Re-engineering systems for the treatment of depression in primary care: Cluster randomised controlled trial

Objective: To test the effectiveness of an evidence based model for management of depression in primary care with support from quality improvement resources. Design: Cluster randomised controlled trial. Setting: Five healthcare organisations in the United States and 60 affiliated practices. Patients: 405 patients, aged ≥ 18 years, starting or changing treatment for depression. Intervention: Care provided by clinicians, with staff providing telephone support under supervision from a psychiatrist. Main outcome measures: Severity of depression at three and six months (Hopkins symptom checklist-20): response to treatment (≥ 50% decrease in scores) and remission (score of < 0.5). Results: At six months, 60% (106 of 177) of patients in intervention practices had responded to treatment compared with 47% (68 of 146) of patients in usual care practices (P = 0.02). At six months, 37% of intervention patients showed remission compared with 27% for usual care patients (P = 0.014). 90% of intervention patients rated their depression care as good or excellent at six months compared with 75% of usual care patients (P = 0.0003). Conclusion: Resources such as quality improvement programmes can be used effectively in primary care to implement evidence based management of depression and improve outcomes for patients with depression.