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A Randomized Trial of Relapse Prevention of Depression in Primary Care
Wayne Katon, MD;
Carolyn Rutter, PhD;
Evette J. Ludman, PhD;
Michael Von Korff, ScD;
Elizabeth Lin, MD, MPH;
Greg Simon, MD, MPH;
Terry Bush, PhD;
Ed Walker, MD;
Jürgen Unützer, MD, MPH
Arch Gen Psychiatry. 2001;58:241-247.
ABSTRACT
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Background Despite high rates of relapse and recurrence, few primary care patients
with recurrent or chronic depression are receiving continuation and maintenance-phase
treatment. We hypothesized that a relapse prevention intervention would improve
adherence to antidepressant medication and improve depression outcomes in
high-risk patients compared with usual primary care.
Methods Three hundred eighty-six patients with recurrent major depression or
dysthymia who had largely recovered after 8 weeks of antidepressant treatment
by their primary care physicians were randomized to a relapse prevention program
(n = 194) or usual primary care (n = 192). Patients in the intervention group
received 2 primary care visits with a depression specialist and 3 telephone
visits over a 1-year period aimed at enhancing adherence to antidepressant
medication, recognition of prodromal symptoms, monitoring of symptoms, and
development of a written relapse prevention plan. Follow-up assessments were
completed at 3, 6, 9, and 12 months by a telephone survey team blinded to
randomization status.
Results Those in the intervention group had significantly greater adherence
to adequate dosage of antidepressant medication for 90 days or more within
the first and second 6-month periods and were significantly more likely to
refill medication prescriptions during the 12-month follow-up compared with
usual care controls. Intervention patients had significantly fewer depressive
symptoms, but not fewer episodes of relapse/recurrence over the 12-month follow-up
period.
Conclusions A relapse prevention program targeted to primary care patients with
a high risk of relapse/recurrence who had largely recovered after antidepressant
treatment significantly improved antidepressant adherence and depressive symptom
outcomes.
INTRODUCTION
OVER THE LAST decade clinicians and researchers have recognized that
for most patients major depression will have either a relapsing/remitting
or chronic course much like asthma. Researchers have found that the risk of
relapse after having experienced 1 episode of major depression is 50% and
after 2 is 80%.1, 2 Moreover, about
10% to 20% of patients have a chronic depressive course.3
The recognition of the high degree of relapse and/or chronicity in many patients
has led to specialty-based trials of continuation and maintenance antidepressant
medication.
Continuation of antidepressant medication for 4 to 6 months after acute-phase
treatment has been shown to significantly decrease relapse rates.4 Efficacy trials testing maintenance antidepressant
medication vs placebo for a 2-year period in patients with recurrent depression
have found that active treatment markedly decreases risks of recurrence.5, 6 Based on these continuation and maintenance
trials, a course of 6 to 9 months of antidepressant medication is recommended
for all patients with major depression and maintenance treatment of 2 years
or more has been recommended for patients with significant residual symptoms
and a history of chronic disorder and those with recurrent depressive episodes.4, 7 Despite these recommendations, few
primary care patients with major depression continue to receive antidepressants
for 6 to 9 months and even fewer patients with a high risk of relapse receive
maintenance treatment.8, 9
The long-term efficacy trials that have been completed involved intensive
follow-up of highly selected specialty care patients. For instance, most maintenance
studies have treated patients with acute-phase antidepressant medication with
weekly follow-up over 12 weeks. The 70% who respond to acute-phase antidepressant
treatment are then monitored with at least monthly follow-up for 3 to 6 months.
Those who remain in full remission are then randomized to maintenance antidepressant
treatment vs placebo and then followed up monthly for 2 years. This intensity
of treatment is in marked contrast with primary care, in which the mean number
of visits for depression treatment is approximately 4 to 6 visits per year.10, 11 There is a need to develop effectiveness
models of continuation and maintenance treatment of primary care patients
with recurrent or chronic depression that are less restrictive in selecting
patients and less time-intensive and costly.
