Practice-Based Interventions Addressing Concomitant Depression and Chronic Medical Conditions in the Primary Care Setting
Watson L, Amick HR, Gaynes BN, Brownley KA, Thaker S, Viswanathan M, Jonas DE. Practice-Based Interventions Addressing Concomitant Depression and Chronic Medical Conditions in the Primary Care Setting. Comparative Effectiveness Review No. 75. (Prepared by the RTI International–University of North Carolina Evidence-based Practice Center under Contract No. 290-2007-10056-I.) AHRQ Publication No. 12-EHC106-EF. Rockville, MD: Agency for Healthcare Research and Quality. August 2012.
For adults with concomitant depression and chronic medical conditions seen in the primary care setting, to assess the effectiveness of practice-based interventions for improving mental health or medical outcomes.
We searched MEDLINE®, Embase, the Cochrane Library, CINAHL®, and PsycINFO® from inception to December 2011. We identified additional studies from reference lists and technical experts.
Two people independently selected, extracted data from, and rated the quality of relevant trials and systematic reviews. We conducted quantitative analyses for outcomes when feasible and reported all results by medical condition when possible. Two reviewers graded the strength of evidence (SOE) using established criteria.
We included 24 published articles reporting data from 12 studies (9 randomized controlled trials and 3 preplanned subgroup analyses from a tenth trial). Sample sizes ranged from 55 to 1,001, and study duration ranged from 6 to 60 months. Eleven studies were conducted in the United States (1 in Puerto Rico) and 1 in Scotland. All studies characterized their respective intervention as a form of collaborative care compared with usual or enhanced usual care, and generally involved a care manager with physician supervision; we found no studies describing other types of practice-based interventions. Settings of care for included studies, although rarely characterized, included both open and closed systems. All studies specified depression as the targeted mental health condition. Medical conditions included arthritis, cancer, diabetes, heart disease, HIV, and one or more conditions. Our meta-analyses found that intervention recipients achieved greater improvement than controls in depression symptoms, response, remission, and depression-free days (moderate SOE); satisfaction with care (moderate SOE); and mental and physical quality of life (moderate SOE). Few data were available on outcomes for chronic medical conditions, except for diabetes; only one trial used a medical outcome as the primary outcome. Diabetic patients receiving collaborative care exhibited no difference in diabetes control as compared with control groups (change in HbA1c: weighted mean difference 0.13, 95% CI, −0.22 to 0.48 at 6 months; 0.24, 95% CI, −0.14 to 0.62 at 12 months; low SOE).
Collaborative care interventions improved outcomes for depression and quality of life in primary care patients with multiple different medical conditions. Few data were available on medical outcomes, except for HbA1c in diabetes, which showed no difference between treatment and usual care. Future studies should be designed to target a broader range of medical conditions, or clusters of conditions, and should compare variations of practice-based interventions in head-to-head trials.