Intervention impact on depression product appraisal and purchasing behavior by employers: a randomized trial.

BACKGROUND: Employers can purchase high quality depression products that provide the type, intensity and duration of depression care management shown to improve work outcomes sufficiently for many employers to achieve a return on investment. The purpose of this randomized controlled trial was to test an intervention to encourage employers to purchase a high quality depression product for their workforce. METHODS: Twenty nine organizations recruited senior health benefit professional members representing public or private employers who had not yet purchased a depression product for all 100+ workers in their company. The research team used randomization blocked by company size to assign eligible employers to: (1) a presentation encouraging employers to purchase a high quality depression product accompanied by a scientifically-derived return on investment estimate, or (2) a presentation encouraging employers to work with their most subscribed health plan to improve depression treatment quality indicators. Two hundred ninety three employers (82.3% of 356) completed baseline data immediately before learning that 140 employers had been randomized to the evidence-based (EB) depression product presentation and 153 had been randomized to the usual care (UC) depression treatment quality indicator presentation. Analysis of 250 (85.3% of 293) employers who completed web-based interviews at 12 and/or 24 months was conducted to determine presentation impact on depression product appraisal and purchasing behavior. RESULTS: The intervention had no impact on depression product appraisal in 232 subjects (F = 2.36, p = .07) or depression product purchasing (chisquare = 1.82, p = .44) in 250 subjects. Depression product appraisal increased in companies with greater health benefit generosity whose benefit professionals were male. Depression product purchasing behavior increased in small companies compared to large companies, companies who knew a vendor that sold depression products at baseline, companies with greater health benefit risk taking, and companies with less politicalization of health care benefit decision making. CONCLUSIONS: Policy makers need to build innovative bridges to the employer community to convince them to purchase evidence-based benefits, even when benefits offer potential financial savings. CLINICAL TRIALS REGISTRATION NUMBER: NCT01013220.

Work productivity loss from depression: evidence from an employer survey.

BACKGROUND: National working groups identify the need for return on investment research conducted from the purchaser perspective; however, the field has not developed standardized methods for measuring the basic components of return on investment, including costing out the value of work productivity loss due to illness. Recent literature is divided on whether the most commonly used method underestimates or overestimates this loss. The goal of this manuscript is to characterize between and within variation in the cost of work productivity loss from illness estimated by the most commonly used method and its two refinements. METHODS: One senior health benefit specialist from each of 325 companies employing 100+ workers completed a cross-sectional survey describing their company size, industry and policies/practices regarding work loss which allowed the research team to derive the variables needed to estimate work productivity loss from illness using three methods. Compensation estimates were derived by multiplying lost work hours from presenteeism and absenteeism by wage/fringe. Disruption correction adjusted this estimate to account for co-worker disruption, while friction correction accounted for labor substitution. The analysis compared bootstrapped means and medians between and within these three methods. RESULTS: The average company realized an annual $617 (SD = $75) per capita loss from depression by compensation methods and a $649 (SD = $78) loss by disruption correction, compared to a $316 (SD = $58) loss by friction correction (p < .0001). Agreement across estimates was 0.92 (95% CI 0.90, 0.93). CONCLUSION: Although the methods identify similar companies with high costs from lost productivity, friction correction reduces the size of compensation estimates of productivity loss by one half. In analyzing the potential consequences of method selection for the dissemination of interventions to employers, intervention developers are encouraged to include friction methods in their estimate of the economic value of interventions designed to improve absenteeism and presenteeism. Business leaders in industries where labor substitution is common are encouraged to seek friction corrected estimates of return on investment. Health policy analysts are encouraged to target the dissemination of productivity enhancing interventions to employers with high losses rather than all employers. CLINICAL TRIALS REGISTRATION NUMBER: NCT01013220.

Electronic medical record availability and primary care depression treatment.

