Mental Health and Mental Illness: Collaborative Care for the Management of Depressive Disorders

The CPSTF finding is based on evidence from a systematic review published in 2006 (Bower et al., 37 studies, search period 1966-2004) combined with more recent evidence (32 studies, search period 2004-2009). The systematic review was conducted on behalf of the CPSTF by a team of specialists in systematic review methods, and in research, practice, and policy related to improving mental health and addressing mental illness.

The U.S. Preventive Services Task Force (USPSTF) recommends screening for depression in adults (2009) and adolescents (2009) in outpatient primary care settings when adequate systems are in place for efficient diagnosis, treatment and follow-up for depressive disorders. The implementation of collaborative care models is one way to ensure that such systems are in place

Earlier Review (Bower et al. 2006)

Thirty-seven studies were identified for the systematic review and meta-analysis. Results show that collaborative care led to the following favorable and statistically significant effects:

• Reduction in the number of depression symptoms patients experienced (from 34 studies)
• Increased antidepressant use and improved adherence to treatment (28 studies)

Updated Evidence (2004-2009)

Thirty-two studies qualified for this systematic review and meta-analysis. Results show that effects due to collaborative care compared to usual care were favorable and statistically significant for the following depression outcomes:

• Depression symptoms patients receiving collaborative care had fewer depression symptoms
• Adherence to prescribed treatment patients more often took the medication prescribed for their depression
• Response to treatment more patients showed a response to treatment, defined as a decrease in half or more of their depression symptoms
• Remission or recovery patients were more likely to have remission of symptoms (short-term absence of symptoms) or recovery (long-term disappearance of symptoms) from depression
• Quality-of-life and functional status patients receiving collaborative care had small improvements in these outcomes
• Satisfaction with treatment – patients receiving collaborative care reported higher satisfaction with their treatment

The economic review identified 20 studies of actual interventions and 2 model-based studies. Also included was an earlier systematic economic review (Gilbody et. al. 2006) that focused only on randomized controlled trials (RCTs). All monetary values are reported in 2008 U.S. dollars.

The 2006 Gilbody et. al. systematic economic review of collaborative care RTCs reported incremental net costs of $17,000 to $39,000 per quality adjusted life year (QALY), making them cost-effective based on the conventional threshold.

The current economic review found:

• Incremental program costs ranged from $104 to $639 per person per year with a median of $204 (9 studies).
  • Variation in program cost is influenced by:
    • The number of participants
    • The number of patient contacts with case managers
    • Whether contact was by phone or in person
    • Whether costs were included for staff training or electronic care management systems
• Of the five studies that considered costs and benefits, four showed that the interventions were cost beneficial.
  • These studies compared program costs to averted health care costs, productivity losses, or estimates of what patients were willing to pay for treatment.
• Of the six studies that looked at cost-effectiveness, five showed that the interventions were cost-effective, based on the conventional threshold.
  • Four of the studies reported estimates less than $21,000 per QALY.
• Studies based on decision models within primary care practice demonstrated that collaborative care could be cost-effective (2 studies).

In conclusion, the evidence from this economic review suggests that collaborative care for the management of depressive disorder is both cost-effective and cost-beneficial.

Based on updated evidence, results are applicable to the following:

• Adults (20-64 years) and older adults (65 years and older)
• Women and men
• Caucasian, African-American, Latino and mixed race populations
• Economically mixed populations
• A diverse range of organizations and settings

CPSTF identified several areas that have limited information. Additional research and evaluation could help answer the following questions and fill remaining gaps in the evidence base. (What are evidence gaps?)

