Improving long-term outcome of major depression in primary care

Background and objective: Depression is often a recurrent or persistent disorder, associated with high levels of disability. Since the majority of depressed patients are treated in primary care, it is clear that to attain more favorable long-term outcomes more effective treatments in this setting are needed. The goal of this study was to review the strategies used for improvement of routine treatment in terms of their effects on patient outcome. Methods: We conducted a systematic literature search to identify improvement strategies. Randomized controlled trials conducted in primary care, reporting at least six months effects on depression course and outcome of psychological treatments and supportive interventions for major depression in adults were included. The search strategy was expanded to include literature on patient outcome of educational programs and targeted approaches used in other settings. Results are presented in the form of a narrative review. Results : Four strategies were identified: (1) training primary care physicians (PCPs) – this appears ineffective; (2) supporting PCPs management of depressed patients by other professionals, which includes collaborative care models– this may result in better short term outcomes but does not prevent recurrence ; (3) quality improvement, by adressing both the contents of treatment as well as the broader care context in which treatment is delivered-this shows improved outcomes at 6 months, and there is some evidence of longer term effectiveness; and (4) integration of recurrence and chronicity prevention strategies into treatment from the start - these have not been shown to be effective. Conclusions: Findings show that effects of the reviewed strategies generally do not seem to persist over time. Moreover, with the exception of some US-based studies, no clear superiority over usual care has been demonstrated. We conclude that for improving long-term outcome of major depression in primary care new directions are needed.


Thesis summary
Improving long-term outcome of major depression in primary care: the role of recurrence prevention Annet Smit wS.l.: s.n.x, 2007, (Grafisch centrum, Facilitair bedrijf Rijksuniversiteit Groningen)

Thesis outline
Introduction: Major depression is a highly prevalent and often recurrent disorder. Since most depressed patients in The Netherlands are treated by general practioners, it is clear that more effective treatments in this primary care setting are needed. The main aim of the research presented in this thesis was to evaluate the effects of enhanced care for depression with a continuation-phase compared with usual care on the course and outcome of depression over three years.
The primary intervention was the depression recurrence prevention (DRP) program, a structured psycho educational intervention that focused on improving patients' resilience and self-management skills. Core elements are three individual face-to-face visits with a prevention specialist and provider-initiated regular follow-up care, consisting of systematic monitoring of depressive symptoms and treatment adherence by four contacts (telephone and mail) over the ensuing three years.
Method: Randomized controlled trial, conducted from 1998 through 2003. A total of 267 patients (referred by fifty-five GPs) with a DSM-depression diagnosis (assessed with a structured psychiatric interview) were randomly assigned to one of four treatment conditions, including care as usual; these patients (ns72) received the care that their GP deemed fit. The other patients (ns195) received the experimental enhanced care program, which consisted of the DRP-program either by itself (ns112), or in combination with a psychiatric consultation (ns39; 1 patient visit with a psychiatrist) or with brief cognitive behavioral therapy (CBT, 12 sessions; ns44).
The mean age of the patients was 43 years and 65% was female. Sixty-seven percent suffered from a recurrent depression, and 36% had experienced more than three previous episodes.
Response rates for the twelve three-monthly telephone interviews ranged from 75% to 90%. Eighty-five percent of all randomised patients participated in the final research assessment three years after inclusion.

Main findings:
The DRP-program proved to be both feasible and appreciated. Short-term outcomes showed that 67% of all patients had recovered from their depression after six months. On the longer run, nearly all patients remitted from the index-episode at some point. However, only one-third of them did not relapse (i.e. worsening of symptoms before recovery) or suffer from a recurrence (new episode) during the full 3-year follow-up period. Depression outcomes were largely similar for all patients; there were no statistically significant differences between treatment groups. The findings demonstrate that, while not all depressions are recurrent in nature, the ones that are continue to be difficult to treat effectively. For a substantial subgroup of patients, recurrence of depression may be the rule rather than the exception.
Conclusion: Enhancement of GP treatment with the DRP-program had no additional benefit over usual care. The findings provide no support for the implementation of this form of enhanced care with a continuation phase in the current healthcare system.
The study is relevant for readers of the IJIC for several reasons. First, because the study was designed as a pragmatic type trial and as such provides detailed information on what constitutes 'treatment as usual' in the management of depression by Dutch GPs, and its results over a prolonged period of time. Second, improved long-term outcome of depression for vulnerable patients may be achieved by a more pro-active risk-reduction approach, focusing on specific factors (such as residual symptoms) or at enhancing protective aspects (like self-care skills). Finally, this study is not unique in finding treatment by the GP for a com-mon mental health disorder to be equally effective as the experimental interventions. The study highlights issues that concern the strengths of the generalist and contextual approach used in primary healthcare.
The results presented in this review are based on the author's thesis presented at the University of Groningen on 6 June 2007.