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Home » Systematic Review

Mental Health: Collaborative Care for the Management of Depressive Disorders

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What the CPSTF Found

About The Systematic Review

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.

Context

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

Summary of Results

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 271 KB]

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

Summary of Economic Evidence

Detailed results from the systematic review are available in the CPSTF Finding and Rationale Statement pdf icon [PDF - 271 KB]

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.

Applicability

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

Evidence Gaps

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

Research Issues

  • 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.

Economic Evidence

  • 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.

Study Characteristics

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.

Publications

Thota AB, Sipe TA, Byard GJ, et al. Collaborative care to improve the management of depressive disorders. A Community Guide systematic review and meta-analysis. American Journal of Preventive Medicine. 2012;42(5):525-38.
Jacob V, Chattopadhyay SK, Sipe TA, Thota AB, Byard GJ, Chapman DP, Community Preventive Services Task Force. Economics of collaborative care for management of depressive disorders. A Community Guide systematic review. American Journal of Preventive Medicine. 2012;42(5):539-49.
Community Preventive Services Task Force. Recommendation from the Community Preventive Services Task Force for use of collaborative care for the management of depressive disorders. American Journal of Preventive Medicine. 2012;42(5):521–4.
Compton MT. Systemic organizational change for the collaborative care approach to managing depressive disorders. American Journal of Preventive Medicine. 2012;42(5):553-5.
Katon W. Collaborative depression care models: from development to dissemination. American Journal of Preventive Medicine. 2012;42(5):550-2.
Calonge N. Clinical and community prevention and treatment service for depression: A whole greater than the sum of its parts. American Journal of Preventive Medicine. 2012;42(5):556-7.

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