A cluster randomized trial comparing two interventions to improve treatment of major depression in primary care
Utrecht University, Utrecht, Utrecht, Netherlands Psychological Medicine
(Impact Factor: 5.94).
02/2005; 35(1). DOI: 10.1017/S003329170400296X
Many patients with major depression are non-adherent to antidepressant medication and do not receive care according to current guidelines. There is increasing evidence that treatment of depression in primary care can be improved. Comparison between effective interventions may help to establish the active ingredients of such interventions.
In a randomized trial two interventions to improve treatment of major depression in primary care were compared (1) a depression care programme, targeting general practitioners (GPs), patients, and systematic follow-up, and (2) a systematic follow-up programme. Thirty GPs were randomized and 211 primary-care patients with current major depression were included. All patients were prescribed a selective serotonin reuptake inhibitor. Outcome measures included adherence to antidepressant medication, and depression outcome.
No significant differences in adherence rates and treatment outcome measures were demonstrated between interventions at week 10 or week 26. Adherence rates were high and treatment outcome was favourable.
The depression care programme was not superior to the systematic follow-up programme. Systematic follow-up in depression treatment in primary care seems to be an intervention per se, having the potential to improve adherence and treatment outcome.
Available from: Martino Belvederi Murri
- "Firstly, the disagreement on the definition of usual care: although it was mainly defined as the PCP's ordinary care without additional training, some studies involved additional – such as PCPs' training  or notifications on their patients' status  – on both the collaborative care arm and the usual care arm, so their effects potentially cancelled out. In only one study , usual care was enhanced with a planned follow-up. Secondly, we acknowledge that in some countries, such as the Netherlands, the specialized mental health care plays an important role that may support the usual care practice. "
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This is a systematic review and meta-analysis of randomized controlled trials (RCTs) investigating the effectiveness of collaborative care compared to Primary Care Physician's (PCP's) usual care in the treatment of depression, focusing on European countries.
A systematic review of English and non-English articles, from inception to March 2014, was performed using database PubMed, British Nursing Index and Archive, Ovid Medline (R), PsychINFO, Books@Ovid, PsycARTICLES Full Text, EMBASE Classic+Embase, DARE (Database of Abstract of Reviews of Effectiveness) and the Cochrane Library electronic database. Search term included depression, collaborative care, physician family and allied health professional. RCTs comparing collaborative care to usual care for depression in primary care were included. Titles and abstracts were independently examined by two reviewers, who extracted from the included trials information on participants' characteristics, type of intervention, features of collaborative care and type of outcome measure.
The 17 papers included, regarding 15 RCTs, involved 3240 participants. Primary analyses showed that collaborative care models were associated with greater improvement in depression outcomes in the short term, within 3 months (standardized mean difference (SMD) -0.19, 95% CI=-0.33; -0.05; p=0.006), medium term, between 4 and 11 months (SMD -0.24, 95% CI=-0.39; -0.09; p=0.001) and medium-long term, from 12 months and over (SMD -0.21, 95% CI=-0.37; -0.04; p=0.01), compared to usual care.
The present review, specifically focusing on European countries, shows that collaborative care is more effective than treatment as usual in improving depression outcomes.
Available from: A.M. Van Dulmen
- "The few observational studies that have been performed before indicate that good medication use and patients' experience with taking medication are only discussed in a minority of regular healthcare visits  . But if patients do meet a well-communicating provider, their adherence appears to improve substantially  . This underlines the need to also take the provider–patient relationship into account in future adherence studies. "
Available from: Louise Howard
- "Direct evidence for the optimum frequency of monitoring of patients is lacking but structured interventions, including systematic follow-up, improve treatment adherence and outcome (see Evidence section 1.4). A meta-analysis of 41 studies that reported weekly HDRS scores found that the response to placebo was enhanced if there were a greater number of follow up visits (Posternak and Zimmerman, 2007b) and a primary care study found that systematic follow-up was as effective as a more intensive depression care programme (Vergouwen, et al., 2005). The risk of suicide attempts during treatment is highest in the first few weeks (Jick, et al., 2004; Simon, et al., 2006b; Simon and Savarino, 2007) and the need to monitor this risk together with side effects and adherence to treatment indicate that weekly monitoring is advisable in the first phase of treatment . "
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ABSTRACT: A revision of the 2000 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in May 2006. Key areas in treating depression were reviewed, and the strength of evidence and clinical implications were considered. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is provided, which identifies the quality of evidence to inform the recommendations, the strength of which are based on the level of evidence. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse, and stopping treatment.
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