• An important research need identified from this systematic review concerns the essential training and background required of key members of the collaborative care team (e.g., requisite skill levels for case managers and intervention-specific training for case managers and primary care providers).
• Other needs include information on the optimal frequency and intensity of case management sessions and the utility of additional sessions for patients who do not improve.
• Studies are also needed to ensure that collaborative care models are consistently effective in improving the management and reducing the impact of depressive disorders among children and adolescents and when targeted to minorities, those of low SES, and those with comorbid conditions.
• Only one study examined the effect of collaborative care on improving the quality of screening practices.
• Research studies that focus on improving depression screening at the primary care level through collaborative care will be vital to implementers of these models. Gaining more robust information and knowledge on these aspects will inform the effective practice of collaborative care in the community.
• There is a need for research in this area on the adolescent population. The effectiveness review included only one study on adolescents, and no studies were identified in the economic review.
• Also, there is a need to separate the collaborative components of the activities of behavioral professionals such as psychiatrists and psychologists from their usual care activities. Hence, program costs should include the cost of staff associated with managing care and coordinating visits/sessions but should exclude psychiatrist/psychologist time associated with treatment.
• Only time that is associated with items beyond treatment, such as consultation with primary care providers for management of medication, should be included in program cost. This careful separation of costs associated with the collaborative care intervention and treatment was not always followed in studies included in the current review.

In studies from the updated evidence, healthcare providers played different roles in collaborative care models.

• Physicians most often fulfilled the role of primary care provider.
• Nurses were employed as case managers in most cases. In some cases, social workers or masters-level mental health workers assumed this role. When masters-level mental health workers with limited clinical experience were used, however, the intervention effects were smaller, which could be addressed by further skills development.
• Psychiatrists and psychologists typically filled the mental health specialist role.

Effectiveness Review

Analytic Framework see Figure 1 on page 528

When starting an effectiveness review, the systematic review team develops an analytic framework. The analytic framework illustrates how the intervention approach is thought to affect public health. It guides the search for evidence and may be used to summarize the evidence collected. The analytic framework often includes intermediate outcomes, potential effect modifiers, potential harms, and potential additional benefits.

Effectiveness Review

Summary Evidence Table Effectiveness Review

Economic Review

Summary Evidence Table Economic Review

The number of studies and publications do not always correspond (e.g., a publication may include several studies or one study may be explained in several publications).

Effectiveness Review

Asarnow JR, Jaycox LH, Duan N, LaBorde AP, Rea MM, Murray P, Anderson M, Landon C, Tang L, Wells KB. Effectiveness of a quality improvement intervention for adolescent depression in primary care clinics: a randomized controlled trial [see comment]. JAMA 2005;293(3):311-9.

Baldwin R. Does a nurse-led mental health liaison service for older people reduce psychiatric morbidity in acute general medical wards? A randomised controlled trial. Age and Ageing 2004;33(5):472.

Bogner HR, de-Vries HF. Integration of depression and hypertension treatment: a pilot, randomized controlled trial. Annals of family medicine 2008;6(4):295 301.

Ciechanowski P, Wagner E, Schmaling K, Schwartz S, Williams B, Diehr P, Kulzer J, Gray S, Collier C, LoGerfo J. Community-integrated home-based depression treatment in older adults: a randomized controlled trial. JAMA 2004;(13):1569 77.

Chew-Graham CA, Lovell K, Roberts C, Baldwin R, Morley M, Burns A, Richards D, Burroughs H. A randomised controlled trial to test the feasibility of a collaborative care model for the management of depression in older people. British Journal of General Practice 2007;57(538):364-70.

Cole MG, McCusker J, Elie M, Dendukuri N, Latimer E, Belzile E. Systematic detection and multidisciplinary care of depression in older medical inpatients: a randomized trial. Canadian Medical Association Journal 2006;174(1):38-44.

Cullum S, Tucker S, Todd C, Brayne C, Effectiveness of liaison psychiatric nursing in older medical inpatients with depression: a randomised controlled trial. Age and Ageing 2007;36(4):436-42.

Dietrich AJ, Oxman TE, Williams JWJ, Schulberg HC, Bruce ML, Lee PW, Barry S, Raue PJ, Lefever JJ, Heo M, Rost K, Kroenke K, Gerrity M, Nutting PA. Re-engineering systems for the treatment of depression in primary care: cluster randomised controlled trial. British Medical Journal 2004;329(7466):602.