BACKGROUND: Electronic medical records (EMR) are commonly believed to improve quality of care. Primary care patients with multiple chronic conditions have potentially greater opportunity to benefit from receiving care at practices with EMRs if these systems help coordinate complex care. OBJECTIVE: To examine how chronic conditions impact the odds that depressed patients receive depression treatment in primary care practices with EMRs compared to practices without EMRs. DESIGN: The study uses logistic regression to analyze cross-sectional data of primary care physician office visits in freestanding, office-based practices from the 2006-2008 National Ambulatory Medical Care Surveys. PATIENTS: All visits to primary care providers made by patients ages 18 and older with physician-identified depression (N = 3,467). MAIN MEASURES: Outcomes include depression treatment which is defined as receipt or ordering of antidepressant medication and/or mental health counseling. KEY RESULTS: EMRs were associated with significantly lowered odds that depressed patients received depression treatment (OR = 0.75, p = 0.009, 95% CI: 0.61-0.93); however when stratified by the number of chronic conditions, this association was observed only in patients with three or more chronic conditions (OR = 0.50, p > 0.001, 95% CI: 0.36-0.70). EMRs did not have a significant association with depression treatment for patients with two or fewer chronic conditions. CONCLUSIONS: EMRs appear to have an unintended negative association with depression care provided during visits made by primary care patients with multiple chronic conditions.

Pilot study of a preliminary criterion standard for prescription opioid misuse.

Multidisciplinary experts created a behaviorally defined preliminary criterion standard definition of probable prescription opioid misuse (PPOM) that could be rated from material found in administrative, pharmacy, and electronic health record databases. They then derived a scoring system to identify PPOM patients requiring referral to a specialist. Experts next rated cases of misuse and nonmisuse. Rater no. 1 correctly differentiated 37 of 40 cases (92.5%); kappa coefficient was .79 (CI: .57, 1.00). Rater no. 2 correctly identified 39 of 40 cases (97.5%); kappa was .94 (CI: .81, 1.00). Kappa for comparing raters was .73 (CI: .49, .98). This preliminary study demonstrates that multidisciplinary raters can use behaviorally based criteria to identify patients with known PPOM from health plan databases.

Testing for statistical discrimination by race/ethnicity in panel data for depression treatment in primary care.

OBJECTIVE: To test for discrimination by race/ethnicity arising from clinical uncertainty in treatment for depression, also known as "statistical discrimination." DATA SOURCES: We used survey data from 1,321 African-American, Hispanic, and white adults identified with depression in primary care. Surveys were administered every six months for two years in the Quality Improvement for Depression (QID) studies. STUDY DESIGN: To examine whether and how change in depression severity affects change in treatment intensity by race/ethnicity, we used multivariate cross-sectional and change models that difference out unobserved time-invariant patient characteristics potentially correlated with race/ethnicity. DATA COLLECTION/EXTRACTION METHODS: Treatment intensity was operationalized as expenditures on drugs, primary care, and specialty services, weighted by national prices from the Medical Expenditure Panel Survey. Patient race/ethnicity was collected at baseline by self-report. PRINCIPAL FINDINGS: Change in depression severity is less associated with change in treatment intensity in minority patients than in whites, consistent with the hypothesis of statistical discrimination. The differential effect by racial/ethnic group was accounted for by use of mental health specialists. CONCLUSIONS: Enhanced physician-patient communication and use of standardized depression instruments may reduce statistical discrimination arising from clinical uncertainty and be useful in reducing racial/ethnic inequities in depression treatment.

Predicting outcomes of primary care patients with major depression: development of a depression prognosis index.

OBJECTIVE: Depression research and practice focus increasingly on diverse patient populations with varying probabilities of response to clinical care. Prognostic indices use preexisting patient characteristics to estimate the probability of subsequent negative clinical outcomes and are useful tools for improving the study and care of diverse populations. Few such measures, however, have been developed for mental health conditions. This study developed and validated a depression prognosis measure for primary care patients with major depression. METHODS: Consecutive patients in 108 primary care practices were screened for depression, and 1,471 with major depression were enrolled. A Depression Prognosis Index (DPI) predicting persistent depression six months after baseline was developed for a random one-third subsample and validated with the remaining two-thirds. Models included prior treatment, demographic characteristics, comorbidities, and other physical, psychological, and social predictors. RESULTS: Sixty-four percent to 65% of patients classified by baseline DPI score as being in the sample quartile with the worst prognosis had probable major depression six months later, compared with 14% to 15% in the best-prognosis quartile. The DPI had an R2 of .40 in the development sample and .27 in the validation sample. Important predictors included severity of depression symptoms at baseline, social support, common physical symptoms, and having completed three months of antidepressants at sample entry. CONCLUSIONS: The ability of the DPI to predict six-month outcomes compares favorably to that of prognostic indices for general medical problems. These results validate the DPI and provide conceptual guidance for further development of depression risk stratification instruments for clinical and research use.

