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RESEARCH EVIDENCE

Press Release
British Medical Journal Publication - Sept., 2004
British Medical Journal Commentary on RESPECT
Learn more about RESPECT-Depression and the Three Component Model
BMJ STUDY: NEW APPROACH SUBSTANTIALLY IMPROVES QUALITY
OF DEPRESSION TREATMENT IN PRIMARY CARE


Defense Department adapting model for post-war treatment of soldiers, families

Patients treated for depression in primary care centers showed significant improvement and increased satisfaction with care when clinicians employed a quality improvement approach that coordinates modest resources already available at many community practices, according to a study published in the prestigious British Medical Journal.

The clinical trial of the RESPECT-Depression approach – short for “Re-Engineering Systems for the Primary Care Treatment of Depression,” reported that 60 percent of patients responded substantially to the approach within six months, with 90 percent rating their care as good or excellent. The study appears in BMJ’s Sept. 11, 2004 issue. Officials at the Defense Department are so impressed with the results that they are developing a modified model of the approach for use with soldiers returning from war and their families.

“Evidence that depression outcomes can be improved through systematic changes in delivery of care is now compelling,” Michael Von Korff – senior investigator with the Seattle-based Center for Health Studies – wrote in a BMJ commentary accompanying the article. “This study shows that community practices are able to implement and sustain improvements when offered a standardized care management program and adequate support.”

Developed by the MacArthur Initiative on Depression and Primary Care, the RESPECT-Depression approach integrates work by primary care clinicians who manage patients, centralized care managers who provide telephone support, and psychiatrists who supervise the care managers and offer suggestions to clinicians about treatment and management. At each practice, these professionals are trained by internal staff, using materials developed by RESPECT-Depression researchers and customized to each setting by the organizations.

“This is a big step forward for patients, for clinicians, and for insurers,” said Dr. Allen J. Dietrich, professor of community and family medicine at Dartmouth Medical School and co-chair of the MacArthur Initiative. “Other studies have provided guidance on steps to enhance primary care of depression. But this study shows how to translate such actions from the page to routine practice." John W. Williams, Jr., MD, professor of the Department of Medicine at Duke University Medical Center is also co-chair of the Initiative.

Officials with the Initiative are making the RESPECT-Depression materials available at no cost to health care practices that want to adopt it. Those materials can be downloaded from the following web site: www.depression-primarycare.org/clinicians/re_engineering/

A 1998 U.S. Surgeon General’s report on mental health found that two-thirds of people with a diagnosable mental illness do not receive treatment. The report said primary care is an important portal to get people into treatment - especially for those reluctant to access mental health services or who are unaware that they need them. However, few programs nationwide are expressly organized to integrate mental health services and primary care.

A number of studies have found benefits from enhanced care programs, including telephone counselors, in the primary care treatment of depression. However, many health care practices often find those approaches were not feasible without the substantial technical and financial support that researchers provided during clinical trials.

Five health care organizations in the United States – three large medical groups and two insurance plans - and 60 of their affiliated practices took part in the RESPECT-Depression clinical trial between February 2002 and February 2003. Researchers randomly assigned 400 patients diagnosed with depression to treatment using either the RESPECT-Depression approach or to usual care practices.

After six months of treatment, 60% of RESPECT-Depression patients had responded substantially to treatment, compared with 47% in usual care (a 28% increase). Remission rates for RESPECT-Depression patients were 37.3% versus 26.7% for usual care (a 40% increase), and 90% of RESPECT-Depression patients rated their depression care as either good or excellent versus 75% with usual care (a 20% increase).

All five organizations participating in the trial have since taken steps to sustain and expand their use of the approach.

“Thanks to the RESPECT-Depression system, we have made what I believe is a permanent transformation in the way people with depression are cared for in primary care practices in our system,” said Neil Korsen, Research Director with the Maine Medical Center’s Family Practice Residency Program in Portland.

The other organizations participating in the clinical trial were: Intermountain Health Care in Salt Lake City, Utah; Colorado Access in Denver, Colo.; Highmark Blue Cross Blue Shield in Pittsburgh, Pa.; and ProHealth Physicians Group in Bloomfield, Conn. The evaluation center was led by Herbert C. Schulberg, PhD, and was based at Cornell University.

The Defense Department’s Deployment Health Clinical Center, located at Walter Reed Army Medical Center in Washington, D.C., is actively working with the RESPECT-Depression team to develop a modified model of the approach that will help meet the post-war primary care needs of returning soldiers and their families.

"Soldiers returning home from war often struggle with depression, post-traumatic stress disorder, and other problems, and they are often reluctant or unable to seek the care of a specialist,” said Dr. Charles C. Engel, Director of the Center.

“An approach based on the RESPECT-Depression model adapted for the care of these other conditions holds enormous promise,” Engel said. “It could improve early access to needed services and reduce stigma by locating the care in the primary care setting." Dr. Engel is also an Associate Professor and Assistant Chair in the Department of Psychiatry at the Uniformed Services University of the Health Sciences.

The John D. and Catherine T. MacArthur Foundation formed the Initiative on Depression and Primary Care in 1995, charging a group of primary care physicians and mental health experts with helping primary care clinicians take a major step forward in enhancing the quality of depression care they provide.

The World Health Organization has estimated that depression was the fourth highest cause of disability and premature death worldwide in 1990, and will be the second highest cause by 2020.

FACT SHEET
RESPECT-Depression: HOW IT WORKS

The RESPECT-Depression approach 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.

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 the clinical trial, most care managers had backgrounds in primary care or mental health nursing.

Psychiatrists at each institution provide 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.

In the clinical trial, care managers received four to eight hours of training, depending on their experience. Psychiatrists received one hour of training, and 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.

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