Managed Care - March 2008 - (Page M22) Depression in Primary Care: Quality Improvement and Economics RICHARD G. FRANK, PHD Professor of Economics, Department of Health Care Policy, Harvard Medical School Research Associate, National Bureau of Economic Research vidence-based treatment of depression improves paby the physician with the patient and with other memtients’ well being and quality of life, and may result in bers of the care team, care manager services, specialty financial gains for health plans, employers, and paconsultation, and registry-decision support. Evidencetients. In primary care, however, the adoption of evidencebased treatment incorporating these elements usually based treatment for patients with depression is lagging. increases treatment costs, but it also improves outcomes Pharmacologic treatment of depression can be (Lave 1998). In a study in which patients with major dethought of as consisting of an acute phase and a continpression were randomly assigned to treatment with eiuation phase. In its measure of the quality of antidepresther nortriptyline, interpersonal psychotherapy, or usual sant care provided by MCOs, the National Committee care (whatever care the physician provided after being inFor Quality Assurance requires a miniformed that the patient was depressed), mum of three follow-up visits over the nortriptyline was slightly more effective course of the first 12 weeks of treatment and less costly than interpersonal psycho(the acute phase) to monitor and adjust therapy, and either therapy was more eftreatment (NCQA 2007). NCQA also fective and more costly than usual care, judges the quality of depression care by but without generating meaningful cost looking at the percentage of members that offsets (Lave 1998). In a few targeted remains in treatment during the acute areas, however, treatment of depression phase and the percentage that continues may offset medical costs; for example, detreatment for 6 months. By these stanpressed patients post myocardial infarcdards, the quality-improvement trend in tion or post hip fracture (especially in recent years has been flat (Figure). The older patients) or with diabetes (Simon lack of improvement in continuity of con2007). A recent meta-analysis suggests tact with patients with depression is conthat evidence-based treatment of depresRICHARD G. FRANK, sistent with reports of declines in psysion also produces modest improvements PHD chosocial aspects of care for patients with in labor outcomes (e.g., hours worked per bipolar disorder or schizophrenia. In these populations, week, odds of being unable to work) (Timbie 2006). there has been an upward trend in the quality of mediThis study involved four randomized controlled trials cation management but a downward drift in the inten(the only ones among 706 studies found through datasity and amount of evidence-based psychosocial supbase searches that met the authors’ inclusion criteria) in port. This tension pervades all mental health treatment which the interventions were mostly collaborative care and is particularly evident in the treatment of depression. and the controls mostly usual care. Measured by Cohen’s The capability of primary care practitioners to effid, the size of the clinical effect (reduction in symptoms ciently care for depression has improved dramatically, of depression) of the interventions was an improvement owing to the development of screening instruments and of 0.34 standard deviation, but the size of their effect on better-tolerated drug therapies. Although primary care the labor supply was only 0.12 standard deviation (a physicians have been historically weak in recognizing Cohen’s d of 0.2 is regarded as representing a small effect and treating depression, they now have tools to improve size). care for patients with depression. Researchers cognizant of the paucity of studies of the effect of depression treatment on workplace productivity recently generated new evidence that a systematic Financial benefits of treating depression program to screen and treat depressed workers can imFor primary care physicians, the key elements of prove clinical outcomes and productivity (Wang 2007). evidence-based treatment of depression are time spent E 22 MANAGED CARE / SUPPLEMENT
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