Practice-Based Versus Telemedicine-Based Collaborative Care for Depression in Rural Federally Qualified Health Centers: A Pragmatic Randomized Comparative Effectiveness Trial.

(Reprinted with permission from American Journal of Psychiatry 2013; 170:414-425).

Multisomatoform disorder: agreement between patient and physician report of criterion symptom explanation.

OBJECTIVE: To determine the level of agreement between patients and expert physicians in whether criterion multisomatoform (MSD) symptoms are explained. METHODS: We systematically collected reports from 280 primary care patients about whether they had suffered from any of 15 criterion MSD symptoms in the past month and whether they had received a medical explanation from a physician for positive criterion symptoms. The research team compared MSD symptom diagnoses derived from patient report with MSD symptom diagnoses derived from an expert physician report. RESULTS: MSD symptom diagnoses derived from patient report had 98.7% sensitivity, 97.9% specificity, 89.3% positive predictive value, and 99.7% negative predictive value compared with MSD symptom diagnoses derived from an expert physician report. Analysis demonstrated that 15.0% of patients met symptom criteria for MSD, according to patient and physician report; 83.0% failed to meet symptom criteria for MSD, according to patient and physician report; 1.8% of patients met symptom criteria for MSD, according to patient report but not physician report, while 0.2% met symptom criteria for MSD according to physician report but not by patient report. CONCLUSION: Patients demonstrated high agreement with a physician expert in somatization about whether criterion MSD symptoms are explained, suggesting revised screeners may accurately identify somatizing patients.

Improving depression treatment by integrated care.

OBJECTIVE: To identify the clinical and economic implications of depression in the workplace and review how integrated care models can improve overall patient outcomes. SUMMARY: Depression is a significant financial burden to the employer due to lost days of work and decreased productivity. Employers are demanding return on the investment for their increasing health care expenditures. The cost of depression to employers may be contained by delivering care using integrated models that leverage primary care provider treatment with care management and mental health consultation. CONCLUSION: There is a need to reduce silos in the organization and financing of mental health care to prevent cost shifting that provides no benefit to patients, payers or providers. Poor mental health care will likely lead to a rise in absenteeism and presenteeism.

Impact of primary care depression intervention on employment and workplace conflict outcomes: is value added?

BACKGROUND: Depression causes significant functional impairment in sufferers and often leads to adverse employment outcomes for working individuals. Recovery from depression has been associated with better employment outcomes at one year. AIMS OF THE STUDY: The study s goals were to assess a primary care depression intervention s impact on subsequent employment and workplace conflict outcomes in employed patients with depression. METHODS: In 1996-1997, the study enrolled 262 employed patients with depression from twelve primary care practices located across ten U.S. states; 219 (84%) of the patients were followed at one year. Intent-to-treat analyses assessing intervention effects on subsequent employment and workplace conflict were conducted using logistic regression models controlling for individual clinical and sociodemographic characteristics, job classification and local employment conditions. To meet criteria for subsequent employment, persons working full-time at baseline had to report they were working full-time at follow-up and persons working part-time at baseline had to report working part-/full-time at follow-up. Workplace conflict was measured by asking patients employed at follow-up whether, in the past year, they had arguments or other difficulties with people at work . RESULTS: Findings showed that 92.1% of intervention patients met criteria for subsequent employment at one year, versus 82.0% of usual care patients (c2=4.42, p=.04). Intervention patients were less likely than usual care patients to report workplace conflict in the year following baseline (8.1% vs. 18.9%, respectively; c2=4.11; p=.04). The intervention s effect on subsequent employment was not mediated by its effect on workplace conflict. DISCUSSION: The intervention significantly improved employment outcomes and reduced workplace conflict in depressed, employed persons at one year. Economic implications for employers related to reduced turnover costs, for workers related to retained earnings, and for governments related to reduced unemployment expenditures and increased tax receipts may be considerable. LIMITATIONS: Although similar primary care depression interventions have been shown to produce comparable effects on subsequent employment at one year, replications in larger samples of depressed, employed patients in different economic climates may be necessary to increase the generalizability and precision of estimates. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Primary care interventions that enhance depression treatment and improve clinical outcomes can contribute meaningful added value to society by improving employment and workplace outcomes. IMPLICATIONS FOR HEALTH POLICIES: Federal/state governments may realize economic benefits from reduced unemployment expenditures and increased tax receipts should primary care depression interventions that improve employment outcomes be broadly disseminated. Policy initiatives to increase the dissemination of such interventions may be an innovative approach for improving labor force participation by depressed individuals. IMPLICATIONS FOR FURTHER RESEARCH: Formal cost-benefit analyses are needed to explore whether economic benefits to societal stakeholders from these and other labor outcomes equal or exceed the incremental costs of disseminating similar primary care interventions nationally. Researchers in other nations may wish to consider investigating the impact primary care depression interventions might have on employment and workplace outcomes in their countries.

