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Improved access to medication and therapy for depressed primary care patients improves 5-year outcomes

Many patients who are depressed do not receive quality care for depression. This is especially true for minority patients who generally receive less care for depression than white patients. A new managed care quality improvement (QI) initiative, which enhanced access to medication and therapy among depressed primary care patients, reduced depression rates up to 5 years after implementation, especially among Hispanic and black patients.

The Partners in Care (PIC) program, supported in part by the Agency for Healthcare Research and Quality (HS08349), randomly assigned 46 primary care clinics in six managed care organizations to usual depression care or one of two QI groups, QI-Meds or QI-therapy, for 6 to 12 months. The QI-Meds group used trained nurses to support medication management by primary care providers, and the QI-Therapy group trained local therapists in cognitive behavior therapy (CBT, which helps change self-defeating behavior and thinking patterns) and lowered the patient copay for use of those therapists. Patients could have any or no treatment in either intervention.

Kenneth Wells, M.D., Ph.D., of RAND, and his colleagues used a telephone survey to gauge the effects of the QI programs on health outcomes and quality of care for 991 primary care patients with depression (including 452 Hispanics and blacks) nearly 5 years (57 months) after study enrollment. Relative to usual care, combined QI-meds and QI-therapy reduced the percentage of patients with probable depressive disorder at 5 years by 6.6 percentage points but reduced the probability of the disorder for blacks and Hispanics by 16.1 percentage points. In the usual care group, blacks and Hispanics combined had worse health outcomes (56 percent had probable depressive disorder) than whites (36 percent had probable depressive disorder). Participation in QI-therapy alone lowered the rate of probable disorder among blacks and Hispanics, but it had little effect among whites. Results were similar for QI-meds alone but were not significant.

See "Five-year impact of quality improvement for depression," by Dr. Wells, Cathy Sherbourne, Ph.D., Michael Schoenbaum, Ph.D., and others, in the April 2004 Archives of General Psychiatry 61, pp. 378-386.

Editor's Note: Another AHRQ-supported study on a related topic calls for new approaches to improving access to appropriate depression care for Hispanic and black primary care patients. The researchers found that Hispanic and black primary care patients with depression remain less likely than similar white patients to obtain appropriate care, such as antidepressant medication or specialty care. For more details, see Miranda, J., and Cooper, L.A. (2004, February). "Disparities in care for depression among primary care patients."(AHRQ grant HS19758 and HS08349). Journal of General Internal Medicine 19, pp. 120-126.

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