October 2000

Grant Results

SUMMARY

During 1998 and 1999, Group Health Cooperative of Puget Sound held a conference on improving care for depression in organized health care systems.

Key Results

  • The conference, entitled "Improving Care for Depression in Organized Health Care Systems," took place in Seattle on February 24–26, 1999. Sixty-eight people attended, including leading researchers and representatives from major health care systems, foundations and the National Institute of Mental Health.

Funding
The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $20,791.

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THE PROBLEM

Increasing the quality of treatment for depression in primary health care settings is important due to the high prevalence of depression, its correlation with high general medical utilization, and its economic costs in lost productivity and human potential.

This is a particular challenge in a changing health care environment in which physician and non-physician time is limited and mental health care (often called behavioral health care) is often "carved out" by managed care organizations to other, independent organizations, resulting in barriers to the recognition and treatment of depression.

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THE PROJECT

The objectives of the conference were to:

  • Present the results of the latest completed randomized controlled trials of depression interventions in primary care.
  • Identify critical unanswered questions concerning the effectiveness and cost-effectiveness of depression interventions in organized care systems.
  • Identify critical next steps to accelerate dissemination of effective interventions.

Additional funding for the conference was provided by the John A. Hartford Foundation ($15,000) and the National Institute of Mental Health, which provided funds for participants' airfare.

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RESULTS

  • The "Improving Care for Depression in Organized Health Care Systems" conference took place Seattle on February 24–26, 1999. Sixty-eight people, including leading researchers and representatives from major health care systems, foundations and the National Institute of Mental Health.

    At the meeting, nine investigators outlined the design and current progress of their clinical trials. (See the Bibliography for presenters and titles of their papers.) In breakout discussion groups and a panel discussion that followed, participants explored three main questions:
    • What populations are benefiting from the current generation of depression treatments?
    • What are the barriers to the dissemination of effective practices?
    • What are the implications of depression care research for real-world dissemination of effective practices?

Following the meeting, the project director and several meeting participants prepared a report synthesizing the discussions and conclusions reached at the conference about the scope and direction of future work in this area. Among their conclusions:

  • What populations are benefiting from the current generation of depression treatments? Patients who are educated, who are having an uncomplicated bout of depression, who have had no more than two episodes of depression, and who have faith in the treatment they are receiving typically respond to current treatments.

    Patients who do not respond have higher levels of acute and chronic stressors, poorer social supports, and a greater number of prior episodes.

    Future research should focus on how best to treat patients who tend not to respond to or accept existing treatments. It should also look into the effectiveness of existing interventions for special populations — including children, the elderly and some minority groups — who have not been included in previous research.
  • What are the barriers to the dissemination of effective practices? Barriers to dissemination exist at the level of:
    • The health care organization, where there may be a lack of motivation or ability to change systems of care.
    • The delivery system, which may be organized to treat acute episodes of illness rather than manage chronic conditions.
    • The clinical information system, which may be unable to track patients with specific conditions.
    • Decision support, where evidence-based guidelines are poorly integrated into daily primary care practice.
    • Patients, who because of bias, stigma, and concerns about confidentiality may be unable to become effective self-managers of their own condition.
  • What are the implications of depression care research for real-world dissemination of effective practices? Previously issued clinical practice guidelines have failed to alter practice in the field.

    Researchers have begun to focus on the manner in which general principles of effective care can be adapted to the structure, finances, and other characteristics of individual primary care practices.

    A key need is to center care of the depressed patient in the ambulatory medical sector rather than "carving" it out to a different specialty sector, thus ensuring continuity of care. Beyond currently available clinical practice guidelines, studies suggest depression treatment outcomes may be improved by:
    • Improving continuity of care.
    • Activating and empowering patients.
    • Matching patients to appropriate interventions.
    • Ensuring that patients follow through with prescribed treatment.
    • Monitoring the clinical course and outcome.
  • What are the implications for future research on depression care? Speakers suggested that efforts should be focused in the following areas:
    • Case management.
    • Intervention research in new populations (such as treatment-resistant patients and patients whose depression is complicated by other diseases).
    • Sequential care management strategies and relapse prevention.
    • Societal benefits of improved depression care, especially its effect on the labor force.
    • Multisite trials (to increase the number of patients studied and thus the reliability of results) and meta-analytic approaches (i.e., statistical integration of independent study results, which would allow for a larger database and thus more reliable results).

