Follow-Ups Prove Powerful Tool for Treating Depression in Primary Care
In the 15
minutes a primary care doctor typically has with a patient, she's
expected to diagnose the current ailment, help manage ongoing health
issues and provide preventive care. In this setting, confronting all
but the most obvious and immediate mental health needs of patients is
an ongoing challenge.
A new study by researchers at the University of
Michigan (U-M) Health System, however, points to an encouraging
strategy for improving and sustaining mental health results in
chronically depressed patients by providing small amounts of flexible,
targeted follow-up care -- without overburdening busy doctors' offices.
The study, published in Annals of Family Medicine,
shows that patients who received interventions that included
self-monitoring tools and follow-up phone calls from a care manager
were more likely a year and a half later to have symptoms that were in
remission and to have fewer reduced-function days than those receiving
usual primary care treatment.
"They key is to keep patients engaged in
treatment," said Michael Klinkman, M.D., M.S., a professor of family
medicine at the University of Michigan Medical School and lead author
of the study. "What it's not is telephone therapy. Patients have a
human contact, somebody who can help them become more actively involved
in their own care. It's hard to do that if you're just spoon feeding
information to 'educate' a patient or telling them to go to a website."
With a more traditional approach that depends on a
follow-up office visit, it might be months before a primary care doctor
learns that his patient's depression is getting worse. And in many
cases patients simply don't follow up.
For the study, a care manager worked in
collaboration with doctors' practices, rather than on the side or
independently, Klinkman said. That helps the family practice office to
act as a home base for all of a patient's medical needs. The approach
can also serve as a model for treating other types of chronic
conditions, he adds.
Many patients have depression alongside other mental health and medical problems, Klinkman noted.
"There are people with chronic issues who have had
multiple depressive episodes in the past," he said. "No one wants to
study them because it's hard to make them better. But we didn't cherry
pick, we took everyone -- and the rate of remission we saw was about
double what it has been with usual care. The other thing that is really
noteworthy: the results persisted over time."
While some patients did become less engaged when
their symptoms started getting better, many got back in touch with
their care manager when things started to slip again.
"We helped get people back into care who otherwise might not have returned to treatment," Klinkman said.
Methodology: Depression interventions were
introduced in five family care practices at the U-M Health System.
Clinicians were free to refer none, some or all of their depressed
patients. In the analysis, 728 enrollees were compared to 78 control
patients receiving usual care. At the end of 18 months, 49.2 percent of
120 enrollees who completed 18-month assessments were in remission,
compared to 27.3 percent of 66 people in the usual-care control group.
Additional U-M authors: Sabrina Bauroth, M.S.W.;
Stacey Fedewa, M.P.H.; Kevin Kerber, M.D.; Julie Kuebler, C.N.P.; Tanya
Adman, M.S.W.; Ananda Sen, Ph.D.
Funding: The project was supported by grants from the Robert Wood Johnson Foundation.
For more information on the University of Michigan Health System, visit http://www.med.umich.edu.