This study will address the following questions in a more representative
sample of high-risk primary care patients with recurrent major depression
or chronic depression who were randomized to a low-intensity relapse prevention
program vs usual primary care: (1) Is the relapse prevention program associated
with improved adherence to antidepressant medication and less depressive symptoms
over a 1-year period? (2) Is the relapse program associated with less relapse/recurrence
of major depressive episodes over a 1-year period?
SUBJECTS AND METHODS
SUBJECTS
The settings for this study were 4 large primary care clinics of Group
Health Cooperative of Puget Sound (GHC), a health maintenance organization
serving more than 400 000 persons in western Washington. The 4 clinics,
with a population of 88 000 enrollees, are staffed by 73 board-certified
family physicians.
Based on automated prescription data, patients between the ages of 18
and 80 years from 1 of 4 primary care clinics who received a new antidepressant
prescription (no prior prescriptions within the last 120 days) from a primary
care physician for the diagnosis of depression or anxiety were eligible for
the study. Five weeks after the prescription, the patients received a letter
from their primary care physician inviting their participation in the study
and informing them that they would receive a telephone call from the study
team.
At 8 weeks, patients received a call from the telephone survey team
who sought verbal informed consent for a 15-minute telephone-screening interview
to determine study eligibility. The goal was to identify patients who recovered
but were at high risk for relapse (the target population of this study) as
well as those at high risk for persistent depression (the target population
of a separate study12). The first-stage screen
included the depression section of the telephone Structured Clinical Interview
for DSM-III-R (SCID),13
which has high reliability with the in-person SCID ( = 0.73).14 Selection criteria for the second-stage interview
were either having a high epidemiologic risk of relapse (see criteria below)
or 4 or more residual major depressive symptoms.
Exclusion criteria included having a screening score of 2 or more on
the CAGE (C Have you ever felt the need to cut down on your drinking? A Have
you ever felt annoyed by criticism of your drinking? G Have you ever felt guilty about
your drinking? E Have you ever taken a drink [eye-opener] first thing in the morning?) alcohol screening
questionnaire,15 being pregnant or currently
nursing, planning to disenroll from GHC within the next 12 months, currently
seeing a psychiatrist, having limited command of English, and recently using
lithium or antipsychotic medication.
Eligible and willing patients were informed that a research assistant
would telephone them within the next week to arrange a second interview and
explain the study in more detail. This interview included the 20-item Hopkins
Symptom Checklist (SCL-20) depression scale.16
Inclusion criteria for the relapse prevention study obtained during the baseline
interview included patients with fewer than 4 DSM-IV
major depressive symptoms and a history of 3 or more episodes of major depression
or dysthymia or 4 residual depressive symptoms but with a mean SCL-20 depression
score of less than 1.0 and a history of major depression/dysthymia. After
baseline interview, patients who met criteria for the relapse prevention study
were provided a written informed consent statement that described randomization
to a program of enhanced care of depression or to continued usual primary
care.
The recruitment procedure and the study protocol were approved by the
institutional review boards of the University of Washington and GHC. Patients
were randomized to the relapse prevention intervention (I) vs usual care (UC)
in blocks of 8. Within each block, the randomization sequence was computer-generated.
A total of 2699 letters were mailed to eligible patients in the 4 GHC
primary care clinics. A total of 2051 (76.1%) completed the screening interview:
336 (12.4%) refused the interview, 171 (6.3%) were found to be ineligible,
and 141 (5.2%) were unable to be contacted. Patients agreeing to be interviewed
did not differ from patients refusing the interview on age (47.8 ±
14.9 compared with 47.6 ± 15.7 [t2385 = -0.20]) or sex (72.3% female in both groups [ 21 = 0.0]).
