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A Randomized Controlled Trial

Philip S. Wang, MD, DrPH; Gregory E. Simon, MD, MPH; Jerry Avorn, MD; Francisca Azocar, PhD; Evette J. Ludman, PhD; Joyce McCulloch, MS; Maria Z. Petukhova, PhD; Ronald C. Kessler, PhD

JAMA. 2007;298:1401-1411.

Context  Although guideline-concordant depression treatment is clearly effective, treatment often falls short of evidence-based recommendations. Organized depression care programs significantly improve treatment quality, but employer purchasers have been slow to adopt these programs based on lack of evidence for cost-effectiveness from their perspective.

Objective  To evaluate the effects of a depression outreach-treatment program on workplace outcomes, a concern to employers.

Design, Setting, and Participants  A randomized controlled trial involving 604 employees covered by a managed behavioral health plan were identified in a 2-stage screening process as having significant depression. Patient treatment allocation was concealed and assessment of depression severity and work performance at months 6 and 12 was blinded. Employees with lifetime bipolar disorder, substance disorder, recent mental health specialty care, or suicidality were excluded.

Intervention  A telephonic outreach and care management program encouraged workers to enter outpatient treatment (psychotherapy and/or antidepressant medication), monitored treatment quality continuity, and attempted to improve treatment by giving recommendations to providers. Participants reluctant to enter treatment were offered a structured telephone cognitive behavioral psychotherapy.

Main Outcome Measures  Depression severity (Quick Inventory of Depressive Symptomatology, QIDS) and work performance (World Health Organization Health and Productivity Questionnaire [HPQ], a validated self-report instrument assessing job retention, time missed from work, work performance, and critical workplace incidents).

Results  Combining data across 6- and 12-month assessments, the intervention group had significantly lower QIDS self-report scores (relative odds of recovery, 1.4; 95% confidence interval, 1.1-2.0; P = .009), significantly higher job retention (relative odds, 1.7; 95% confidence interval, 1.1-3.3; P = .02), and significantly more hours worked among the intervention (=2.0; P=.02; equivalent to an annualized effect of 2 weeks of work) than the usual care groups that were employed.

Conclusions  A systematic program to identify depression and promote effective treatment significantly improves not only clinical outcomes but also workplace outcomes. The financial value of the latter to employers in terms of recovered hiring, training, and salary costs suggests that many employers would experience a positive return on investment from outreach and enhanced treatment of depressed workers.

Trial Registration  clinicaltrials.gov Identifier: NCT00057590

Author Affiliations: Division of Services and Intervention Research, National Institute of Mental Health, Rockville, Maryland (Dr Wang); Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital (Drs Wang and Avorn) and Department of Health Care Policy, Harvard Medical School (Drs Wang, Petukhova and Kessler), Boston, Massachusetts; Center for Health Studies, Group Health Cooperative, Seattle, Washington (Dr Simon and Ludman); and United Behavioral Health, San Francisco, California (Dr Azocar).

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