PSYCHIATRY AND PRIMARY CARE
Designing and implementing a primary care intervention trial to improve the quality and outcome of care for major depression

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Abstract

Complex interventions, which have been shown to improve primary care depression outcomes, are difficult to disseminate to routine practice settings. To address this problem, we developed a brief intervention to train primary care physicians and nurses employed by the practice to improve the detection and management of major depression. Before recruitment began, the research team conducted academic detailing conference calls with primary care physicians and nurses, and provided in-person training with nurses and administrative staff. Administrative staff screened over 11,000 patients before their visits to identify those with probable major depression. Primary care physicians delegated increased responsibility to office nurses, who educated over 90% of patients about effective depression treatment and systematically monitored their progress over time. Early results demonstrate that community primary care practices can rebundle traditional team roles over the short-term to provide more systematic mental health treatment without adding additional personnel. A rigorous evaluation of this effort will reduce time-consuming, expensive, and often unsuccessful efforts to “translate” research intervention findings into everyday practice.

Introduction

There is good evidence of growing enthusiasm for improving the treatment of depression in primary care settings. Most depressed individuals visit primary care physicians during the course of their episode 1, 2, 3, where there is great potential for improving detection 4, 5 and treatment 4, 6, 7, 8, 9. Landmark trials 10, 11, 12, 13 demonstrated that interventions that integrate mental health professionals into the primary care setting produced remission rates comparable to those seen in specialty care efficacy studies. However, models that integrate mental health professionals into the primary care setting will be difficult to disseminate widely because most primary care practices do not employ onsite mental health professionals [14]. This study builds on these earlier trials by developing a brief intervention that supports the efforts of primary care physicians and nurses employed by the practice to provide care concordant with the Agency for Health Care Policy and Research’s (AHCPR) Guidelines for depression management 15, 16. This manuscript discusses the development of the intervention, the study’s design (including practice selection and randomization), intervention training, patient recruitment, and intervention implementation to provide perspective often missing in the literature about the challenges to conducting quality improvement interventions in community practices where most patients receive their care.

Section snippets

Development of the intervention

The objective of the intervention was to train primary care physicians and nurses to increase the proportion of depressed subjects who completed a guideline-concordant dose of antidepressant medication and/or psychotherapy during the 6 months following the index visit. Intervention components targeting health care professionals and patients were drawn from PRECEDE model [17] analysis of predisposing and enabling barriers, plus reviews from the relevant patient 18, 19, 20, 21 and provider 22, 23

Design

We evaluated the intervention using a blocked design to randomize 12 primary care practices into enhanced or usual care. Two physicians in each practice and one nurse from each enhanced-care practice volunteered to participate in the study. Physicians and nurses in the enhanced care condition completed brief training before patient recruitment commenced. Administrative staff in each practice used two-stage screening to recruit 20 patients with 5 or more symptoms of current major depression per

Intervention training

Chaired by one of the investigators (PAN), four 1.5-h telephone conference calls with physicians and nurses in each enhanced care practice took place at 2- to 3-week intervals during February–March, 1996. The first call provided an overview of the study protocol, addressed questions that the participants had about study procedures, and reviewed guideline recommendations for detection and evaluation of the primary care patient with major depression. The second call dealt extensively with

Patient selection

Trained administrative staff recruited a cohort of 40 eligible patients in each practice (19–21 patients per physician) over 7 to 16 months, recruiting the final patient an average of 9.2 months after the final academic detailing conference call had been completed in enhanced care settings. Patients were eligible to participate in the study if they were making routine-length visits where care was provided by one of the participating physicians. When patients arrived in the office,

Intervention protocol

Immediately after a patient in an enhanced care practice agreed to be in the study, administrative staff placed a note on the front of the patient’s chart. The note informed the doctor that the patient had screened positive for major depression and agreed to be in the study. The note also requested that the doctor evaluate the depression diagnosis, give the patient a copy of AHCPR’s Patient Guide to Depression [29], and ask the patient to return in 1 week’s time to meet with the nurse and see

Discussion

The purpose of this article was to describe what we learned during the design and implementation of a brief intervention trial to inform multiple interventions currently being designed to improve care for other prevalent mental heath problems in primary care. In terms of design, three points deserve particular attention. First, in order to test practice-wide interventions, quality improvement studies often need to randomize practices rather than patients to the intervention condition. Because

Acknowledgements

The authors wish to acknowledge Marcia Blake, Nancy Burris, Byron Burton, Amanda Davis, Naihua Duan, Carl Elliott, Linda Freeman, Debbie Hodges, Barbara Howard, Joylyn Humphrey, JoAnn Kirchner, Kathryn Magruder, Susan Moore, Cynthia Moton, Jody Rath, Becky Saddler, Melonie Shelton, and Margaret White. We would also like to gratefully acknowledge the physicians, nurses, office staff and patients of the participating primary care practices, who have donated large blocks of time in pursuit of

References (34)

  • W Katon et al.

    Adequacy and duration of antidepressant treatment in primary care

    Med Care

    (1992)
  • K.B Wells et al.

    Management of patients on psychotropic drugs in primary care clinics

    Med Care

    (1988)
  • H.C Schulberg et al.

    Treating major depression in primary care practiceeight-month clinical outcomes

    Arch Gen Psychiatry

    (1996)
  • W Katon et al.

    Collaborative management to achieve treatment guidelinesImpact on depression in primary care

    JAMA

    (1995)
  • L.M Mynors-Wallis et al.

    Randomised controlled trial comparing problem solving treatment with amitriptyline and placebo for major depression in primary care

    Br Med J

    (1995)
  • W Katon et al.

    A multifaceted intervention to improve treatment of depression in primary care

    Arch Gen Psychiatry

    (1996)
  • J.W Williams et al.

    Primary care physicians’ approach to depressive disordersEffects of physician specialty and practice structure

    Arch Fam Med

    (1999)
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    This research was supported by National Institute of Mental Health grant MH54444 and by a grant from the John D. and Catherine T. MacArthur Foundation.

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