Long-Term Clinical Outcomes of Care Management for Chronically Depressed Primary Care Patients: A Report From the Depression in Primary Care Project

Michael S. Klinkman; Sabrina Bauroth; Stacey Fedewa; Kevin Kerber; Julie Kuebler; Tanya Adman; Ananda Sen

doi:10.1370/afm.1168

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Figure 1.
The DPC care process: care manager case notes for patients D.F.
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Figure 2.
Flow of patients and dropout in DPC enrollees and usual care control group.

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Table 1.

Demographic Comparison of DPC Enrollees and Usual Care Patients Completing 18-Month Assessments

Variable	DPC Enrollees (n=120)	Usual Care (n=65)	P Value
DPC = Depression in Primary Care; PHQ = Physician health Questionnaire.
^a Assessed using t test.
^b Assessed using χ².
^c Available for only the subset of DPC enrollees who completed questionnaires.
Mean age, y	46.1	46.0	.96^a
Female, %	79.2	70.7	.20^b
Insurance type, %
Health maintenance organization	48.7	48.3
Fee for service	39.3	40.3
Medicare	9.4	6.5
Other (Medicaid/safety net)	2.6	4.8	.79^b
Ethnic/racial minority, %	5.0	6.3	.72^b
Self-reported conditions, %
Heart disease	7.5	4.6	.42^b
Diabetes	10.8	16.9	.24^b
Asthma	12.5	20.0	.17^b
Chronic obstructive pulmonary disease	5.0	6.2	.74^b
Comorbid medical problems, %
0	68.3	61.5
1	25.8	29.2
2	4.2	7.7
3 or more	1.7	1.5	.69^b
Known recurrent (>3 episodes) or chronic depression, %	65.8	76.6	.18^b
Taking antidepressant medication before intake/baseline, %	60.8	71.9	.18^b
Mean PHQ-8 score at entry	10.98	9.94	.24^a
Self-reported lifetime history, %	(n=26)	(n=65)
Bipolar disorder^c	15.4	15.6	.98^b
Anxiety disorder^c	30.8	36.4	.61^b
Panic disorder^c	19.2	9.2	.17^b

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Table 2.

Clinical Outcome Comparison for DPC Enrollees and Usual Care Patients at 6, 12, And 18 Months

	DPC Enrollees		Usual Care
Measure	n	Mean (SD)	n	Mean (SD)	P Value
DPC=Depression in Primary Care.
^a Assessed using t test.
^b Assessed using χ²; with insurance type = managed care as comparator.
PHQ-8 score at entry	728	12.00 (5.65)	78	10.42 (5.64)	.190^a
PHQ-8 score at 6 mo	587	7.48 (5.58)	69	8.70 (5.16)	.084^a
PHQ-8 score at 12 mo	269	6.87 (5.88)	59	8.58 (5.24)	.040^a
PHQ-8 score at 18 mo	120	6.89 (5.32)	66	8.77 (4.85)	.019^a
Change in PHQ scores from baseline
Baseline to 6 mo	584	−4.40 (5.71)	68	−1.59 (4.57)	<.001^a
6 to 12 mo	267	−0.42 (4.92)	58	0.04 (3.86)	.430^a
12 to 18 mo	113	0.03 (4.77)	57	0.36 (3.97)	.650^a
Baseline to 18 mo	119	−4.17 (6.37)	65	−1.07 (4.78)	<.001^a
Patients in remission		%		%
At 6 mo	587	43.4	69	33.3	.110^b
At 12 mo	269	52.0	59	33.9	.012^b
At 18 mo	120	49.2	66	27.3	.004^b

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Supplemental Appendix, Tables, & Figure

Supplemental Appendix. Methods Used for Outcome Analyses; Supplemental Table 1. Change Between Baseline and Most Recent PHQ and Reduced-Function Days for Full DPC Enrollee Cohort By Quarter: Q2 2003 Through Q4 2005; Supplemental Table 2. Clinical Outcome Comparison for DPC Enrollees and Usual Care Patients Completing 18-Month Assessments; Supplemental Table 3. Linear Regression Model: Factors Potentially Associated With Change in PHQ-8 Score Over an 18-Month Period; Supplemental Figure 1. Clinical outcomes by quarter for the full Depression in Primary Care project enrollee cohort.

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Supplemental data: Appendix, Tables, & Figure - PDF file, 5 pages, 143KB
The Article in Brief

Long-Term Clinical Outcomes of Care Management for Chronically Depressed Primary Care Patients: A Report From the Depression in Primary Care Project

Michael S. Klinkman , and colleagues

Background Primary care practices increasingly provide care management programs for depressed patients, but little is known about whether such efforts are effective over time. This study evaluated the ongoing effectiveness of a low-intensity, tailored management program for chronically depressed patients in the primary care setting.

What This Study Found This program to support primary care clinicians� management of patients with depression was feasible and highly effective over time. It resulted in sustained improvement in core clinical outcomes, including improved remission rates and reduced-function days for a period of 18 months. The program was acceptable to patients, with most patients remaining active in the program for at least 6 months.

Implications

A low-intensity, tailored care management program can lead to sustainable improvement in depression care for chronically depressed patients in real-world primary care practices.
The study results support a shift in depression care management from a focus on short-term results for patients entering a new treatment episode to longer-term results for patients receiving enhanced primary care treatment over time.