Improving long-term outcome of major depression in primary care: the role of recurrence prevention
International Journal of Integrated Care, 10 December 2007 - ISSN 1568-4156
Thesis summary
Improving long-term outcome of major depression in primary care: the role of recurrence prevention
Annet Smit
[S.l.: s.n.] (Grafisch centrum, Facilitair bedrijf Rijksuniversiteit Groningen) Thesis University of Groningen, 2007, pp 206,
ISBN 978 90 367 3068 6 (paper version)
ISBN 978 90 367 3069 3 (electronic version)
Annet Smit
Thesis outline

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.


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 (n=72) received the care that their GP deemed fit. The other patients (n=195) received the experimental enhanced care program, which consisted of the DRP-program either by itself (n=112), or in combination with a psychiatric consultation (n=39; 1 patient visit with a psychiatrist) or with brief cognitive behavioral therapy (CBT, 12 sessions; n=44).

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.


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 common 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.

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