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The initial projects, conducted primarily between 1995 and 1999, informed the next phase of the MacArthur Initiative. In 2000, the initiative launched development of the Three Component Model and its test in the RESPECT-Depression Trial. RESPECT-Depression stands for Re-Engineering System in Primary Care Treatment of Depression. RESPECT-Depression evaluated the feasibility, effectiveness, and durability of the Three Component Model for depression care. The Three Component Model (3CM™) of depression care drew from current research but emphasized applicability in a wide variety of primary care settings. In 3CM™, a prepared primary care clinician, centralized care management, and cooperating mental health professional work together in partnership with the patient using a common set of routines and tools.

RESPECT-Depression used 3CM™ as an intervention compared to usual care. The 3CM™ integrates work by a primary care clinician, a care manager, and a mental health professional, all of whom cooperate with the patient and with each other in providing care.

In implementing 3CM™ in RESPECT-Depression primary care clinicians participated in a one-to-two hour educational program that addressed depression diagnosis, suicide assessment, and the assessment and modification of management strategies to achieve remission. The primary care component of the 3CM™ also includes an office staff in-service thus creating the Prepared Practice ready to provide state of the art depression care.

Patients receiving 3CM™ care also have the support of a trained ‘care manager’ who can provide patients with education about depression, help to overcome barriers to treatment, focus on adherence to treatment, and monitor the patient’s condition. This care management is the second component of the 3CM™. Patients receive a follow-up telephone call from the care manager one week after the initial primary care visit, a monthly call thereafter, and then additional calls as needed until remission is achieved. During these calls, care managers assist patients in overcoming adherence barriers, and support them in self-management activities such as exercise or engaging in social activities. In RESPECT-Depression, most care managers had backgrounds in primary care or mental health nursing. In the clinical trial, care managers received four to eight hours of training, depending on their experience.

Through 3CM™, participating clinicians and care managers have routine access to consulting psychiatrists to assist in depression management issues. In RESPECT-Depression psychiatrists at each institution received one hour of training in the model and then provided supervision to care managers through weekly telephone calls. During these calls, care managers discuss new and follow-up patients and the psychiatrist can suggest changes in management to the clinician. These supports create the enhanced primary care/mental health interface, the third component of 3CM™. Care managers play a key role in facilitating communication between and among the primary care clinician, the patient, and the mental health specialist.

The impact of 3CM™ was tested in RESPECT-Depression through five health care organizations in over 60 practices. Three of the organizations were large medical groups, one was a regional health insurance plan, and another was the behavioral health provider for a statewide Medicaid program. The project design was a randomized controlled trial with evaluation data collected by an independent center at Weill Medical College of Cornell University.

In the trial, primary care clinicians identified 405 patients, age 18 or older who were starting or changing depression treatment and consented to participate. The main outcomes were severity of depression at three and six months, response to treatment (that is at least a 50% reduction in depression scores), and remission of depression. The results demonstrated that at six months, 60% (106 of 177) patients in practices randomized to 3CM™ had responded to treatment compared with 47% (68 of 146) patients in practices randomized to continue usual care. Also at six months, 37% of patients in intervention practices showed remission from depression compared with 27% of patients in usual care practices. 90% of intervention patients rated their depression care as good or excellent at six months compared with 75% of usual care patients. All of these findings were statistically significant.

RESPECT-Depression demonstrated that resources such as quality improvement programs can be used effectively in primary care to implement evidence based management of depression and significantly improve outcomes for patients with depression. British Medical Journal Publication - Sept., 2004

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