Minor acute illness: a preliminary research report on the "worried well".

OBJECTIVES: Our objectives were to determine how patients who make frequent use of the medical system (high users) with medically unexplained symptoms met our chart-rating criteria for somatization and minor acute illness and what the stability of such diagnoses were over time. STUDY DESIGN: A chart review was performed at baseline and 1 and 2 years; we re-rated the charts of patients initially rated as having somatization, as well as a 15% sample of those with minor acute illness. POPULATION: We obtained a random sample of high-use patients (= 6 visits/year) aged 21 to 55 years who were identified from the management information system. OUTCOMES: We measured chart review designations as organic disease, somatization, or minor acute illness. RESULTS: Among 883 high users at baseline, 35% had organic diseases; 14% had somatization; and 51% had minor acute illness as their primary problems. No patients with initial minor acute diagnoses were reclassified as having somatization 1 or 2 years later, and all but 2 patients had minor acute illness in 1 or both follow-up years. CONCLUSIONS: Minor acute illness was more common among high users than somatization and organic diseases combined. It has not previously been studied but probably has been recognized by clinicians as the "worried well." Diagnoses of somatization were unstable over 2 years follow-up, while minor acute diagnoses were stable, supporting the latter as a valid entity.

Practice-based versus telemedicine-based collaborative care for depression in rural federally qualified health centers: a pragmatic randomized comparative effectiveness trial.

OBJECTIVE: Practice-based collaborative care is a complex evidence-based practice that is difficult to implement in smaller primary care practices that lack on-site mental health staff. Telemedicine-based collaborative care virtually co-locates and integrates mental health providers into primary care settings. The objective of this multisite randomized pragmatic comparative effectiveness trial was to compare the outcomes of patients assigned to practice-based and telemedicine-based collaborative care. METHOD: From 2007 to 2009, patients at federally qualified health centers serving medically underserved populations were screened for depression, and 364 patients who screened positive were enrolled and followed for 18 months. Those assigned to practice-based collaborative care received evidence-based care from an on-site primary care provider and a nurse care manager. Those assigned to telemedicine-based collaborative care received evidence-based care from an on-site primary care provider and an off-site team: a nurse care manager and a pharmacist by telephone, and a psychologist and a psychiatrist via videoconferencing. The primary clinical outcome measures were treatment response, remission, and change in depression severity. RESULTS: Significant group main effects were observed for both response (odds ratio=7.74, 95% CI=3.94-15.20) and remission (odds ratio=12.69, 95% CI=4.81-33.46), and a significant overall group-by-time interaction effect was observed for depression severity on the Hopkins Symptom Checklist, with greater reductions in severity over time for patients in the telemedicine-based group. Improvements in outcomes appeared to be attributable to higher fidelity to the collaborative care evidence base in the telemedicine-based group. CONCLUSIONS: Contracting with an off-site telemedicine-based collaborative care team can yield better outcomes than implementing practice-based collaborative care with locally available staff.

Marketing depression care management to employers: design of a randomized controlled trial.

