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A Randomized Controlled Trial

Kenneth B. Wells, MD, MPH; Cathy Sherbourne, PhD; Michael Schoenbaum, PhD; Naihua Duan, PhD; Lisa Meredith, PhD; Jürgen Unützer, MD, MPH; Jeanne Miranda, PhD; Maureen F. Carney, MS; Lisa V. Rubenstein, MD, MSHS

JAMA. 2000;283:212-220.

Context  Care of patients with depression in managed primary care settings often fails to meet guideline standards, but the long-term impact of quality improvement (QI) programs for depression care in such settings is unknown.

Objective  To determine if QI programs in managed care practices for depressed primary care patients improve quality of care, health outcomes, and employment.

Design  Randomized controlled trial initiated from June 1996 to March 1997.

Setting  Forty-six primary care clinics in 6 US managed care organizations.

Participants  Of 27,332 consecutively screened patients, 1356 with current depressive symptoms and either 12-month, lifetime, or no depressive disorder were enrolled.

Interventions  Matched clinics were randomized to usual care (mailing of practice guidelines) or to 1 of 2 QI programs that involved institutional commitment to QI, training local experts and nurse specialists to provide clinician and patient education, identification of a pool of potentially depressed patients, and either nurses for medication follow-up or access to trained psychotherapists.

Main Outcome Measures  Process of care (use of antidepressant medication, mental health specialty counseling visits, medical visits for mental health problems, any medical visits), health outcomes (probable depression and health-related quality of life [HRQOL]), and employment at baseline and at 6- and 12-month follow-up.

Results  Patients in QI (n = 913) and control (n = 443) clinics did not differ significantly at baseline in service use, HRQOL, or employment after nonresponse weighting. At 6 months, 50.9% of QI patients and 39.7% of controls had counseling or used antidepressant medication at an appropriate dosage (P<.001), with a similar pattern at 12 months (59.2% vs 50.1%; P = .006). There were no differences in probability of having any medical visit at any point (each P.21). At 6 months, 47.5% of QI patients and 36.6% of controls had a medical visit for mental health problems (P = .001), and QI patients were more likely to see a mental health specialist at 6 months (39.8% vs 27.2%; P<.001) and at 12 months (29.1% vs 22.7%; P = .03). At 6 months, 39.9% of QI patients and 49.9% of controls still met criteria for probable depressive disorder (P = .001), with a similar pattern at 12 months (41.6% vs 51.2%; P = .005). Initially employed QI patients were more likely to be working at 12 months relative to controls (P = .05).

Conclusions  When these managed primary care practices implemented QI programs that improve opportunities for depression treatment without mandating it, quality of care, mental health outcomes, and retention of employment of depressed patients improved over a year, while medical visits did not increase overall.

Author Affiliations: RAND, Health Program, Santa Monica, Calif (Drs Wells, Sherbourne, Schoenbaum, Duan, Meredith, Rubenstein, and Ms Carney); UCLA-Neuropsychiatric Institute and Department of Psychiatry and Biobehavioral Sciences (Drs Wells and Unützer) and Department of Medicine (Dr Rubenstein), School of Medicine, University of California, Los Angeles; Department of Psychiatry, Georgetown University Medical Center, Washington, DC (Dr Miranda); and Department of Medicine, VA Greater Los Angeles Healthcare System, Los Angeles, Calif (Dr Rubenstein).

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JAMA. 2003;290(15):1992-1993.
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