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Results of a Randomized Controlled Trial

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

JAMA. 2001;286:1325-1330.

Context  Depression is a leading cause of disability worldwide, but treatment rates in primary care are low.

Objective  To determine the cost-effectiveness from a societal perspective of 2 quality improvement (QI) interventions to improve treatment of depression in primary care and their effects on patient employment.

Design  Group-level randomized controlled trial conducted June 1996 to July 1999.

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

Participants  One hundred eighty-one primary care clinicians and 1356 patients with positive screening results for current depression.

Interventions  Matched practices were randomly assigned to provide usual care (n = 443 patients) or to 1 of 2 QI interventions offering training to practice leaders and nurses, enhanced educational and assessment resources, and either nurses for medication follow-up (QI-meds; n = 424 patients) or trained local psychotherapists (QI-therapy; n = 489). Practices could flexibly implement the interventions, which did not assign type of treatment.

Main Outcome Measures  Total health care costs, costs per quality-adjusted life-year (QALY), days with depression burden, and employment over 24 months, compared between usual care and the 2 interventions.

Results  Relative to usual care, average health care costs increased $419 (11%) in QI-meds (P = .35) and $485 (13%) in QI-therapy (P = .28); estimated costs per QALY gained were between $15 331 and $36 467 for QI-meds and $9478 and $21 478 for QI-therapy; and patients had 25 (P = .19) and 47 (P = .01) fewer days with depression burden and were employed 17.9 (P = .07) and 20.9 (P = .03) more days during the study period.

Conclusions  Societal cost-effectiveness of practice-initiated QI efforts for depression is comparable with that of accepted medical interventions. The intervention effects on employment may be of particular interest to employers and other stakeholders.

Author Affiliations: Health Program, RAND, Arlington, Va (Dr Schoenbaum); RAND, Health Program, Santa Monica, Calif (Drs Sherbourne, Duan, Rubenstein, Meredith, and Wells, and Ms Carney); UCLA-Neuropsychiatric Institute, University of California, Los Angeles (Drs Unützer, Duan, Miranda, and Wells); and HSR&D Center of Excellence for the Study of Healthcare Provider Behavior, Sepulveda VA Medical Center, Sepulveda, Calif (Dr Rubenstein).

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