Dobscha SK, Corson K, Hickam DH, Perrin NA, Kraemer DF, Gerrity MS. Depression decision support in primary care: a cluster randomized trial [see comment][summary for patients in Ann Intern Med 2006;145(7):I10; PMID: 17015861]. Annals of Internal Medicine 2006;145(7):477-87.

Dwight-Johnson M, Ell K, Lee PJ. Can collaborative care address the needs of low-income Latinas with comorbid depression and cancer? Results from a randomized pilot study.Psychosomatics 2005;46(3):224-32.

Ell K, Unutzer J, Aranda M, Gibbs NE, Lee PJ, Xie B. Managing depression in home health care: a randomized clinical trial. Home Health Care Services Quarterly 2007;26(3):81-104.

Ell K, Xie B, Quon B, Quinn DI, Dwight-Johnson M, Lee PJ. Randomized controlled trial of collaborative care management of depression among low-income patients with cancer. Journal of Clinical Oncology 2008;26(27):448-96.

Fortney JC, Pyne JM, Edlund MJ, Williams DK, Robinson DE, Mittal D, Henderson KL. A randomized trial of telemedicine-based collaborative care for depression. Journal of General Internal Medicine 2007;22(8):1086-93.

Gallo JJ, Bogner HR, Morales KH, Post EP, Lin JY, Bruce ML. The effect of a primary care practice-based depression intervention on mortality in older adults: a randomized trial. Annals of Internal Medicine 2007;146(10):689 98.

Gensichen J, von Korff M, Peitz M, Muth C, Beyer M, G thlin C, Torge M, Petersen JJ, Rosemann T, K nig J, Gerlach FM. Case management for depression by health care assistants in small primary care practices: a cluster randomized trial. Annals of Internal Medicine 2009;151:369-378.

Joubert J, Joubert L, Reid C, Barton D, Cumming T, Mitchell P, House M, Heng R, Meadows G, Walterfang M, Pantelis C, Ames D, Davis S. The positive effect of integrated care on depressive symptoms in stroke survivors. Cerebrovascular Diseases 2008;26(2):199-205.

Ludman EJ, Simon GE, Grothaus LC, Luce C, Markley DK, Schaefer J. A pilot study of telephone care management and structured disease self-management groups for chronic depression. Psychiatric Services 2007;58(8):1065-72.

McMahon L, Foran KM, Forrest SD, Taylor ML, Ingram G, Rajwal M, Cornwall PL, Lister-Williams RH. Graduate mental health worker case management of depression in UK primary care: a pilot study. British Journal of General Practice 2007;57(544):880-5.

Oslin DW, Thompson R, Kallan MJ, TenHave T, Blow FC, Bastani R, Gould RL, Maxwell AE, Rosansky J, Van SW, Jarvik L. Treatment effects from UPBEAT: a randomized trial of care management for behavioral health problems in hospitalized elderly patients. Journal of Geriatric Psychiatry and Neurology 2004;17(2):99-106.

Reiss-Brennan B, xBriot G, Daumit G, Ford D. Evaluation of “Depression in Primary Care” Innovations. [References]. Adm Policy Ment Health 2006;33(1):91.

Richards DA, Lovell K, Gilbody S, Gask L, Torgerson D, Barkham M, Bland M, Bower P, Lankshear AJ, Simpson A, Fletcher J, Escott D, Hennessy S, Richardson R. Collaborative care for depression in UK primary care: a randomized controlled trial. Psychological Medicine 2008;38(2):279-87.

Rollman BL, Belnap BH, LeMenager MS, et al. Telephone-delivered collaborative care for treating post-CABG depression: a randomized controlled trial. JAMA 2009;302(19):2095-103.

