Search tips
Search criteria 


Logo of bmjThe BMJ
BMJ. 2001 October 27; 323(7319): 948–949.
PMCID: PMC1121496

Improving outcomes in depression

The whole process of care needs to be enhanced
Michael Von Korff, senior investigator
Center for Health Studies, Group Health Cooperative, Seattle, WA 98101, USA (gro.chg@m.ffroknoV)
David Goldberg, professor emeritus

Around 450 million people worldwide have mental or psychosocial problems, but most of those who turn to health services for help will not be correctly diagnosed or will not get the right treatment.1 Even those whose problems are recognised may not receive adequate care. In a World Health Organization study of psychological disorders in general health care carried out in 14 countries around the world patients with major depression were as likely to be treated with sedatives as with antidepressants, although antidepressants were associated with more favourable outcomes at three month follow up. This benefit had dissipated by follow up at 12 months; but patients had only been taking drug treatment for a mean of 11 weeks, with a quarter of them doing so for less than a month.2 About two thirds of patients whose illnesses were recognised and treated with drugs still had a diagnosis of mental illness at follow up one year later, and in nearly a half the diagnosis was still major depression. Indeed, there are no observational studies of routine care for patients with major depression in the United Kingdom or in the United States that have found most patients to be receiving care consistent with evidence based guidelines.

Improving outcomes for patients with major depression is not as simple as prescribing a new treatment: the whole process of care needs to be enhanced. This requires changes in the organisation and function of healthcare teams, like those already being used to improve outcomes in other chronic diseases.3 Responsibility for active follow up should be taken by a case manager (for example, a practice nurse); adherence to treatment and patient outcomes should be monitored; treatment plans should be adjusted when patients do not improve; and the case manager and primary care physician should be able to consult and refer to a psychiatrist when necessary.4,5

Change is hard work for overtaxed healthcare teams, and many might be tempted to adopt quality improvement strategies that are quick and easy. Such strategies do not usually work, however, as single initiatives. Ineffective interventions include distribution of guidelines;6 education for doctors and nurses that does not increase their skills or change how the healthcare team works; feedback reports on indicators of quality of care; and stand alone screening programmes. Each of these steps might be useful as part of a comprehensive programme to change the management of patients with major depression, but in isolation they are largely a waste of time and energy.

Randomised controlled trials reported since 1995, for example those by Schulberg et al 7 and others (see table) have established that enhanced care of major depression can lead to better outcomes than the care that patients with depression usually receive. Moreover, enhanced care improves patients' ability to function,8 and, although it moderately increases the costs of care per case treated, it is more cost effective than usual care.913 What has been learnt from these trials about how care for depressed patients can be more effectively organised and delivered? The table summarises 12 different trials of enhanced care for major depression in primary care settings.

Both effective and ineffective interventions used treatment guidelines, patient education, and screening for depression. The interventions that consistently improved patient outcomes incorporated some form of case management with specialist support. In these trials case management typically comprised taking responsibility for following up patients; determining whether patients were continuing the prescribed treatment as intended; assessing whether depressive symptoms were improving; and taking action when patients were not adhering to guideline based treatment or when they were not showing expected improvement. In many of these experiments, case management services were provided over the telephone at low cost per case treated. Effective interventions typically employed novel and economical approaches to integrating specialist support into the primary care of patients with depression. In some interventions, the psychiatrist supervised the case manager to provide guidance on difficult clinical problems, provided consultation to the treating physician, or saw patients with more difficult problems when necessary to devise an effective treatment plan.

This evidence suggests that efforts to improve the primary care of major depression should focus on low cost case management coupled with fluid and accessible working relationships among the primary care doctor, the case manager, and a mental health specialist. This model allows most patients with depression to access effective treatment in primary care, while the minority needing ongoing specialist care can be identified and referred more reliably.

Enhanced care for people with depression will go a long way towards improving the lives of these patients. But the large gap in the quality of care cannot be closed only by the increased efforts of individual practitioners who are already overburdened. The question now is whether insurers and organisations that provide patient care will act on the scientific evidence to benefit the millions of people worldwide who are afflicted by major depression.

Elements of interventions to improve care of patients with major depression in primary care settings tested in randomised controlled trials: trials with positive versus negative results.

Supplementary Material

[extra: References cited in table]


References cited in the table appear on the BMJ's website


1. World Health Organization. World health report 2001: mental health: new understanding, new hope. Geneva: WHO; 2001.
2. Goldberg DP, Privett M, Ustun B, Simon G, Linden M. The effects of detection and treatment on the outcome of major depression in primary care: A naturalistic study in 15 cities. Br J Gen Pract. 1998;48:1840–1844. [PMC free article] [PubMed]
3. Wagner EH, Austin BT, Von Korff M. Organizing care for patients with chronic illness. Milbank Q. 1996;74:511–544. [PubMed]
4. Katon W, Von Korff M, Lin E, Simon G. Rethinking practitioner roles in chronic illness: the specialist, primary care physician, and the practice nurse. Gen Hosp Psychiatry. 2001;23:138–144. [PubMed]
5. Von Korff M, Tiemens B. Individualized stepped care of chronic illness. West J Med. 2000;172:133–137. [PMC free article] [PubMed]
6. Thompson C, Kinmonth AL, Stevens L, Peveler RC, Stevens A, Ostler KJ, et al. Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomized controlled trial. Lancet. 2000;355:185–191. [PubMed]
7. Schulberg HC, Block MR, Madonia MJ, Scott CP, Rodriguez E, Imber SD, et al. Treating major depression in primary care practice. Eight-month clinical outcomes. Arch Gen Psychiatry. 1996;53:913–919. [PubMed]
8. Ormel H, Von Korff M. Synchrony of change in depression and disability: what next? Arch Gen Psychiatry. 2000;57:381–382. [PubMed]
9. Lave J, Frank R, Schulberg H, Kamlet M. Cost-effectiveness of treatments for major depression in primary care practice. Arch Gen Psychiatry. 1998;55:645–651. [PubMed]
10. Von Korff M, Katon W, Bush T, Lin E, Simon G, Saunders K, et al. Treatment costs, cost offset, and cost-effectivness of collaborative management of depression. Psychosom Med. 1998;60:143–149. [PubMed]
11. Simon G, Manning W, Katzelnick D, Perarson S, Henk H, Helstad C. Cost-effectiveness of systematic depression treatment for high utilizers of general medical care. Arch Gen Psychiatry. 2001;58:181–187. [PubMed]
12. Simon GE, Katon WJ, Von Korff M, Unutzer J, Lin EH, Walker EA, et al. Cost-effectiveness of a collaborative care program for primary care patients with persistent depression. Am J Psychiatry. 2001;158:1638–1644. [PubMed]
13. Schoenbaum M, Unutzer J, Sherbourne C, Duan N, Rubenstein LV, Miranda J, et al. Cost-effectiveness of practice-initiated quality improvement for depression: results of a randomized controlled trial. JAMA. 2001;286:1325–1330. [PubMed]

Articles from The BMJ are provided here courtesy of BMJ Publishing Group