Case review vs. usual care in primary care patients with depression: a pilot study.

This paper reports on the results of a pilot study comparing the efficacy of an experimental case review program between psychiatrists and primary care physicians (PCPs) with PCPs' usual care on the outcome of depressive disorders at 1-year. The secondary aim of the paper is to identify correlates of remission of depressive disorders at the 1-year follow-up. The experimental case review program consisted of 12 biweekly meetings of primary care physicians with a psychiatrist. Meetings lasted two hours and were based on review of cases identified at the interview as suffering from full-blown or subthreshold conditions. Subjects were assessed at baseline, 3 months and 1 year. The baseline assessment included the Composite International Diagnostic Interview, the Hamilton Depression (HDRS) and Anxiety (HARS) Rating Scales, the Medical Outcomes Study SF-36 and some forms to collect life events, major difficulties, social support, and ongoing treatments. At 3 months patients received by mail the General Health Questionnaire (GHQ-12) and at one year the baseline clinical assessment was replicated. Assessments were conducted on eighty cases with major, minor or subsyndromal depression (SSD). The experimental case review program was similar in efficacy to usual care, with an average reduction of 5.5 points on the HAMD. Significant reduction in the severity of depression was associated with a limited number of baseline characteristics, such as being married and having minor depression as compared to major depression and SSD. On the contrary, chronic physical illness at baseline predicted a lower reduction of HAMD scores at one year. While major difficulties and life events during the one-year interval between the two assessments significantly predicted a poorer outcome, social support at home was related to a better outcome. This pilot study indicates that a case review intervention program is not efficacious in a mixed sample of patients with subsyndromal to major depression representative of the current practice of primary case physicians. Still, it might be worthwhile for "difficult" patients selected by the PCPs. In our sample, psychosocial factors seem to be important predictors of outcome. Future trials and large naturalistic studies are needed to address this key point.

[1]  J Ormel,et al.  Training primary-care physicians to recognize, diagnose and manage depression: does it improve patient outcomes? , 1999, Psychological Medicine.

[2]  A. Stewart,et al.  The functioning and well-being of depressed patients. Results from the Medical Outcomes Study. , 1989, JAMA.

[3]  K. Merikangas,et al.  The depressive spectrum: diagnostic classification and course. , 1997, Journal of affective disorders.

[4]  E. Paykel.  Use of the Hamilton Depression Scale in general practice. , 1990, Psychopharmacology series.

[5]  M. Hamilton.  The assessment of anxiety states by rating. , 1959, The British journal of medical psychology.

[6]  G. Simon,et al.  Outcomes of recognized and unrecognized depression in an international primary care study. , 1999, General hospital psychiatry.

[7]  S. Kisely,et al.  Physical and Psychiatric Comorbidity in General Practice , 1996, British Journal of Psychiatry.

[8]  J. Froom,et al.  Minor depression and functional impairment. , 1994, Archives of family medicine.

[9]  P. Rucci,et al.  Mental, Physical and Functional Status in Primary Care Attenders , 1999, International journal of psychiatry in medicine.

[10]  M. Weissman,et al.  Depressive symptoms as relative and attributable risk factors for first-onset major depression. , 1992, Archives of general psychiatry.

[11]  M. Tansella,et al.  Subthreshold psychiatric disorders in primary care: prevalence and associated characteristics. , 2003, Journal of affective disorders.

[12]  John A. Rice,et al.  A prospective 12-year study of subsyndromal and syndromal depressive symptoms in unipolar major depressive disorders. , 1998, Archives of general psychiatry.

[13]  D. Schuyler.  The Depressive Spectrum , 1975 .

[14]  E. Frank,et al.  Correlates of remission in primary care patients treated for minor depression. , 2002, General hospital psychiatry.

[15]  Michael J. Campbell,et al.  Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial , 2000, The Lancet.

[16]  P. Rucci,et al.  DSM-III Mental Disorders in General Medical Sector: Predictors of Outcome , 1996, The International journal of social psychiatry.

[17]  D. Goldberg.  The detection of psychiatric illness by questionnaire : a technique for the identification and assessment of non-psychotic psychiatric illness , 1972 .

[18]  K Kroenke,et al.  Health-related quality of life in primary care patients with mental disorders. Results from the PRIME-MD 1000 Study. , 1995, JAMA.

[19]  K. Wells,et al.  The course of depression in adult outpatients. Results from the Medical Outcomes Study. , 1992, Archives of general psychiatry.

[20]  G. Cassano,et al.  DEPRESSION IN THE COMMUNITY , 1981 .

[21]  W. Katon,et al.  A multifaceted intervention to improve treatment of depression in primary care. , 1996, Archives of general psychiatry.

[22]  J. Ormel,et al.  Outcome of depression and anxiety in primary care. A three-wave 3 1/2-year study of psychopathology and disability. , 1993, Archives of general psychiatry.

[23]  J. Ormel,et al.  Predictors of time to remission from depression in primary care patients: do some people benefit more from positive life change than others? , 2000, Journal of abnormal psychology.

[24]  C. V. D. Feltz-Cornelis,et al.  Randomization in psychiatric intervention research in the general practice setting , 2000 .

[25]  A. Rush,et al.  Treating major depression in primary care practice: an update of the Agency for Health Care Policy and Research Practice Guidelines. , 1998, Archives of general psychiatry.

[26]  L. Judd,et al.  Minor depressive disorder and subsyndromal depressive symptoms: functional impairment and response to treatment. , 1998, Journal of affective disorders.

