Mental Health and Mental Illness: Collaborative Care for the Management of Depressive Disorders
Findings and Recommendations
The Community Preventive Services Task Force (CPSTF) 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 CPSTF also finds that collaborative care models provide good economic value based on the weight of evidence from studies that assessed both costs and benefits.
The full CPSTF Finding and Rationale Statement and supporting documents for Improving Mental Health and Addressing Mental Illness: Collaborative Care for the Management of Depressive Disorders are available in The Community Guide Collection on CDC Stacks.
Intervention
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:
- Improve the routine screening and diagnosis of depressive disorders
- Increase provider use of evidence-based protocols for the proactive management of diagnosed depressive disorders
- Improve clinical and community support for active patient engagement in treatment goal setting and self-management
Collaborative care models (Katon et al., 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.
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).
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.
Summary of Results
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
The evidence from this economic review suggests that collaborative care for the management of depressive disorder is both cost-effective and cost-beneficial.
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).
- Of the five studies that considered costs and benefits, four showed that the interventions were cost beneficial.
- 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).
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
- 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.
- 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.
Implementation Considerations and Resources
- While physicians were the primary care providers in most studies, the few studies that used other professionals (e.g., nurses and physician assistants) in this role reported similar effects.
- Nurses served as case managers in most of the included studies. In some instances, social workers or master’s-level mental health workers served in this role.
- The effect estimate from studies using master’s-level mental health workers was smaller than the overall estimate. More skills development is likely needed for those serving as case managers.
- Organizations should ensure that training is adequate for all individuals working as case managers and emphasize effective communication among providers.
- Psychiatrists and psychologists most often served as the mental health specialists, though two studies that used physicians or nurses with advanced training in this role reported comparable results.
- Results suggest collaborative care interventions are effective when implemented by a variety of organizations, including managed care organizations, academic medical centers, community-based organizations, the Veterans Health Administration, and universal health coverage systems (e.g., the National Health Service in the United Kingdom).
- Reported barriers to implementation of collaborative included the following.
- Patient reluctance to enroll
- Low patient appointment attendance
- Limited insurance coverage for mental health care
- Challenges locating organizations in the community that offer depression care at nonconventional points-of-care such as homes or worksites
- Training specialists from other fields in collaborative care for patients with depression comorbid with other chronic illnesses
- Difficulties reaching patients who prefer face-to-face over telephone contact for counseling and care management
Crosswalks
Healthy People 2030 includes the following objectives related to this CPSTF recommendation.