Virtual Collaborative Care Effective for Depression

Telemedicine-based collaborative care can significantly decrease depressive symptoms for patients living in rural areas, a new randomized controlled trial shows.

The trial, which included 364 rural patients with depression, showed that those assigned to receive telemedicine-based collaborative care had significantly better response and remission rates and greater reductions in depression severity compared with those assigned to practice-based collaborative care.

They also had greater increases in mental health status and quality-of-life scores and were more likely to report receiving helpful information about their depression and treatment, which the investigators describe as care manager fidelity.

Dr. John Fortney

"I was surprised by the effect size we found, the odds ratio of response. Typically, they're not that large, but I think that has to do with working with this underserved population," lead author John C. Fortney, PhD, professor of psychiatry at the University of Arkansas for Medical Sciences in Little Rock, told Medscape Medical News.

"There's a lot of talk now about integrating mental health and primary care. But that's much easier said than done, especially in medically underserved areas. So even if you have the funds to hire a mental health provider, chances are it would be difficult to locate one," added Dr. Fortney.

The investigators note that more research into treatment delivery mechanisms is needed.

The study was published online February 22 in the American Journal of Psychiatry.

Challenging Models

Although practice-based collaborative care has been shown to improve depression outcomes in numerous randomized effectiveness trials, implementing this model in smaller practices can be challenging — and employing on-site, full-time care managers and mental health professionals is often not feasible.

In fact, the investigators note that only 25% of US primary care practices have on-site mental health specialists.

With advances in technology, many organizations are looking into adapting telemedicine models that combine off-site teams with on-site primary care providers and that use telephones, videoconferencing, and electronic patient health records.

For this study, enrollment included 364 patients (81.6% women; 72% white, 21% black; mean age, 47.2 years) from 5 health centers in Arkansas' Mississippi Delta region and the Ozarks Highlands who screened positive for depression from 2007 to 2009.

"This is a setting that's not commonly studied — federally qualified health centers, which is the largest primary care network in the country," said Dr. Fortney. "They treat patients regardless of their ability to pay or health insurance status. And they serve populations that are in medically underserved areas."

All participants were randomly assigned to receive for up to 12 months either practice-based (n = 185) or telemedicine-based collaborative care (n = 179).

The practice-based care model included an on-site primary care provider and an on-site or available-by-telephone nurse depression care manager.

The telemedicine-based care model included the on-site–primary care provider plus telephone contact with an off-site nurse depression care manager and pharmacist and videoconferencing with a psychologist and a psychiatrist. These patients also had access to cognitive-behavioral therapy through videoconferencing.

Telephone follow-up interviews were conducted at 6, 12, and 18 months.

Worth Teaming Up

The primary outcome measures included depression severity, as measured on the 20-item Hopkins Symptom Checklist (HSCL); treatment response, as defined as a change of 50% or more in HSCL score from baseline; and remission rates, defined as HSCL scores of less than 0.5.

Results showed that the telemedicine-based group had a significantly better overall treatment response than the practice-based group (odds ratio [OR], 7.74; 95% confidence interval [CI], 3.94 - 15.20; P < .001), as well as significantly higher remission rates (OR, 12.69; 95% CI, 4.81 - 33.46; P < .001) and greater reductions in severity over time (P < .001).

"Improvements in outcomes appeared to be attributable to higher fidelity to the collaborative care...in the telemedicine-based group," explain the investigators.

They note that an important limitation of "this pragmatic trial" is that the results do not conclusively identify treatment mechanisms.

Nevertheless, the findings do suggest that "contracting with an off-site telemedicine-based collaborative care team can yield better outcomes than implementing practice-based collaborative care with locally available staff," they write.

In other words, "when small clinics don't really have the capacity to hire a mental health specialist, the recommendation is to try to come together as a group of primary care clinics, band together resources, and contract with outside specialists in this collaborative care model rather than doing just some of the evidence-based practice themselves with the resources they have on site," added Dr. Fortney.

"The take-away message is that it's worth trying to team up with these mental health specialists to provide integrative care."

The study was funded by a grant from the National Institute of Mental Health. The study authors have reported no relevant financial relationships.

AJP in Advance. Published online February 22, 2013. Abstract