Of the 2051 patients completing the screening interview, 702 (34.2%)
were eligible for the baseline interview for the relapse prevention study
based on first-stage screening. A total of 1349 (66.3%) were not eligible
for the relapse prevention study; 264 (12.9%) were ineligible because of having
4 or more major depressive symptoms on the SCID depression module and an SCL-20
depression score greater than 1.0, 766 (37.3%) had or 0 to 3 symptoms but
no risk factors for relapse, and 319 patients (15.5%) were ineligible for
other reasons.
Of the 702 eligible for the baseline interview for the relapse prevention
study, 24 (3.4%) were unable to be contacted, 56 (8.0%) refused the baseline
interview, 87 (12.4%) were ineligible because of lack of time to attend potential
I visits, and 55 (7.9%) were ineligible for other reasons. Baseline interviews
were completed with 480 patients (68.4%). Patients refusing baseline interviews
or who were ineligible for participation in the trial did not differ on age,
sex, medical comorbidity, number of current depressive symptoms on the SCID,
or prior mental health utilization compared with those successfully randomized.
Of the 480 patients completing baseline interviews for the relapse study,
386 patients (80.4%) were successfully randomized to the relapse prevention
study; 69 patients (14.4%) accepted randomization to a separate persistence
study12 based on having 4 DSM-IV symptoms and an SCL-20 depression score greater than 1.0; and
25 (5.2%) refused randomization.
USUAL CARE
In most cases, UC for depression provided by GHC family physicians in
the 4 primary care clinics involved prescription of an antidepressant medication,
2 to 4 visits over the first 6 months of treatment, and an option to refer
to GHC mental health services. Both I and UC patients could also self-refer
to a GHC mental health provider.
RELAPSE PREVENTION INTERVENTION
A multifaceted intervention was developed that included patient education,
2 visits with a depression specialist, and telephone monitoring and follow-up.
PATIENT EDUCATION
Before the first study visit, the I patients were provided a book and
videotape developed by the study team entitled, Depression
(Recurrent and Chronic): Self-Care Companion for Better Living17, 18 that was aimed at increasing patient
education and enhancing self-treatment of their depression.
VISITS WITH DEPRESSION SPECIALISTS
They were also scheduled for 2 visits with a depression specialist (one
90-minute initial session and one 60-minute follow-up session) in the primary
care clinic. Three depression prevention specialists (a psychologist, a nurse
practitioner with a master's degree in psychosocial nursing, and a social
worker) received a 60-page training manual19
and participated in 2 half-day training sessions with a psychiatrist (W.K.),
primary care physician (E.L.), and psychologist (E.J.L.).
TELEPHONE MONITORING AND FOLLOW-UP
Three additional telephone visits at 1, 4, and 8.5 months from session
2 with the depression specialist and 4 personalized mailings (2, 6, 10, and
12 months) were scheduled over the following year. The mailed personalized
feedback contained a graph of patients' Beck Depression20
scores over the course of the I program and checklists for patients to send
back to the depression specialist, including early warning signs of depression
and whether they were still adhering to their medication plan. The depression
specialist reviewed monthly automated pharmacy data on antidepressant refills
and alerted the primary care physician and telephoned the patients when mailed
feedback or automated data indicated they were symptomatic and/or had discontinued
medication.
At the initial visit, the depression specialist reviewed the course
of the current depressive episode as well as a complete biopsychosocial history.
The intervention had the following specific self-treatment goals: to improve
long-term adherence to antidepressants, to increase awareness of prodromal
symptoms and the use of self-monitoring strategies to identify recurrence,
and to increase proactive steps, such as early help seeking, in response to
early warning signs. The other goals included increasing the daily use of
depression treatment techniques, such as increasing pleasant activities, exercise,
and socializing, and identifying potential high-risk situations to promote
problem-solving ability, coping, and self-efficacy for managing depression.