BACKGROUND: Randomized trials demonstrate that depression care management can improve clinical and work outcomes sufficiently for selected employers to realize a return on investment. Employers can now purchase depression products that provide depression care management, defined as employee screening, education, monitoring, and clinician feedback for all depressed employees. We developed an intervention to encourage employers to purchase a depression product that offers the type, intensity, and duration of care management shown to improve clinical and work outcomes. METHODS: In a randomized controlled trial conducted with 360 employers of 30 regional business coalitions, the research team proposes to compare the impact of a value-based marketing intervention to usual-care marketing on employer purchase of depression products. The study will also identify mediators and organizational-level moderators of intervention impact. Employers randomized to the value-based condition receive a presentation encouraging them to purchase depression products scientifically shown to benefit the employee and the employer. Employers randomized to the usual-care condition receive a presentation encouraging them to monitor and improve quality indicators for outpatient depression treatment. Because previous research demonstrates that the usual-care intervention will have little to no impact on employer purchasing, depression product purchasing rates in the usual-care condition capture vendor efforts to market depression products to employers in both conditions while the value-based intervention is being conducted. Employers in both conditions are also provided free technical assistance to undertake the actions each presentation encourages. The research team will use intent-to-treat models of all available data to evaluate intervention impact on the purchase of depression products using a cumulative incidence analysis of 12- and 24-month data. DISCUSSION: By addressing the 'value to whom?' question, the study advances knowledge about one of the most pivotal problems in the translation of evidence-based care to 'real world' settings: whether purchasers can be influenced to buy healthcare products on the basis of value and not exclusively on the basis of cost. If value-based marketing increases depression product purchase rates over usual care, this study will provide encouragement to market new healthcare products on the basis of the product's value to the purchaser as well as the recipient of care. CLINICAL TRIALS REGISTRATION NUMBER: NCT01013220.

Primary care patients' involvement in decision-making is associated with improvement in depression.

BACKGROUND: Depression is undertreated in primary care settings. Little research investigates the impact of patient involvement in decisions on guideline-concordant treatment and depression outcomes. OBJECTIVE: The objective of this study was to determine whether patient involvement in decision-making is associated with guideline-concordant care and improvement in depression symptoms. DESIGN: Prospective cohort study. SETTING: Multisite, nationwide randomized clinical trial of quality improvement strategies for depression in primary care. SUBJECTS: Primary care patients with current symptoms and probable depressive disorder. MEASUREMENTS: Patients rated their involvement in decision-making (IDM) about their care on a 5-point scale from poor to excellent 6 months after entry into the study. Depressive symptoms were measured every 6 months for 2 years using a modified version of the Center for Epidemiologic Studies-Depression (CES-D) scale. We examined probabilities (Pr) of receipt of guideline-concordant care and resolution of depression across IDM groups using multivariate logistic regression models controlling for patient and provider factors. RESULTS: For each 1-point increase in IDM ratings, the probability of patients' report of receiving guideline-concordant care increased 4% to 5% (adjusted Pr 0.31 vs. 0.50 for the lowest and highest IDM ratings, respectively, P < 0.001). Similarly, for each 1-point increase in IDM ratings, the probability of depression resolution increased 2% to 3% (adjusted Pr 0.10 vs. 0.19 for the lowest and highest IDM ratings respectively, P = 0.004). CONCLUSIONS: Depressed patients with higher ratings of involvement in medical decisions have a higher probability of receiving guideline-concordant care and improving their symptoms over an 18-month period. Interventions to increase patient involvement in decision-making may be an important means of improving care for and outcomes of depression.

One size fits some: the impact of patient treatment attitudes on the cost-effectiveness of a depression primary-care intervention.

BACKGROUND: Despite their impact on outcomes, the effect of patient treatment attitudes on the cost-effectiveness of health-care interventions is not widely studied. This study estimated the impact of patient receptivity to antidepressant medication on the cost-effectiveness of an evidence-based primary-care depression intervention. METHOD: Twelve community primary-care practices were stratified and then randomized to enhanced (intervention) or usual care. Subjects included 211 patients beginning a new treatment episode for major depression. At baseline, 111 (52.6%) and 145 (68.7%) reported receptivity to antidepressant medication and counseling respectively. The intervention trained the primary-care teams to assess, educate, and monitor depressed patients. Twelve-month incremental (enhanced minus usual care) total costs and quality-adjusted life years (QALYs) were calculated. RESULTS: Among patients receptive to antidepressants, the mean incremental cost-effectiveness ratio was dollar 5,864 per QALY (sensitivity analyses up to dollar 14,689 per QALY). For patients not receptive to antidepressants, the mean incremental QALY score was negative (for both main and sensitivity analyses), or the intervention was at least no more effective than usual care. CONCLUSIONS: These findings suggest a re-thinking of the 'one size fits all' depression intervention, given that half of depressed primary-care patients may be non-receptive to antidepressant medication treatment. A brief assessment of treatment receptivity should occur early in the treatment process to identify patients most likely to benefit from primary-care quality improvement efforts for depression treatment. Patient treatment preferences are also important for the development, design, and analysis of depression interventions.

