In primary care the implementation of an organised programme of care monitoring, follow up by telephone, feedback to doctors, and practice support by a care manager had no effect on number of follow up visits of patients with depression but led to significant improvements in the intensity of antidepressant treatment and in clinical outcomes. Incremental costs for depression treatment (including costs of the intervention) were around $80 (£50) per patient. A programme limited to monitoring and feedback using available computerised data had no significant effect on treatment received or patient outcomes.
Our results contrast with previous research showing that feedback of computerised data can improve the quality of ambulatory care,22
increase compliance with screening guidelines,10,11
and improve laboratory monitoring.11
We propose two explanations. Firstly, feedback arrived separately from patient visits when implementation of reminder suggestions would have required active outreach. Secondly, automated reminders may be sufficient to influence one time decisions but insufficient to support the regular follow up and treatment adjustments necessary for management of chronic illness.
Our findings are consistent with previous studies showing the benefits of follow up by telephone in the management of chronic illness12,13
and change in health behaviour.14
Follow up by telephone initiated by a doctor (“active”) may be a cost effective substitute for patients making visits to clinics. Follow up by telephone can reduce the time costs of treatment (travel and waiting time) and improve access for patients with limitations to mobility and those living in rural areas.
We cannot be certain whether the benefits of the care management programme are attributable to more intensive pharmacotherapy, more appropriate follow up care, or the non-specific effects of supportive contact with the care manager. Our findings might not be generalised to primary care doctors with different levels of knowledge, motivation, or experience in the management of depression. Our study was also limited to patients with new antidepressant prescriptions, excluding those who were unrecognised, untreated, or not given an initial prescription.
Our care management intervention seems to lie between more intensive depression interventions that have shown robust clinical effects3,4,6,7
and less intensive interventions (such as screening programmes not linked to structured intervention23
and physician training programmes24
) that have proved ineffective. Organised and consistent follow up care seems necessary to improve the management of depression, but modest interventions can yield significant benefits.
We believe that these results support the implementation of organised monitoring and care management programmes to improve the management of depression. Similar programmes might prove valuable in the management of other common chronic illnesses. Such programmes, however, are only one component of a population based approach to treatment of depression. When persistent depression results from inadequate monitoring and follow up, more organised treatment significantly improves outcomes. When depression persists despite optimal primary care management, specialty consultation or referral may be needed. Achieving good clinical outcomes may prove neither simple nor inexpensive for patients with more severe or complicated depression.
What is already known on this topic
Management of depression in primary care often falls short of evidence based recommendations
Several randomised trials have shown that organised treatment programmes significantly improve quality of depression treatment and patient outcomes, but these programmes typically require several visits to specialists and additional expenditures of $500 (£312.50) or more per patient
What this study adds
A programme of two telephone monitoring contacts (eight and 16 weeks after initiation of depression treatment) followed by feedback to the doctor and care management by telephone when required showed significant benefits in the treatment of depression in primary care
In contrast, a programme limited to feedback of available computerised information (number of visits and prescriptions) had no effect