The ultimate aim of the intervention was to have each patient complete and
follow a 2-page written personal relapse prevention plan, which was also shared
with his/her primary care provider. Follow-up telephone calls and personalized
mailings were geared toward monitoring progress and adherence to each patient's
plan. Primary care physicians were notified if their patient was in I vs UC
and received intermittent verbal and written consultation about their I patients'
progress.
The self-treatment intervention protocol and goals were designed to
build on general principles of motivational interviewing21, 22
as well as cognitive-behavioral theories of relapse prevention.23
In line with principles of motivational interviewing, depression prevention
specialists helped patients clarify the potential rewards of engaging in self-treatment
behaviors as well as the risks of not doing so, acknowledging patients' personal
choice with respect to changing their behavior.
STUDY MEASURES
Patients' adherence to antidepressant medication and depressive symptoms
were assessed at 3, 6, 9, and 12 months after randomization by a telephone
interviewer blinded to the patients' randomization status. The baseline and
follow-up telephone interviews included the SCL-20 depression items (scored
on a 0-4 scale),15 the dysthymia and current
depression modules of the SCID,12 the NEO Personality
Inventory Neuroticism Scale,24 and the Longitudinal
Interval Follow-up Evaluation25 to measure
incidence and duration of episodes within each 3-month block of time. The
SCL-20 has been found to have high reliability and validity in multiple studies
with medical patients and to be sensitive to change in depressed primary care
patients.16 A score of 1.72 on the SCL-20 has
been shown to have the highest positive predictive value for major depression.26
Based on computerized automated data from prescription refills, patients
were rated as adherent at the 3-, 6-, 9-, and 12-month follow-up periods as
well as whether they received adequate dosage of antidepressant medication
for 90 days or more during the 1-year period. The lowest dosages in the ranges
recommended in the Agency for Health Care Policy and Research guidelines27 and in guidelines developed for newer agents28 were used to define a minimum dosage standard. The
ranges of therapeutic dosages in Agency for Health Care Policy and Research
guidelines were 75 to 300 mg for imipramine, amitriptyline, doxepin, and desipramine;
40 to 200 mg for nortriptyline hydrochloride; 10 to 40 mg for fluoxetine and
paroxetine; 100 to 300 mg for amoxapine, maprotiline, and venlafaxine; 150
to 500 mg for trazodone; 50 to 200 mg for sertraline and fluvoxamine; and
30 to 60 mg for mirtazapine.
Medical comorbidity was assessed using the health maintenance organization's
computerized prescription refill records. The Chronic Disease Score is a measure
of chronic medical illness derived from the patient's use of prescription
medications over a 6-month period that has been found to have a high correlation
with physician ratings of severity of medical illness.29
Telephone and in-person baseline interviewers received 3 to 6 hours
of training before the first interview, plus individual practice sessions
with the supervisor (a master's-level clinician with extensive training in
structured interviews) lasting 3 hours. Each interviewer was tested against
either the supervisor or project director during practice interviews until
agreement exceeded 90% for each interview question.
STATISTICAL METHODS
Depression Outcomes
Statistical analyses focus on the intervention's effect on depression
severity (SCL-20) during the year after baseline assessment, with secondary
analyses examining effects on episodes of major depression. We used regression
models to estimate the effect of treatment while adjusting for patient characteristics
that we believe are related to both depression severity and the probability
of relapse: age, sex, physical comorbidity (Chronic Disease Score), neuroticism
(NEO), and baseline SCL-20. These models accounted for correlation in longitudinal
assessments across the 4 follow-up times using an unstructured correlation
matrix, with estimation carried out using generalized estimating equations.
Linear regression models implemented by SAS PROC MIXED30, 31
were used to model semicontinuous SCL-20 scores. Logistic regression models
implemented by the SAS GLIMMIX macro32 were
used to model major depression. Regression models include an overall effect
of intervention, a linear time effect, and an interaction between time and
intervention. The main effect of intervention estimates differences at 3 months,
and the interaction between intervention and time estimates differences in
change over time. If we found no evidence of a group x time interaction,
we dropped this effect, testing for a sustained effect of intervention during
follow-up. If we found no evidence of a time effect, we dropped this, testing
for overall (average) differences between randomization groups over the follow-up
period.