Schrader G, Cheok F, Hordacre AL, Marker J, Wade V, Effect of psychiatry liaison with general practitioners on depression severity in recently hospitalised cardiac patients: a randomised controlled trial. Medical Journal of Australia 2005;182(6):272-6.

Sharpe M, Strong V, Allen K, Rush R, Maguire P, House A, Ramirez A, Cull A., Management of major depression in outpatients attending a cancer centre: a preliminary evaluation of a multicomponent cancer nurse-delivered intervention. British Journal of Cancer 2004;90(2):310-3.

Simon GE, Ludman EJ, Operskalski BH. Randomized trial of a telephone care management program for outpatients starting antidepressant treatment. Psychiatric Services 2006;57(10):1441-5.

Simon GE, Katon WJ, Lin EH, Rutter C, Manning WG, von Korff M, Ciechanowski P, Ludman EJ, Young BA. Cost-effectiveness of systematic depression treatment among people with diabetes mellitus[see comment]. Archives of General Psychiatry 2007;64(1):65-72.

Smit A, Kluiter H, Conradi HJ, van der Meer K, Tiemens BG, Jenner JA, van Os TW, Ormel J. Short-term effects of enhanced treatment for depression in primary care: results from a randomized controlled trial. Psychological Medicine 2006;36(1):15-26.

Stiefel F, Zdrojewski C, Bel Hadj F, Boffa D, Dorogi Y, So A, Ruiz J, de Jonge P. Effects of a multifaceted psychiatric intervention targeted for the complex medically ill: a randomized controlled trial. Psychotherapy and Psychosomatics 2008;77(4):247-56.

Strong V, Waters R, Hibberd C, Murray G, Wall L, Walker J, McHugh G, Walker A, Sharpe M. Management of depression for people with cancer (SMaRT oncology 1): a randomised trial.Lancet 2008;372(9632):40-8.

Wang PS, Simon GE, Avorn J, Azocar F, Ludman EJ, McCulloch J, Petukhova MZ, Kessler RC. Telephone screening, outreach, and care management for depressed workers and impact on clinical and work productivity outcomes: a randomized controlled trial [see comment]. JAMA 2007;298(12):1401-11.

Wells KB, Tang L, Miranda J, Benjamin B, Duan N, Sherbourne CD. The effects of quality improvement for depression in primary care at nine years: results from a randomized, controlled group-level trial. Health Services Research 2008;43(6):1952-74.

Williams LS, Kroenke K, Bakas T, Plue LD, Brizendine E, Tu W, Hendrie H. Care management of poststroke depression: a randomized, controlled trial. Stroke 2007;38(3):998-1003.

Additional References Related to the Included Studies

Bogner HR, Morales KH, Post EP, Bruce ML. Diabetes, depression, and death: a randomized controlled trial of a depression treatment program for older adults based in primary care (PROSPECT). Diabetes Care 2007;30(12):3005 10.

Cheok F, Schrader G, Banham D, Marker J, Hordacre AL. Identification, course, and treatment of depression after admission for a cardiac condition: rationale and patient characteristics for the Identifying Depression As a Comorbid Condition (IDACC) project. The American Heart Journal 2003;146(6):978-84.

Reiss-Brennan B, Briot P, Cannon W, James B. Mental health integration: rethinking practitioner roles in the treatment of depression: the specialist, primary care physicians, and the practice nurse. Ethnicity & Disease 2006;16(2 Suppl 3):37-43.

Reiss-Brennan B, Cannon W, Smith D, Flint T, Wilcox A, Briot Pl, Snow G, James B, Cattrell V. IHC Mental Health Integration – Primary Care Clinical Programs, IHC Community Team, 2003. Depression Key Levers to Overcome Barriers to High Quality Care. Iowa Coalition on Mental Health & Aging. University of Iowa.

Reiss-Brennan B. Can mental health integration in a primary care setting improve quality and lower costs? A case study. Journal of Managed Care Pharmacy 2006;12(2 Suppl):14 20.

