, Liu CF, Heagerty P, Felker BL, Hedrick SC. The influence of patient preference on depression treatment in primary care. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine. 2005 Oct 1; 30(2):164-73. [view]

Conference Presentations

1. Hedrick SC, Chaney EF, Rubenstein LZ, Yano E. Approaches to Guidelines Implementation: Primary Care Depression Treatment. Paper presented at: VA HSR&D National Meeting; 2000 Mar 15; Washington, DC. [view]
2. Felker B, Chaney E, Hedrick S. Collaborative care for depression in primary care: Studies on Integration of Mental Health and Primary Care in the Veterans Administration. Paper presented at: American Psychiatric Association Annual Meeting; 2001 May 8; New Orleans, LA. [view]
3. Kanter J, Epler A, Chaney E, Hedrick S, Liu C, Heagerty P, Lin P, Felker B. Depression screening: Comparison of three methods to provider referral in primary care. Paper presented at: VA HSR&D National Meeting; 2003 Feb 14; Washington, DC. [view]
4. Chan D, Liu CF, Chaney EF, Hedrick S. Effectiveness and Cost-Effectiveness of Collaborative Care Depression Treatment in Veterans who Screen Positive for PTSD in Primary Care. Presented at: AcademyHealth Annual Research Meeting; 2006 Jun 25; Seattle, WA. [view]
5. Liu C, Hedrick S, Chaney E, Heagerty P. Effectiveness of collaborative care depression treatment on utilization and cost in a veteran primary care population. Paper presented at: VA HSR&D National Meeting; 2003 Feb 14; Washington, DC. [view]
6. Liu C, Hedrick S, Chaney E, Heagerty P. Effectiveness of collaborative care depression treatment on utilization and cost in a veteran primary care population. Paper presented at: International Health Economics Association Biennial World Congress on Health Economics; 2003 Jul 8; San Francisco, CA. [view]
7. Felker B, Chaney E. Effectiveness of team treatment of depression in primary care: Design of a study of guideline implementation. Paper presented at: American Psychiatric Association Institute on Psychiatric Services Annual Conference; 1998 Oct 5; Los Angeles, CA. [view]
8. Chaney EF, Hasenberg N, Hedrick SC. Implementing depression screening in primary care: An effective strategy? Presented at: VA HSR&D National Meeting; 1999 Sep 15; Washington, DC. [view]
9. Chaney EF, Hedrick S, Paden G, McDonell M, Rasmussen J, Goldberg H, Fihn S. Improving quality of care for depression in elderly primary care patients. Paper presented at: VA HSR&D National Meeting; 1998 Sep 15; Washington, DC. [view]
10. Chaney E, Hedrick S, Felker B, Liu C, Paden G, Hasenberg N. Improving Treatment for Depression in Primary Care: Alternate Strategies. Paper presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2001 Mar 23; Seattle, WA. [view]
11. Chaney E, Hedrick S, Felker B, Liu C. Improving Treatment for Depression in Primary Care: Alternate Strategies. Paper presented at: American Psychiatric Association Annual Meeting; 2001 May 1; New Orleans, LA. [view]
12. Hedrick S, Chaney E, Liu C, Felker B, Bagala R, Paden G. Process of Care in Innovative and Traditional Treatments for Depression in VA Primary Care: Reallocating Resources. Paper presented at: VA HSR&D National Meeting; 2001 Feb 15; Washington, DC. [view]
13. Felker B. Studies on Integration of Mental Health and Primary Care in the Veterans Administration. Improving Treatment of depression in Primary care: Alternate Strategies (workshop). Paper presented at: American Psychiatric Association Annual Meeting; 2001 May 8; New Orleans, LA. [view]
14. Liu C, Hedrick S, Chaney E, Felker B, Hasenberg N. Time Costs in Integrated Care for Depression Treatment in Primary Care. Paper presented at: VA HSR&D National Meeting; 2000 Mar 1; Washington, DC. [view]
15. Liu C, Chaney E, Hedrick S. Using HEDIS to Measure Quality of Care in VA Primary Care--The Case of Antidepressant Management. Paper presented at: AcademyHealth Annual Research Meeting; 2002 Jun 11; Atlanta, GA. [view]

DRA: Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Treatment - Observational
Keywords: Depression, Organizational issues, Primary care
MeSH Terms: Depression, Primary Health Care