Impact of ongoing primary care intervention on long term outcomes in uninsured and insured patients with depression.

BACKGROUND AND OBJECTIVES: To assess the differential impact of an ongoing primary care depression intervention on uninsured and insured patients' outcomes 12, 18, and 24 months following baseline. RESEARCH DESIGN: Quasi-experimental longitudinal study of insured and uninsured patients with depression receiving treatment from 12 practices randomized to enhanced (intervention) and usual care study conditions. SUBJECTS: In 1996 to 1997, 383 nonelderly patients with depression (290 insured, 93 uninsured) were enrolled and followed for 24 months. MEASURES: Mental-health-related-quality-of-life (MHQOL) was assessed at each follow-up using the SF-36 Mental Component Summary scale. Presence of major depressive episode was assessed at 24-month follow-up with the Composite International Diagnostic Interview. RESULTS: Uninsured enhanced-care patients had significantly better MHQOL outcomes at 24 months than uninsured usual care patients (40.6 vs. 32.7, respectively; P = 0.01). The intervention had no significant impact on insured patients' MHQOL outcomes at any follow-up interval. Among patients receiving usual care, the uninsured compared with the insured had significantly poorer MHQOL outcomes (32.7 vs. 40.7, respectively; P = 0.002) and significantly increased probability of experiencing a major depressive episode (40.6% vs. 19.8%, respectively; P = 0.04) at 24 months. No such disparities were observed between uninsured and insured patients receiving enhanced care. CONCLUSIONS: The ongoing intervention significantly improved quality-of-life outcomes in uninsured patients at 24 months. If the intervention's impact on MHQOL can be confirmed and proved cost-effective in larger uninsured patient populations, clinicians serving the uninsured may want to consider implementing the study's intervention.

Does a depression intervention result in improved outcomes for patients presenting with physical symptoms?

OBJECTIVE: To investigate the effects of exclusively physical presentation of depression on 1). depression management and outcomes under usual care conditions, and 2). the impact of an intervention to improve management and outcomes. DESIGN AND SETTING: Secondary analysis of a depression intervention trial in 12 community-based primary care practices. PARTICIPANTS: Two hundred adults beginning a new treatment episode for depression. MEASUREMENTS: Presenting complaint and physician depression query at index visit; antidepressant use, completion of adequate antidepressant trial, change in depressive symptoms, and physical and emotional role functioning at 6 months. MAIN RESULTS: Sixty-six percent of depressed patients presented exclusively with physical symptoms. Under usual care conditions, psychological presenters were more likely than physical presenters to complete an adequate trial of antidepressant treatment but experienced equivalent improvements in depressive severity and role functioning. In patients presenting exclusively with physical symptoms, the intervention significantly improved physician query (40.8% vs 18.0%; P =.06), receipt of any antidepressant (63.0% vs 20.1%; P =.001), and an adequate antidepressant trial (34.9% vs 5.9%; P =.004), but did not significantly improve depression severity or role functioning. In patients presenting with psychological symptoms, the intervention significantly improved receipt of any antidepressant (79.9% vs 38.0%; P =.01) and an adequate antidepressant trial (46.0% vs 23.8%; P =.004), and also improved depression severity and physical and emotional role functioning. CONCLUSIONS: Our results suggest that there is a differential intervention effect by presentation style at the index visit. Thus, current interventions should be targeted at psychological presenters and new approaches should be developed for physical presenters.

Cost-effectiveness of a primary care depression intervention.