Reiss-Brennan B, Briot PC, Savitz LA, Cannon W, Staheli R. Cost and quality impact of intermountain’s mental health integration program. Journal of Healthcare Management 2010;55(2):97-113 [discussion 113-4].

Rubenstein LV, Jackson-Triche M, Unutzer J, Miranda J, Minnium K, Pearson ML, Wells KB. Evidence-based care for depression in managed primary care practices. Health Affairs 1999;18(5):89-105.

Sharpe M, Strong V, Allen K, Rush R, Postma K, Tulloh A, Maguire P, House A, Ramirez A, Cull A. Major depression in outpatients attending a regional cancer centre: screening and unmet treatment needs. British Journal of Cancer 2003;90(2):314-20.

Sherbourne CD, Edelen MO, Zhou A, Bird C, Duan N, Wells KB. How a therapy-based quality improvement intervention for depression affected life events and psychological well-being over time: a 9-year longitudinal analysis. Medical Care 2008;46(1):78-84.

Unknown. Care managers affect worker productivity. Disease Management Advisor 2007;13(12):133-7.

Wells KB. The design of Partners in Care: evaluating the cost-effectiveness of improving care for depression in primary care. Social Psychiatry & Psychiatric Epidemiology 1999;34(1):20-9.

Economic Review

Ciechanowski P, Wagner E, Schmaling K, et al. Community-integrated home-based depression treatment in older adults: A randomized controlled trial.JAMA 2004;291(13):1569-77.

Dickinson LM, Rost K, Nutting PA, Elliott CE, Keeley RD, Pincus H. RCT of a care manager intervention for major depression in primary care: 2-year costs for patients with physical vs psychological complaints. Ann Fam Med 2005;3(1):15-22.

Domino ME, Maxwell J, Cody M, et al. The influence of integration on the expenditures and costs of mental health and substance use care: Results from the Randomized PRISM-E Study. Ageing Int 2008;32(2):108-27.

Ell K, Xie B, Quon B, Quinn DI, Dwight-Johnson M, Lee PJ. Randomized controlled trial of collaborative care management of depression among low-income patients with cancer. J Clin Oncol 2008;26(27):4488-96.

Grypma L, Haverkamp R, Little S, Unntzer J. Taking an evidence-based model of depression care from research to practice: Making lemonade out of depression. Gen Hosp Psychiatry 2006;28(2):101-7.

Kominski G, Andersen R, Bastani R, et al. UPBEAT: the impact of a psychogeriatric intervention in VA medical centers. Med Care 2001;39(5):500-12.

Sasso L, Anthony T, Rost K, Beck A. Modeling the impact of enhanced depression treatment on workplace functioning and costs: A cost-benefit approach. Med Care 2006;44(4):352.

Matalon A, Nahmani T, Rabin S, Maoz B, Hart J. A short-term intervention in a multidisciplinary referral clinic for primary care frequent attenders: Description of the model, patient characteristics and their use of medical resources. Fam Pract 2002;19(3):251-6.

Pyne JM, Smith J, Fortney J, Zhang M, Williams DK, Rost K. Cost-effectiveness of a primary care intervention for depressed females. J Affect Disord 2003;74(1):23-32.

Pyne JM, Rost KM, Farahati F, et al. One size fits some: the impact of patient treatment attitudes on the cost-effectiveness of a depression primary-care intervention.Psychol Med 2005;35(6):839-54.

Reiss-Brennan B. Can mental health integration in a primary care setting improve quality and lower costs? A case study. J Manag Care Pharm 2006;12(2 Suppl):14-20.

Reiss-Brennan B, Briot PC, Savitz LA, Cannon W, Staheli R. Cost and quality impact of Intermountain’s mental health integration program. J Healthc Manag 2009;55(2):97-113.

Rost K, Pyne JM, Dickinson LM, LoSasso AT. Cost-effectiveness of enhancing primary care depression management on an ongoing basis. Ann Fam Med 2005;3(1):7-14.

