Managing depression as a chronic disease: a randomised trial of ongoing treatment in primary care

doi:10.1136/bmj.325.7370.934

BMJ 2002;325:934 ( 26 October )

Primary care

Managing depression as a chronic disease: a randomised trial of ongoing treatment in primary care

Kathryn Rost, professor, ^a Paul Nutting, director of research, ^b Jeffrey L Smith, project director, ^a Carl E Elliott, statistical analyst, ^a Miriam Dickinson, biostatistician. ^a

^a Center for Studies in Family Medicine, Department of Family Medicine, University of Colorado Health Sciences Center, UCHSC at Fitzsimons, PO Box 6508 Mail Stop F496, Aurora, CO 80045-0508, USA, ^b Center for Research Strategies, 225 East 16th Avenue, Suite 1150, Denver, CO 80203, USA

Correspondence to: Kathryn Rost Kathryn.Rost{at}UCHSC.edu

Objectives: To evaluate the long term effect of ongoingintervention to improve treatment of depression in primarycare.
Design: Randomised controlledtrial.
Setting: Twelve primary care practices across the UnitedStates.
Participants: 211 adults beginning a new treatment episodefor major depression; 94% of patients assigned to ongoing interventionparticipated.
Intervention: Practices assigned to ongoing interventionencouraged participating patients to engage in active treatment,using practice nurses to provide care management over 24months.
Main outcome measures: Patients' report of remission andfunctioning.
Results: Ongoing intervention significantly improvedboth symptoms and functioning at 24 months, increasing remissionby 33 percentage points (95% confidence interval 7% to 46%), improvingemotional functioning by 24 points (11 to 38) and physical functioningby 17 points (6 to 28). By 24 months, 74% of patients in enhancedcare reported remission, with emotional functioning exceeding90% of population norms and physical functioning approaching 75%of populationnorms.
Conclusions: Ongoing intervention increased remission ratesand improved indicators of emotional and physical functioning.Studies are needed to compare the cost effectiveness of ongoingdepression management with other chronic disease treatment routinelyundertaken by primarycare.

What is already known on this topic
Most trials of depression treatment incorporate principles of chronic disease management into the interventions tested in recognition of the chronicity of the condition

Research shows that brief implementation of these interventions has little or no impact on depressive symptoms and functioning a year after the intervention ends

What this study adds
Ongoing efforts to improve depression management yield ongoing benefits for patients starting a new treatment episode for depression

These results encourage health services to make a small but continuing investment in their depressed populations to reduce the substantial disability they bear, matching the duration of the intervention to the chronicity of the condition

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