This randomized trial demonstrated that indigent IM outpatients who screened positive for depression, but who were not receiving or seeking care for depression, benefited from intervention by resident physicians who were trained with AHRQ depression guidelines.23
Successful treatment of depression in primary care settings appears to require more than guideline education.20
The trial intervention reported here used an education component with a simple screening process, then combined both with a basic protocol, as well as screening nurse assistance to patients for behavioral care. The combination proved superior to screening patients and then allowing them to apprise residents concerning depression during their visit. The improvement demonstrated included depression symptoms as well as the nature and extent of treatment. Intervention group patients’ depression symptoms were significantly lower than usual care patients over the follow-up. Benefits were consistent across different depression symptoms, including those that can reflect the poor financial status of the study patients. Significant differences were not found between the 2 groups on QOL or health care costs, but results were in the direction of higher QOL and lower overall costs. Prior randomized trials regarding depression treatment also did not provide convincing evidence of a cost reduction.19, 34, 46, 47
The attempt to increase communication between the IM clinic and local mental health agency was not successful. Although the screening nurse tried to facilitate access to the agency for the intervention group, only 8 of 33 patients made at least one visit to the agency. For these 8 patients, the majority kept their appointments. Beyond referral and fax to the agency, no further communication was identified between personnel at the clinic and agency. Whether the lack of success was related to distance, cost, inconvenience, or reluctance of patients to seek behavioral care is not known.
Among our sample of depressed clinic patients, many had chronic health problems that resulted in a high hospitalization rate (23%) over the follow-up. More than half of the sample had cardiovascular disease and/or diabetes. The abundance of literature on the association of depression and chronic long-term disease outcomes such as mortality and other complications supports comprehensive depression management in IM clinics.44, 48 – 50
Although the Enhancing Recovery in Coronary Heart Disease (ENRICHD) randomized trial failed to find a significant impact overall on survival with depression treatment, subgroup analysis suggested that SSRIs increase survival.48
Of the IM clinic patients screened, 45% were positive for depression. In this clinic, 80% of the positive screen patients were already being treated for depression. Other comparable clinics may not have as high a percentage of diagnosed or treated patients with depression. Educating residents in depression guidelines might have made the percentage already treated higher than was found in the pilot to this study (50% of positives were being treated), and therefore the yield of screening might be higher in other clinics. The high prevalence, the disease burden of depressed patients, and the successful trial clearly justified screening and treatment. The experience suggested, however, that behavioral care should be better integrated into IM care for the indigent. This model with a limited attempt to better integrate the internal medicine clinic and local public mental health agency, both serving the indigent, was unsuccessful. System change might be required. Meaningful change might be accomplished by setting up a mental health and social support on-site clinic with local public mental health agency providers immediately available. Another possibility would be instituting a collaborative management model with greater hospital resource provisions. The financial pressures on Medicaid and academic medical centers makes this possibility remote at the present time.
This study has limitations. Explicit referral to the mental health agency in the intervention group may have been compromised by the distance between the clinic and agency and the difficulties of transportation in the population studied. Furthermore, the lack of formal coordination between the IM clinic and agency may have made successful referral and follow-up difficult. The initial pilot study increased the number of patients screened and treated for depression, thereby decreasing the number of potential enrollees from the IM clinic. In this regard, the number lost to follow-up was low. Because of the large variability of costs and the small estimated effect size, this study had low power to detect differences in costs. It also had insufficient power to find a significant impact on QOL, but the effect size was larger here. Finally, the study does not allow separation of the effects of the main components of the intervention, especially because the screening, nurse assistance, and the standardized protocol were tightly linked. The number of “usual” patients who told their resident about a positive depression screen was not available, but it was likely very low given the low prevalence of depression treatment in the usual care controls. It appears that follow-up with behavioral therapy will require more personnel and financial support than is presently available.