The inadequate treatment of depression in primary care settings continues to be a major public health problem despite efforts to improve care. “In primary care, most depressed patients have chronic or recurrent depression,” explains Michael S. Klinkman, MD, MS, “and many cases are further complicated by comorbid health disorders. Treatment protocols that are designed to improve the effectiveness of acute-phase care apply only to a small fraction of the depressed patients that are seen by primary care physicians [PCPs].”
The DPC Intervention
Dr. Klinkman and colleagues at the University of Michigan had a study published in the September/October 2010 Annals of Family Medicine in which the Depression in Primary Care (DPC) intervention was assessed. “The primary aim of the DPC project was to develop, implement, and evaluate the effectiveness and sustainability of a depression management program that could support how PCPs manage patients in both acute and chronic phases of treatment,” says Dr. Klinkman.
The DPC clinical intervention included several components, including care managers who offered support at specific sites, disease monitoring and clinician feedback, patient activation and self-management assistance, and a clinical information system in which a secure email system enabled care managers, PCPs, and consultation-liaison psychiatrists to communicate efficiently to coordinate care. The DPC intervention consisted of a series of telephone calls and email exchanges between enrollees and care managers, care managers and referring physicians, and, on occasion, care managers and consultation-liaison psychiatrists (Table 1). Dr. Klinkman says “the primary goals were to increase enrollees’ self-management of depression and provide feedback to referring physicians about clinical progress and possible complications in treatment.”
The intake telephone call, which required 20 to 30 minutes, consisted of a review of the enrollee’s clinical history, introduction to the program components, and a first discussion of depression self-management and goal-setting. The second telephone call, which usually lasted less than 10 minutes, focused on answering questions from DPC intervention materials (which patients received) and setting a self-management goal. Subsequent calls that focused on support and specific support needs were addressed as they emerged. “The DPC project was designed to meet the needs of PCPs as well as their office staff,” Dr. Klinkman adds. “They’ve made it clear that their main need was for help with chronically ill, severely depressed, more-complex patients. The goal was to improve and sustain mental health results by providing small amounts of flexible, targeted follow-up care without overburdening busy primary care offices.”
The Annals of Family Medicine study reported on the primary clinical outcomes for DPC enrollees and compared outcomes for DPC enrollees with usual care patients over 18 months. Patients receiving the DPC intervention were more likely to have symptoms that were in remission and to have fewer reduced-function days than those receiving usual primary care treatments after 18 months (Table 2). “Our results confirmed that the DPC intervention was feasible and highly effective over time,” says Dr. Klinkman. “The clinical protocol was successfully introduced in five primary care sites. These are places where change is constant, clinician turnover is high, and workflow is highly complex.”
Almost half of patients met criteria for clinical remission at 18 months, almost doubling the remission rate seen in usual care delivered in academic primary care settings, says Dr. Klinkman. “Every outcome comparison favored DPC enrollees.” In addition, 83% of patients who were referred completed enrollment—a higher proportion than has been previously reported for these types of interventions. Most enrollees also remained active in the program for at least 6 months. Dr. Klinkman points out that the key is to keep patients engaged in treatment. “Patients need to have contact with people who can help them become more actively involved in their own care. It’s hard for PCPs to do that if they’re only offering a little information about depression or steering them to a website to learn more about their condition. A more patient-centered approach is necessary.”
More to Come
The methods developed for the DPC project were intended to be transportable to disease management programs for other chronic health conditions. “By integrating care management tools and personnel across several related conditions—such as depression, diabetes, and heart failure—it should be possible to further integrate patient-centered disease management,” Dr. Klinkman says. “In the future, we’re going to explore the impact of the DPC intervention with regards to costs and outcomes for subgroups of patients, the direct relationships between intensity of care and clinical outcomes, the impact of care management on clinician attitudes and practices, and patient beliefs, attitudes, and adherence to treatment over time. We hope these analyses will help guide the development of chronic care management programs that can benefit ‘real-world’ primary care practices.”
Readings & Resources (click to view)
Klinkman MS, Bauroth S, Fedewa S, et al. Long-term clinical outcomes of care management for chronically depressed primary care patients: a report from the Depression in Primary Care Project. Ann Fam Med.2010;8:387-396. Available at: http://www.annfammed.org/cgi/content/full/8/5/387.
Dietrich AJ, Oxman TE, Williams JW Jr, et al. Re-engineering systems for the treatment of depression in primary care: cluster randomised controlled trial. BMJ. 2004;329(7466):602.
Neumeyer-Gromen A, Lampert T, Stark K, Kallischnigg G. Disease management programs for depression: a systematic review and meta-analysis of randomized controlled trials. Med Care. 2004;42:1211–1221.
Katon WJ, Unützer J, Simon G. Treatment of depression in primary care: where we are, where we can go. Med Care. 2004;42:1153–1157.