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Quality improvement programs that encouraged depressed patients to undergo standard treatments for depression (psychotherapy or antidepressant medication) and gave them and their doctors up-to-date information and resources to increase access to treatments reduced depression rates among black and Hispanic patients from baseline to 5 years after the start of the 6 to 12 month programs. The study, which was supported by the National Institute of Mental Health and the Agency for Healthcare Research and Quality (HS08349), is published in the April issue of the Archives of General Psychiatry.
Nearly 19 million Americans suffer from a depressive disorder, and the cost in medical care and lost worker productivity is roughly $44 billion a year. Studies have shown that black and Latino patients tend to have poorer quality of care for depression and worse outcomes compared with white patients.
At the start of the program, patients were randomly assigned to either standard primary care depression management or one of two quality improvement interventions, which included provider and patient education plus either practice therapists trained in providing cognitive behavior therapy—an effective psychotherapy for depression (QI-therapy)—or specially trained nurses to help patients manage their medications (QI-meds). These special programs lasted 6 to 12 months. However, in both programs, patients could have either treatment, both treatments, or no treatment, and that choice was left up to the patients and their primary care clinicians. The randomization was to resources for improved care, not mandated treatment. The study involved roughly 1,000 patients in community-based Medicaid and private managed care practices in California, Colorado, Texas, Maryland, and Minnesota.
When the patients were evaluated 4 years after the programs ended, the researchers found that, relative to standard care, the two special programs reduced the overall percentage of patients with a probable depressive disorder by 6.6 percentage points. The QI-therapy program reduced the percentage of black and Hispanic patients with depression, relative to those who received standard care only, by 20.2 percentage points, but the reduction was only 1.7 percentage points for non-Hispanic whites in the same program relative to those in standard care.
The QI-therapy program brought the rate of probable depressive disorder in black and Hispanic patients down to 35.6 percent, close to the 34.4 percent rate for non-Hispanic whites in the same program. In contrast, while the depression rate of non-Hispanic white patients receiving standard care also reached roughly 36 percent by the end of the study, almost 56 percent of the black and Hispanic patients who received standard care still suffered from depression. Further, both intervention programs reduced unmet need for treatment—that is, the percentage of patients who were still depressed but not receiving either medication or psychotherapy 5 years later.
The study was led by Kenneth Wells, M.D. Dr. Wells is a senior scientist at RAND and professor of psychiatry and behavioral sciences at the David Geffen School of Medicine and Neuropsychiatric Institute of the University of California, Los Angeles. AHRQ funded the initial treatment phase of the study and also supported the development of toolkits and training resources for the program. These materials are available through the RAND Partners in Care Web site at www.rand.org.
For more information, see "Five-year impact of quality improvement for depression: Results of a group-level randomized controlled trial," by Dr. Wells, Cathy Sherbourne, Ph.D., Michael Schoenbaum, Ph.D., and others, in the April 2004 Archives of General Psychiatry 61(4), pp. 378-386.
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