Schoenbaum M, Miranda J, Sherbourne C, Duan N, Wells K. Cost-effectiveness of interventions for depressed Latinos. J Ment Health Policy Econ 2004;7(2):69-76.

Simon GE, Katon WJ, Lin EHB, et al. Cost-effectiveness of systematic depression treatment among people with diabetes mellitus. Arch Gen Psychiatry 2007;64(1):65-72.

Strong V, Waters R, Hibberd C, et al. Management of depression for people with cancer (SMaRT oncology 1): a randomised trial. Lancet 2008;372(9632):40-8.

Unutzer J, Katon WJ, Russo J, et al. Willingness to pay for depression treatment in primary care. Psychiatr Serv 2003;54(3):340-5.

Unutzer J, Katon WJ, Fan M, et al. Long-term cost effects of collaborative care for late-life depression. Am J Manag Care 2008;14(2):95-100.

Wang PS, Simon GE, Avorn J, et al. Telephone screening, outreach, and care management for depressed workers and impact on clinical and work productivity outcomes: A randomized controlled trial. JAMA 2007;298(12):1401.

Wells KB, Schoenbaum M, Duan N, Miranda J, Tang L, Sherbourne C. Cost-effectiveness of quality improvement programs for patients with subthreshold depression or depressive disorder. Psychiatr Serv 2007;58(10):1269.

Gilbody S, Bower P, Whitty P. Costs and consequences of enhanced primary care for depression: systematic review of randomised economic evaluations. Br J Psychiatry 2006;189(4):297.

Modeled Studies (Not included in the economic review)

Chisholm D, Sanderson K, Ayuso-Mateos JL, Saxena S. Reducing the global burden of depression: population-level analysis of intervention cost-effectiveness in 14 world regions. Br J Psychiatry 2004;184(5):393-403.

Wang PS, Patrick A, Avorn J, et al. The costs and benefits of enhanced depression care to employers. Arch Gen Psychiatry 2006;63(12):1345-53.

Definitions of Terms

• Concordance is the degree to which a healthcare provider follows evidence-based guidelines/protocols/algorithms for treatment or interventions.
• Collaboration refers to interaction/communication among providers and between providers and clients/consumers/patients intended to facilitate participation and clarification of health-related goals.
• Case Management is a collaborative process of assessment, planning, facilitation and advocacy to maintain a continuous and coordinated process of care (Case Management Society of America).
• Adherence is the client/consumer/patient administration of therapies in a manner consistent with an agreed upon treatment plan.
• Case Manager is an individual provider whose role is to interact with other providers and with clients/consumers/patients for management, coordination and continuity of care.
• Primary Healthcare Provider is a healthcare provider with broad medical responsibility for clients/consumers/patients and who often serves as the first healthcare system point-of-contact.
• Mental Health Specialist a healthcare professional with specialized training and expertise in the treatment and/or management of mental health disorders and other mental health issues.
• Screening is a brief process to identify persons in the community at high risk for depressive symptoms/disorders requiring further assessment or management.
• Client/Consumer/Patient is an individual in the healthcare system who might have depressive symptoms and may or may not be diagnosed as having a depressive disorder.
• Community is a group of stakeholders at any level and from all backgrounds (e.g. clients/consumers/patients, families, healthcare providers, case managers) sharing an environment (e.g. health system, living areas, worksites, schools, colleges).
• Health system is a network that is inclusive of all activities and whose primary purpose is to promote, restore or maintain health (World Health Organization).
• System support is a sustained supply of services and material necessary for the use and improvement of a system.
• Goal clarification is an intended product of the processes of collaboration and care management in order to allow patients/consumers/clients to participate, to be informed and updated with respect to their health-related goals.