In addition to the unpublished conference report, conference results were also reported at a July 1999 NIMH conference, "Improving Mental Health through Quality Intervention in Primary Care." (See the Bibliography for more details.)

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GRANT DETAILS & CONTACT INFORMATION

Project

Conference on Improving Care for Depression in Organized Health Care Systems

Grantee

Group Health Cooperative of Puget Sound (Seattle,  WA)

  • Amount: $ 20,791
    Dates: November 1998 to May 1999
    ID#:  035211

Contact

Michael R. Von Korff, Sc.D.
(206) 287-2874
vonkorff.m@ghc.org

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BIBLIOGRAPHY

(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)

Articles

Von Korff M, Unützer J, Katon W and Wells K. "Improving Care for Depression in Organized Health Care Systems: A Conference Report." Journal of Family Practice, 50(6): 530–531, 2001. Includes:

  • Areán PA and Alvidrez J. "Treating Depressive Disorders: Who Responds, Who Does Not Respond, and Who Do We Need to Study?" Journal of Family Practice, 50(6): E2, 2001. Abstract available online.
  • Schulberg HC. "Treating Depression in Primary Care Practice: Applications of Research Findings." Journal of Family Practice, 50(6): 535–537, 2001.
  • Von Korff M, Katon W, Unützer J, Wells K, and Wagner EH. "Improving Depression Care: Barriers, Solutions and Research Needs." Journal of Family Practice, 50(6): E1, 2001. Abstract available online.

Sponsored Conferences

"Improving Care for Depression in Organized Health Care Systems," February 25–26, 1999, Seattle, Wash. Attended by 68 people (mental health services researchers and representatives from large health care systems, foundations, and the National Institute of Mental Health) from approximately 38 organizations. 10 presentations, one panel.

Presentations

  • James Barrett, Dartmouth College, "Treatment of Minor Depression and Dysthymia in Primary Care: Response to Paroxetine and Problem-Solving Therapy-PC."
  • Laurence Mynors-Wallace, University of London, "A Further Evaluation of Problem-Solving and Antidepressant Medication for Major Depression in Primary Care."
  • Jeanne Miranda, Georgetown University, "Treating Depression in Low-Income Medical Patients: The Effect of Adding Case Management."
  • Wayne Katon (Seattle, Wash.), "Stepped Collaborative Care for Depressed Primary Care Patients with Persistent Symptoms."
  • Ken Wells, University of Southern California/RAND, "The Depression PORT: Initial Results."
  • Katherine Rost, University of Arkansas, "Primary Care Physician — Nurse Teams Improve Depression Outcomes: 6 Month Results."
  • David Katzelnick, Dean Foundation, Stepwise Depression Management in High Utilizers of Medical Care."
  • Greg Simon (Seattle, Wash.), "Telephone Case Management and Practice Support."
  • Enid Hunkeler, Kaiser-North Carolina, "Efficacy and Cost of Nurse Telephone Follow-up to Improve Depression Treatment in Primary Care."
  • Grayson Norquist, National Institute of Mental Health; Christopher Langston, Hartford Foundation; and Constance Pechura, The Robert Wood Johnson Foundation: "Observations from the NIMH, Hartford Foundation, and the Robert Wood Johnson Foundation."

Panel

  • "Progress and Challenges in Determining How Depression Interventions Affect Societal Costs, Disability, and Quality of Life," Greg Simon (Seattle, Wash.); Willard Manning, University of Chicago; Debra Lerner, New England Medical Center; Michael Schoenbaum, University of Southern California/RAND; and Cathy Sherbourne, University of Southern California/RAND.

Presentations and Testimony

Charles Schulberg, "Treating Depression in Primary Care. What Do We Know and What Should We Do?" at the National Institute of Mental Health conference, "Improving Mental Health Through Quality Intervention in Primary Care," July 12–13, 1999, Washington, D.C.

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Report prepared by: Robert Crum
Reviewed by: James Wood
Reviewed by: Richard Camer
Program Officer: Constance M. Pechura

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