Differential Dropout and Treatment of Missing Data
We found differences in follow-up rates for I and UC groups, with follow-up
more likely among I than UC patients. Across all interviews, 10.1% of follow-up
interviews were missing, 6.2% in the I group and 12.5% in the control group.
The percentage of missing interviews increased over the follow-up period,
and at the 12-month follow-up 10.3% of the I group and 20.8% of the UC group
missed interviews. We assumed that missingness depended only on observed outcomes
and used observed data to account for differential dropout via multiple imputation
with propensity-score matching of missing to observed cases.33, 34
We adjusted only for unit-nonresponse (ie, missing interviews) because there
was very little item nonresponse. Propensity scores were estimated separately
for each time point using logistic regression models with completely observed
baseline covariates (randomization group, married [yes/no], lives alone, single
parent [yes/no], college graduate, panic attack in the last 2 weeks, self-rated
health, self-reported high stress, satisfaction with health maintenance organization
care, physical comorbidity [Chronic Disease Score], and baseline SCL-20).
Propensity score matching was stratified by I group, quartile of propensity
score, and interview. We imputed data for entire cases but imputed data separately
for each missed follow-up time, thus incorporating the cross-sectional correlation
of outcome and covariate data, but ignoring between-time correlation of outcomes.
Probabilities of nonresponse based on this set of variables achieved good
prediction of missingness at each follow-up. For example, at the 12-month
follow-up the estimated probability of nonresponse exceeded 25% for 13% of
subjects actually interviewed vs 40% of subjects who were missing.
Process Outcomes
We examined 3 types of process outcomes: visits, antidepressant refills,
and antidepressant adequacy of dosage. Between-group differences in process
outcomes were estimated using regression models that adjusted for patient
age, sex, physical comorbidity, baseline neuroticism, and baseline SCL-20.
Visit data were summarized for the 12 months after randomization. Mental health
specialty visits were dichotomized as any/none because few subjects made more
than 1 visit. Refill rates (any refill vs none) were summarized quarterly
for the year after randomization. Antidepressant adequacy for 90 days or more
(yes vs no) was summarized in the two 6-month periods after randomization.
Linear regression was used to test for between-group differences in the number
of visits. Logistic regression was used to test for between-group differences
in mental health visits, antidepressant refills, and treatment adequacy. Models
for antidepressant refills and treatment adequacy were estimated via generalized
estimating equations, as described above, to account for repeated measures
within subjects. Analysis of process outcomes did not require application
of imputation methods because these outcomes were based on automated data
so that data were missing for only a few patients (n = 9) who disenrolled
from the health maintenance organization.
RESULTS
PATIENT CHARACTERISTICS AND PARTICIPATION IN THE INTERVENTION PROGRAM
The only significant difference between I and control patients on any
demographic or clinical variable (Table
1) was that a higher percentage of UC patients had a major depressive
episode within the last 2 years compared with I patients (21 = 5.1, P = .02). High rates of patients with
recurrent depression and dysthymia were seen, reflecting the selection of
these patients into the relapse prevention trial.
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Table 1. Demographic and Clinical Characteristics of Depressed Patients*
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Of the 194 patients randomized to the I arm, 188 (96.9%) made at least
1 visit to the depression specialist and 181 (93.3%) attended both visits.
Patients in the I arm of the study had a mean of 1.9 ± 0.39 visits
and a mean of 3.4 ± 0.12 follow-up telephone calls with the depression
specialist, with 155 (79.9%) completing all of the 3 telephone call follow-ups.
Thirteen patients (6.7%) had a consultation with a study psychiatrist because
of having persistent depressive symptoms.
