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

Collaborative care for the management of depressive disorders is a multicomponent, healthcare system-level intervention that uses case managers to link primary care providers, patients, and mental health specialists. This collaboration is designed to:

1. Improve the routine screening and diagnosis of depressive disorders
2. Increase provider use of evidence-based protocols for the proactive management of diagnosed depressive disorders
3. Improve clinical and community support for active patient engagement in treatment goal setting and self-management

Collaborative care models (Katon 2001) typically have case managers, who support primary care providers with functions such as:

• Patient education
• Patient follow up to track depression outcomes and adherence to treatment
• Adjustment of treatment plans for patients who do not improve

Primary care providers are usually responsible for:

• Routine screening for and diagnosing of depressive disorders
• Initiating treatment for depression
• Referring patients to mental health specialists as needed

These mental health specialists provide clinical advice and decision support to primary care providers and case managers. These processes are frequently coordinated by technology-based resources such as electronic medical records, telephone contact, and provider reminder mechanisms.

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 Task Force Recommendations & Findings

The Task Force on Community Preventive Services recommends collaborative care for the management of depressive disorders based on strong evidence of effectiveness in improving depression symptoms, adherence to treatment, response to treatment, and remission and recovery from depression.

The Task Force also finds that collaborative care models provide good economic value based on the weight of evidence from studies that assessed both costs and benefits.

Task Force Finding & Rationale Statement

Results from the Systematic Reviews & Meta-Analyses

This Task Force recommendation is based on evidence from an earlier review (Bower et al. 2006; search period 1966-2004) and a current review (search period 2004-2009).

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)

Community Guide Review (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

Results suggest collaborative care models are applicable to:

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

Healthcare providers play different roles in collaborative care models.

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

This review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice and policy related to mental health and mental illness.

Economic Review

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.

Supporting Materials

• Definitions of terms
• Research gaps
• Summary evidence table [PDF - 481KB]
• Summary evidence table – Economic Review [PDF - 783KB]
• Included studies
• Search strategy

References

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.

Publications

The findings and results of this systematic review have not been published. Read other Community Guide publications about Mental Health and Mental Illness in our library. You may also subscribe to be notified as new materials on this topic become available.

Promotional Materials

• Promotional materials about Collaborative Care to Manage Depressive Disorders

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Sample Citation

The content of publications of the Guide to Community Preventive Services is in the public domain. Citation as to source, however, is appreciated. Sample citation: Guide to Community Preventive Services. Mental health & mental illness: collaborative care for the management of depressive disorders. www.thecommunityguide.org/mentalhealth/collab-care.html. Last updated: MM/DD/YYYY.

Review Completed: July 2010