Recommendation Outcomes

• Proportion of population screened is coverage of screening for depressive symptoms/disorders among the target population
• Response is a 50% or greater reduction in depressive symptoms from baseline (Rush et al 2006)
• Remission is improvement of symptoms for 3 successive weeks such that the individual no longer meets the diagnostic criteria for a depressive disorder and has minimal symptoms at most (Rush et al. 2006)
• Recovery is an improvement in depressive symptoms, such that the individual no longer meets the diagnostic criteria for a depressive disorder that is sustained for 4 months after achieving remission (Rush et al. 2006)
• Functional Status is the extent to which an individual can perform normal daily activities required to meet basic needs, fulfill usual roles, and maintain health and well-being (American Thoracic Society)
• Quality of Life is “an individual’s or group’s perceived physical and mental health over time” (CDC)

Other Outcome(s)

• Satisfaction with care is “a patient’s perception of the quality of healthcare providers, access to services, communication with providers and administrative staff, and of the success of their treatment” (Cherin et al 2001; Rapkin et al 2008)

Effectiveness Review

The following databases were searched from 1980 up to April 2009 to identify studies assessing the effectiveness of Collaborative Care interventions in improving depression outcomes: The Cochrane Library; MEDLINE; EMBASE; ERIC; NTIS (National Technical Information Service); PsycINFO; CABI; LILACS; CINAHL; and Dissertation Abstracts International. Hand-searches were conducted of 5 journals, published over the preceding 10 years and identified by the team as the most relevant to the field and this intervention. Also included were papers, conference proceedings, reports, books, and book chapters identified by team members and other subject matter experts.

Depression Keywords

1. exp *Depression
2. exp *Dysthymic Disorder/ or exp *Depressive Disorder
3. exp *Mood disorders
4. minor depression.mp.
5. exp *Depressive Disorder, Major
6. exp *Anxiety
7. exp *Stress Disorders, Post-Traumatic
8. affective disorder$.mp.
9. or/1-8

Keywords for intervention of interest: Collaborative Care

10. exp *”Delivery of Health Care”
11. exp *Family Practice
12. exp *Primary Health Care
13. exp *Community Health Services/ or exp *Community Health Aides/ or exp *Community Health Nursing/ or exp *Community Health Centers
14. exp *Community Mental Health Services/ or exp *Community Mental Health Centers
15. exp *Health Maintenance Organizations
16. exp *Ambulatory Care Facilities/ or exp *Ambulatory Care/ or exp *Ambulatory Care Information Systems
17. exp *Adolescent Health Services/ or exp *School Health Services/ or exp *Student Health Services/ or exp *Academic Medical Centers
18. exp *Private Practice
19. community service boards.mp
20. exp *Hospitals, Teaching/ or exp *Hospitals, University
21. or/10-20
22. stepped care.mp.
23. exp *Patient Care Team/ or shared care.mp
24. collaborative care.mp
25. exp *Primary Prevention
26. exp *Total Quality Management/ or exp *Quality Assurance, Health Care/ or exp *”Quality of Health Care”
27. exp *Physicians
28. exp *Nurses
29. exp *Pharmacists
30. exp *Pharmacy
31. exp *Algorithms
32. exp *Guideline Adherence/ or exp *Guideline/ or exp *Practice Guideline
33. psychoeducation.mp
34. exp *Information Centers/ or exp *Access to Information/ or exp *Integrated Advanced Information Management Systems
35. exp *Disease Management
36. exp *Reminder Systems
37. exp *Feedback
38. exp *”Referral and Consultation”
39. exp *Guideline Adherence/ or exp *Advance Directive Adherence
40. exp *Mental Health Services/ or mental health counselor.mp
41. mental health specialist.mp
42. exp *Students
43. exp *Case Management/ or case manager.mp
44. school student personnel.mp
45. guidance counselor.mp
46. exp *Psychology
47. exp *Psychiatric Nursing
48. exp *Social Work, Psychiatric
49. psychiatrist.mp. or exp *Psychiatry
50. exp *Peer Group/ or peer support.mp. or exp *Hotlines/ or exp *Self-Help Groups
51. evaluation.mp. or exp *Evaluation Studies as Topic
52. or/22-51
53. economic$.mp. or exp *Economics, Nursing/ or exp *Economics, Medical/ or exp Economics/ or exp *Economics, Pharmaceutical
54. cost$.mp. or exp *”Costs and Cost Analysis”
55. exp *”Cost of Illness”
56. cost benefit analysis.mp. or exp *Cost-Benefit Analysis
57. cost consequence$.mp
58. cost effectiveness analysis.mp
59. exp *”Cost Savings”/ or cost minimization analysis.mp
60. cost utility analysis.mp
61. exp *”Costs and Cost Analysis”
62. or/53-61
63. 9 and 21 and 52 and 62
64. limit 63 to yr=”1980 – 2009″
65. *Developing Countries
66. 64 not 65
67. from 66 keep