[27]  M. Tansella,et al.  Validity and test-retest reliability of the Italian version of the 12-item General Health Questionnaire in general practice: a comparison between three scoring methods. , 1993, Comprehensive psychiatry.

[28]  C. Sherbourne,et al.  The MOS 36-Item Short-Form Health Survey (SF-36) , 1992 .

[29]  W. Katon,et al.  Collaborative management to achieve treatment guidelines. Impact on depression in primary care. , 1995, JAMA.

[30]  T. B. Üstün,et al.  Preventing mental illness : mental health promotion in primary care , 1998 .

[31]  W. Katon,et al.  Can enhanced acute-phase treatment of depression improve long-term outcomes? A report of randomized trials in primary care. , 1999, The American journal of psychiatry.

[32]  David Goldberg,et al.  The effects of detection and treatment on the outcome of major depression in primary care: a naturalistic study in 15 cities. , 1998, The British journal of general practice : the journal of the Royal College of General Practitioners.

[33]  M. Hegel,et al.  The treatment effectiveness project. A comparison of the effectiveness of paroxetine, problem-solving therapy, and placebo in the treatment of minor depression and dysthymia in primary care patients: background and research plan. , 1999, General hospital psychiatry.

[34]  S. Weich,et al.  Do socio-economic risk factors predict the incidence and maintenance of psychiatric disorder in primary care? , 1997, Psychological Medicine.

[35]  G. Simon,et al.  Recognition, management, and outcomes of depression in primary care. , 1995, Archives of family medicine.

[36]  M. Trivedi,et al.  Evidence Report: Treatment of Depression - Newer Pharmacotherapies , 1999 .

[37]  G. Apolone,et al.  The Italian SF-36 Health Survey: translation, validation and norming. , 1998, Journal of clinical epidemiology.

[38]  W. Katon,et al.  Treatment of dysthymia and minor depression in primary care: A randomized controlled trial in older adults. , 2000, JAMA.

[39]  E. Frank,et al.  Predictors of nonresponse to treatment in primary care patients with dysthymia. , 2002, General hospital psychiatry.

[40]  W. Manning,et al.  Randomized trial of a depression management program in high utilizers of medical care. , 2000, Archives of family medicine.

[41]  K. Magruder,et al.  Public health consequences of different thresholds for the diagnosis of mental disorders. , 2000, Comprehensive psychiatry.

[42]  W. Katon,et al.  The predictors of persistence of depression in primary care. , 1994, Journal of affective disorders.

[43]  H. Wagner,et al.  Does a coexisting anxiety disorder predict persistence of depressive illness in primary care patients with major depression? , 1999, General hospital psychiatry.

[44]  M. Hotopf,et al.  What's in a name? A comparison of four psychiatric assessments , 1997, Social Psychiatry and Psychiatric Epidemiology.

[45]  W. Katon,et al.  Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial. , 1999, Archives of general psychiatry.

[46]  P. Bech,et al.  The Hamilton Scales , 1990, Psychopharmacology Series.

[47]  J. Coyne,et al.  Short-term outcomes of detected and undetected depressed primary care patients and depressed psychiatric patients. , 1997, General hospital psychiatry.

[48]  F. Creed,et al.  Outcome of anxiety and depressive disorders in primary care , 1997, British Journal of Psychiatry.

[49]  J. Coyne,et al.  Persistently poor outcomes of undetected major depression in primary care. , 1998, General hospital psychiatry.

[50]  G Lewis,et al.  Putting trials on trial--the costs and consequences of small trials in depression: a systematic review of methodology. , 1997, Journal of epidemiology and community health.

[51]  G. Simon,et al.  Lessons from recent research on depression in primary care1 , 2000, Epidemiologia e Psichiatria Sociale.

[52]  C. Sherbourne,et al.  Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. , 2000, JAMA.

[53]  N. Sartorius,et al.  Mental illness in general health care : an international study , 1995 .

[54]  M. Hamilton.  A RATING SCALE FOR DEPRESSION , 1960, Journal of neurology, neurosurgery, and psychiatry.

[55]  R. Kessler,et al.  Prevalence, correlates, and course of minor depression and major depression in the National Comorbidity Survey. , 1997, Journal of affective disorders.

[56]  M. Weissman,et al.  Service utilization and social morbidity associated with depressive symptoms in the community. , 1992, JAMA.

[57]  L. George,et al.  Depression, disability days, and days lost from work in a prospective epidemiologic survey. , 1990, JAMA.

[58]  J. Lave,et al.  Treating major depression in primary care practice. Eight-month clinical outcomes. , 1996, Archives of general psychiatry.

[59]  R. Crum,et al.  Empirical examination of current depression categories in a population-based study: symptoms, course, and risk factors. , 2000, The American journal of psychiatry.

[60]  L. Mynors-Wallis,et al.  Randomised controlled trial comparing problem solving treatment with amitriptyline and placebo for major depression in primary care , 1995, BMJ.

[61]  L. Mynors-Wallis,et al.  Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care , 2000, BMJ : British Medical Journal.

[62]  J Ormel,et al.  Disability and depression among high utilizers of health care. A longitudinal analysis. , 1992, Archives of general psychiatry.

[63]  M. Tansella,et al.  Results from the Verona Centre , 1995 .

[64]  K. Wells,et al.  Socioeconomic burden of subsyndromal depressive symptoms and major depression in a sample of the general population. , 1996, The American journal of psychiatry.

[65]  H A Pincus,et al.  ‘Subthreshold’ mental disorders , 1999, British Journal of Psychiatry.

[66]  G. Simon,et al.  Occurrence, recognition, and outcome of psychological disorders in primary care. , 1996, The American journal of psychiatry.