A program of telephone care management plus structured cognitive-behavioral psychotherapy yielded “significant and sustained benefits” for primary care patients starting treatment for depression, without raising health care costs appreciably, said Dr. Gregory E. Simon and his associates in the Group Health Cooperative, Seattle.
A similar telephone care management program without the psychotherapy component improved clinical outcomes to an intermediate degree and led to slightly lower costs, compared with standard care.
The investigators compared the two programs against standard care in a study of 600 patients attending seven primary care clinics in Washington State and Idaho. Both interventions were designed to improve the quality of medication management and continuity in patients who were beginning treatment for depression. Participants were identified using computerized pharmacy and visit registration records. Patients already receiving psychotherapy or other specialty mental health care were excluded. Depression severity was measured using the Symptom Checklist 90, and those with SCL-90 scores of 0.5 or above were enrolled. The mean age of participants was 44 years, and 74% were female (Arch. Gen. Psychiatry 2009;66:1081-9).
Dr. Simon and his colleagues previously reported the clinical outcomes in their study. In this report, they focused on health care costs associated with the interventions.
The 198 patients randomly assigned to the care management plus psychotherapy program received up to 12 phone calls from master's-level clinicians after receiving their first prescription for antidepressants from a primary care physician.
These calls focused on overall care management but also included a structured cognitive-behavioral psychotherapy program of eight initial sessions followed by “booster” sessions that targeted adhering to and/or refining each patient's patients' self-care plan.
The initial phone sessions lasted a mean of 31 minutes, and the booster sessions lasted a mean of 18 minutes.
The other intervention included the same telephone care-management program but not the psychotherapy component. This included five brief phone calls or mailings to monitor and improve antidepressant adherence and to support follow-up with the primary caregiver. These calls lasted a mean of 13 minutes.
After 2 years, depression scores were lowest with the first intervention, intermediate with the second intervention, and highest with standard care.
When measured in depression-free days during the 24 months of the study, patients in the management-plus-psychotherapy program gained 46 days without depression, and those in the management-only program gained 29 days, compared with patients who received standard care.
Costs were $650 higher with the first intervention and $450 higher with the second intervention, compared with standard care. Additional costs were mostly “up front”—greatest during the first 6 months of treatment, relatively small in the second 6 months of treatment, and absent after 12 months of treatment, the investigators said.
The investigators acknowledged that the main goal of depression treatment is to relieve suffering rather than decrease health care costs. “Our findings do, however, offer some guidance to insurers or health care systems considering efforts to improve care for depression.
“Efforts to improve depression treatment in primary care should consider incorporating structured psychotherapy interventions.”
The investigators noted that “a significant portion of participants was lost to follow-up over 2 years” and that possibly costs-benefits balance were different in the lost population.
This study was sponsored by the National Institute of Mental Health. Dr. Simon reported receiving consulting fees from Wyeth Pharmaceuticals and Bristol-Myers Squibb Co.