Bower P, Gilbody S, Fletcher J, Sutton A. Collaborative care for depression in primary care: making sense of a complex intervention: systematic review and meta-regression. The British Journal of Psychiatry 2006;189(6):484-93.

Gilbody S, Bower P, Whitty P. Costs and consequences of enhanced primary care for depression: systematic review of randomised economic evaluations. The British Journal of Psychiatry 2006; 189(4):297-308.

Katon W, Von Korff M, Lin E, Simon G. Rethinking practitioner roles in chronic illness: the specialist, primary care physician, and the practice nurse. General Hospital Psychiatry 2001;23(3):138-44.

U.S. Preventive Services Task Force. Screening for depression in adults: U.S. Preventive Services Task Force Recommendation Statement. Annals of Internal Medicine 2009;151(11):784-92.

U.S. Preventive Services Task Force. Screening and treatment for major depressive disorder in children and adolescents: U.S. Preventive Services Task Force Recommendation Statement. Pediatrics 2009(b);123(4):1223-8.

The following considerations are drawn from studies included in the evidence review, the broader literature, and expert opinion.

• While physicians were the primary care providers in most studies, the few studies that used other professionals (e.g., nurses and physician assistants) in this role reported similar effects.
• Nurses served as case managers in most of the included studies. In some instances, social workers or master’s-level mental health workers served in this role.
  • The effect estimate from studies using master’s-level mental health workers was smaller than the overall estimate. More skills development is likely needed for those serving as case managers.
  • Organizations should ensure that training is adequate for all individuals working as case managers and emphasize effective communication among providers.
• Psychiatrists and psychologists most often served as the mental health specialists, though two studies that used physicians or nurses with advanced training in this role reported comparable results.
• Results suggest collaborative care interventions are effective when implemented by a variety of organizations, including managed care organizations, academic medical centers, community-based organizations, the Veterans Health Administration, and universal health coverage systems (e.g., the National Health Service in the United Kingdom).
  • The effect estimate for VA studies was in the favorable direction though it was somewhat smaller than the overall estimate. Usual care in the context of the VA may be different from usual care in other situations (i.e., with greater integration of primary care and behavioral health care), and veterans presenting with depression may have higher rates of comorbidities, such as substance abuse and posttraumatic stress disorder (PTSD) than other populations.
  • Other VA-based studies of collaborative care have reported estimated effect sizes similar to the overall effect estimate from this review, but results were published outside the search period for this review.
• Reported barriers to implementation of collaborative included the following.
  • Patient reluctance to enroll
  • Low patient appointment attendance
  • Limited insurance coverage for mental health care
  • Challenges locating organizations in the community that offer depression care at nonconventional points-of-care such as homes or worksites
  • Training specialists from other fields in collaborative care for patients with depression comorbid with other chronic illnesses
  • Difficulties reaching patients who prefer face-to-face over telephone contact for counseling and care management

Healthy People 2030

Healthy People 2030 includes the following objectives related to this CPSTF recommendation.

• Increase the proportion of adults with depression who get treatment — MHMD‑05