HEALTH CARE VISITS EXCLUDING DEPRESSION SPECIALIST VISITS
During the year after randomization, UC patients made significantly
more primary care visits for reasons other than depression (UC: 3.94 vs I:
3.13; mean adjusted difference, 0.90; 95% CI, 0.18-1.63; P = .02), and made fewer primary care visits for depression (UC: 1.15
vs I: 1.46; mean adjusted difference, -0.31; 95% CI, -0.61 to
0.00); P = .05). We found no difference in the percentage
of patients who made at least 1 visit to a nonstudy mental health specialist
(UC: 24.2% vs I: 31.9%; adjusted odds ratio for I: control, 0.69; 95% CI,
0.43-1.09; P = .11).
MEDICATION ADHERENCE
As shown in Table 2, I patients
were significantly more likely to refill antidepressant medication prescriptions
than UC patients during the 1-year follow-up (adjusted odds ratio for I: control,
1.91; 95% CI, 1.37-2.65; P<.001). Intervention
patients were also more likely to receive adequate dosage of antidepressant
treatment compared with UC patients during the 1-year follow-up period (adjusted
odds ratio for I: control, 2.08; 95% CI, 1.41-3.06; P<.001).
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Table 2. Intervention vs Usual Care: Observed Percentage of Patients
Who Filled Antidepressant Prescriptions at Follow-up
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DEPRESSIVE SYMPTOM OUTCOMES
As shown in Figure 1, the
UC group had higher unadjusted average SCL-20 scores at follow-up than the
I group. Based on regression models, we found no evidence of an I x
time interaction, and therefore this term was not included in final models
(Table 3). There was, however,
evidence of change in average SCL-20 scores over time (P = .02), with a modest but sustained I effect (P = .04). Across follow-up times, I patients had SCL-20 scores that
were, on average, 0.08 points below UC patients. There were no differences
in patient SCL-20 outcomes across the 3 depression specialists at 6, 9, or
12 months; at 3 months, there was a significant difference in patient depression
outcome between 2 of the depression specialists.
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Figure 1. Observed and estimated average
Hopkins 20-Item Symptom Checklist (SCL-20) scores in intervention (N = 194)
vs usual care patients (N = 192) over time. Estimated SCL-20 scores are based
on fitted values for an average group of subjects: aged 45.9 years, 26.2%
male, baseline Chronic Disease Score of $1030, baseline Neuroticism score
of 3.034, and baseline SCL-20 of 0.84.
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Table 3. Intervention vs Usual Care Outcomes on the 20-Item Hopkins
Symptom Checklist (SCL) Depression Items and Percentage With Major Depression*
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RELAPSE/RECURRENCE
Figure 2 shows the prevalence
of patients who either had a current episode of depression at the 3-, 6-,
9-, and 12-month follow-up or who did not meet criteria for a current episode
based on the SCID, but had an interval episode based on the Longitudinal Interval
Follow-up Evaluation. We found no evidence of a time x I or an overall
time effect, so these terms were dropped from the model. The final model showed
no differences in the overall odds of an episode of major depression during
the follow-up period for I vs control patients. Overall rates of relapse were
similar for I (35%) and UC groups (34.6%).
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Figure 2. Percentage of intervention vs
control patients reporting a current or interval episode of major depression
at follow-up (results based on 25 imputed data sets).
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COMMENT
The relapse prevention program was associated with a significant improvement
in adherence to antidepressants as well as a significant decrease in depressive
symptoms but not relapse/recurrence over time compared with usual primary
care. A more intensive relapse prevention program may be needed to decrease
relapse rates. The more robust differences in relapse rates reported in specialty
continuation and maintenance trials may be because of patients being randomized
to continued antidepressant care vs placebo. For instance, at each follow-up
time point between 49% and 65% of UC patients had evidence of a refill of
antidepressant medications, a much higher rate than anticipated in planning
this trial. Moreover, patients in specialty maintenance trials are highly
selected because of being required to be in remission for 3 to 6 months and
to receive monthly visits, which probably explains the higher rate of medication
adherence in specialty intervention patients. We selected patients who were
often still symptomatic after 8 weeks of primary care treatment as evidenced
by SCID symptoms and a mean baseline SCL-20 score of 0.83 to 0.84 (an SCL-20
score of <0.5 approximates a Hamilton-Depression remission score of <8).