OBJECTIVE: To determine the incremental cost-effectiveness of a quality improvement depression intervention (enhanced care) in primary care settings relative to usual care. DESIGN: Following stratification, we randomized 12 primary care practices to enhanced or usual care conditions and followed patients for 12 months. SETTING: Primary care practices located in 10 states across the United States. PATIENTS/PARTICIPANTS: Two hundred eleven patients beginning a new treatment episode for major depression. INTERVENTIONS: Training the primary care team to assess, educate, and monitor depressed patients during the acute and continuation stages of their depression treatment episode over 1 year. MEASUREMENTS AND MAIN RESULTS: Cost-effectiveness was measured by calculating incremental (enhanced minus usual care) costs and quality-adjusted life years (QALYs) derived from SF-36 data. The mean incremental cost-effectiveness ratio in the main analysis was US dollars 15463 per QALY. The mean incremental cost-effectiveness ratios for the sensitivity analyses ranged from US dollars 11341 (using geographic block variables to control for pre-intervention service utilization) to US dollars 19976 (increasing the cost estimates by 50%) per QALY. CONCLUSIONS: This quality improvement depression intervention was cost-effective relative to usual care compared to cost-effectiveness ratios for common primary care interventions and commonly cited cost-effectiveness ratio thresholds for intervention implementation.

The acceptability of treatment for depression among African-American, Hispanic, and white primary care patients.

BACKGROUND: Ethnic minority patients are less likely than white patients to receive guideline-concordant care for depression. It is uncertain whether racial and ethnic differences exist in patient beliefs, attitudes, and preferences for treatment. METHODS: A telephone survey was conducted of 829 adult patients (659 non-Hispanic whites, 97 African Americans, 73 Hispanics) recruited from primary care offices across the United States who reported 1 week or more of depressed mood or loss of interest within the past month and who met criteria for Major Depressive Episode in the past year. Within this cohort, we examined differences among African Americans, Hispanics, and whites in acceptability of antidepressant medication and acceptability of individual counseling. RESULTS: African Americans (adjusted OR, 0.30; 95% CI 0.19-0.48) and Hispanics (adjusted OR, 0.44; 95% CI, 0.26-0.76) had lower odds than white persons of finding antidepressant medications acceptable. African Americans had somewhat lower odds (adjusted OR, 0.63; 95% CI, 0.35-1.12), and Hispanics had higher odds (adjusted OR, 3.26; 95% CI, 1.08-9.89) of finding counseling acceptable than white persons. Some negative beliefs regarding treatment were more prevalent among ethnic minorities; however adjustment for these beliefs did not explain differences in acceptability of treatment for depression. CONCLUSIONS: African Americans are less likely than white persons to find antidepressant medication acceptable. Hispanics are less likely to find antidepressant medication acceptable, and more likely to find counseling acceptable than white persons. Racial and ethnic differences in beliefs about treatment modalities were found, but did not explain differences in the acceptability of depression treatment. Clinicians should consider patients' cultural and social context when negotiating treatment decisions for depression. Future research should identify other attitudinal barriers to depression care among ethnic minority patients.

Primary care patients with depression are less accepting of treatment than those seen by mental health specialists.

OBJECTIVE: This study examined whether depressed patients treated exclusively in primary care report less need for care and less acceptability of treatment options than those depressed patients treated in the specialty mental health setting after up to 6 months of treatment. DESIGN: Cross-sectional study. SETTING: Forty-five community primary care practices. PARTICIPANTS: A total of 881 persons with major depression who had received mental health services in the previous 6 months and who enrolled in 3 of the 4 Quality Improvement for Depression Collaboration Studies. MEASUREMENTS AND RESULTS: Patients were categorized into 1 of 2 groups: 1) having received mental health services exclusively from a primary care provider (45%), or 2) having received any services from a mental health specialist (55%) in the previous 6 months. Compared with patients who received care from mental health specialists, patients who received mental health services exclusively from primary care providers had 2.7-fold the odds (95% confidence interval [CI], 1.6 to 4.4) of reporting that no treatment was definitely acceptable and had 2.4-fold the odds (95% CI, 1.5 to 3.9) of reporting that evidence-based treatment options (antidepressant medication) were definitely not acceptable. These results were adjusted for demographic, social/behavioral, depression severity, and economic factors using multiple logistic regression analysis. CONCLUSIONS: Patients with depression treated exclusively by primary care providers have attitudes and beliefs more averse to care than those seen by mental health specialists. These differences in attitudes and beliefs may contribute to lower quality depression care observed in comparisons of primary care and specialty mental health providers.