Can depression treatment in primary care reduce disability? A stepped careapproach

Objective: To assess effects of stepped collaborative care depression inter vention on disability. Design: Randomized controlled trial. Setting: Four primary care clinics of a large health maintenance organizati on. Patients: Two hundred twenty-eight patients with either 4 or more persisten t major depressive symptoms or a score of 1.5 or greater on the Hopkins Sym ptom Checklist. Depression items were randomized to stepped care interventi on or usual care 6 to 8 weeks after initiating antidepressant medication. Intervention: Augmented treatment of persistently depressed patients by an on-site psychiatrist collaborating with primary care physicians. Treatment included patient education, adjustment of pharmacotherapy, and proactive mo nitoring of outcomes. Main Outcome Measures: Baseline, 1-, 3-, and 6-month assessments of the She ehan Disability Scale and the social function and role limitation subscales of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). Results: Patients who received the depression intervention experienced less interference in their family, work, and social activities than patients re ceiving usual primary care (Sheehan Disability Scale, z = 2.23; P = .025). Patients receiving intervention also reported a trend toward more improveme nt in SF-36-defined social. functioning than patients receiving usual care (z=1.63,P=.10),but there was no significant difference in role performance (z=0.07, P=.94). Conclusions: Significant disability accompanied depression in this persiste ntly depressed group. The stepped care intervention resulted in small to mo derate functional improvements for these primary care patients.