Patients in psychiatry trials also may have higher relapse rates (often as
high as 50% to 80% over a 1- to 2-year period)5, 6, 7
compared with the relapse rate of 35% to 36% found in this trial.
The higher than anticipated rates of longitudinal use of antidepressant
medication in UC patients may reflect the fact that these patients had generally
experienced multiple episodes of depression or chronic depression that may
have convinced them and their primary care physicians about the importance
of long-term treatment. It also may be because of the modern era, where almost
all patients are prescribed serotonin reuptake inhibitors, which have less
adverse effects than previously used antidepressant agents, making patients
and physicians less reticent about long-term medication use.
The relapse prevention program is a low-intensity intervention that
included enhanced patient education, 2 visits with the depression specialists,
3 to 4 telephone calls, and symptom monitoring over the 12-month period.19 The program blended seamlessly into busy primary
care practices and was well accepted by a more representative sample of patients
than those studied previously in specialty maintenance trials. More than 90%
of patients adhered to the 2 in-person visits with the depression clinical
specialist and almost 80% received the 3 scheduled telephone visits. Depression
specialist backgrounds were diverse (master's-level social worker, psychiatric
nurse, and doctoral-level psychologist), with no important clinician difference
in outcomes. Weekly supervision with a psychiatrist to review patient history,
medication adherence, adverse effects, and clinical outcomes may have helped
standardize antidepressant medication treatment regimens.
Primary care systems need to begin to adapt services to improve care
of patients with recurrent and chronic medical and psychiatric illness. Primary
care has been better organized historically to treat acute illness and systematic
changes will need to occur to improve chronic illness management.35 These changes would ideally include patient education
and activation, monitoring of adherence and outcomes of treatment, and referral
of selected treatment-resistant patients.35, 36
The relapse prevention program tested here sought to extend research on the
"collaborative care model"11, 36
from acute-phase treatment to improving continuation and maintenance phases
of treatment.
Limitations of this research included the sample studied and our ability
to accurately adjust our findings for missing data. We relied on imputation
models that assumed that we could reasonably predict nonresponse using baseline
data. Although these assumptions are untestable, we believe they are reasonable
and that our results offer a more realistic estimate of intervention effects
than analyses that completely ignore missing data. Our sample included patients
from one region of the country with high rates of employment and 1 or more
years of college who were members of a single, large organized system of health
care with only family practice physicians. The results in this sample may
not generalize to more diverse racial and ethnic groups, patients from lower
socioeconomic status, and other types of primary care settings. However, effectiveness
trials have shown successful adaptation of the collaborative model of care
to patients with diverse racial and socioeconomic backgrounds, and to diverse
practice settings.37
AUTHOR INFORMATION
Accepted for publication October 11, 2000.
Supported by grants MH 4-1739 and MH 016473 from the National Institute
of Mental Health Services Division, Bethesda, Md (Dr Katon).
From the Department of Psychiatry and Behavioral Sciences, University
of Washington Medical School, Seattle (Drs Katon and Walker); Center for Health
Studies, Group Health Cooperative of Puget Sound, Seattle, Wash (Drs Rutter,
Ludman, Von Korff, Lin, Simon, and Bush); and the Department of Psychiatric
and Behavioral Sciences, University of California Los Angeles, UCLA School
of Medicine (Dr Unützer).
Corresponding author: Wayne Katon, MD, Department of Psychiatry,
University of Washington School of Medicine, Box 35-6560, Seattle, WA 98195
(e-mail: wkaton{at}u.washington.edu).
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