Collaborative Care Promising for Severe, Persistent Depression

Megan Brooks

August 11, 2016

A multidisciplinary specialist depression service (SDS) may be an effective way of managing patients with persistent moderate to severe depression, new research suggests.

Investigators found that collaborative specialist care involving integrated psychiatric and pharmacologic treatment lasting at least 12 months was more effective for depressive symptoms than usual generic community mental health care by 18 months' follow-up. However, cost may be a limiting factor.

"We think this line of research should be pursued," Richard Morriss, MD, professor of psychiatry, University of Nottingham, United Kingdom, told Medscape Medical News. The intervention showed "clinically important benefits, although at increased cost, over 18 months."

The study was published online August 3 in Lancet Psychiatry.

Common, Costly Illness

Persistent moderate to severe depression is a common and costly illness that requires combined pharmacotherapy and psychotherapy. The current study, Dr Morriss said, was prompted by the observation that services in the United Kingdom and in most parts of the world, including the United States, "rarely" provide combined care together as a service, "and often they are provided by different providers altogether."

Dr Richard Morriss

He and his colleagues assessed the efficacy and cost-effectiveness of SDS vs usual specialist mental health care in 187 adults with chronic moderate to severe unipolar depression who were already in secondary care.

Participants had had a current major depressive episode, a score of at least 16 on the 17-item Hamilton Depression Rating Scale (HDRS-17), a score of 60 or higher on the Global Assessment of Function (GAF), and had not responded to treatment lasting 6 months or longer.

Patients were randomly allocated to receive either treatment as usual (TAU) (n = 94) by a community mental health team or SDS care (n = 93) for least 12 months. SDS included 3 months of graduated transfer of care, an active approach to medication management by a consultant psychiatrist, and long-term cognitive-behavioral therapy (CBT).

"The distinctive feature of SDS care, which was completely absent from TAU, was integrated psychiatric and psychological treatment sustained over 12 months with a collaborative care approach that systematically offered and reviewed specialist psychological and pharmacological treatment," the investigators explain.

Intention-to-treat primary outcome measures were changes in HDRS-17 and GAF scores between baseline and 6, 12, and 18 months.

According to the researchers, there were no significant differences between SDS and TAU at 6 and 12 months' follow-up in the mean change in HDRS-17 score and GAF score.

However, by 18 months' follow-up, the HDRS-17 score had improved by a significantly greater extent in the SDS group compared with the TAU group. At this point, the mean HDRS-17 score was lower (better) in the SDS group than in the TAU group (13.6 vs 16.1; P = .015). Improvement in the GAF score was not significantly different between the SDS and TAU groups at 18 months (61.2 vs 57.7; P = .113).

The investigators say a treatment effect of SDS on depression symptoms is "supported by significant or minimum clinically important differences between the SDS and TAU groups in all the self- rated depression symptom outcomes at 18 months' follow-up or earlier. No significant improvements in function were reported at 18 months' follow-up."

On the basis of cost-benefit analyses, the incremental benefit of SDS vs TAU was 0.079 quality-adjusted life-years (QALYs), and the incremental cost was ₤3446 (US$4491). The average cost of staff time associated with SDS was ₤2298 ($2995) per patient.

The incremental cost-effectiveness ratio of SDS vs TAU was ₤43,603 per QALY, which is above the usual National Institute of Clinical Excellence (NICE) willingness-to-pay threshold of ₤20,000 per QALY, the researchers note.

But Dr Morriss told Medscape Medical News, "If people continue to remain well over 3 years after being ill for on average 16 years, then SDS may be better value for money than current usual generic specialist mental health care, because there may also be benefits from returning to work, improved parenting and family life, improved physical health, and reduced need to call out emergency services, such as ambulance and police, when suicidal."

And the patients clearly preferred the specialist depression service, he said.

Rare Research

In a linked comment, Glyn Lewis, PhD, Division of Psychiatry, University College of London, United Kingdom, notes that this study is a "rare example" of a randomized trial that looks at how best to manage patients with severe, persistent depression, a population that has been "rather neglected by the research community.

"As always with complex interventions such as this, it is impossible to know which element of the intervention might have been effective. Was it the active medication management, the long-term CBT, or was it, as the authors suggested, the integration between the psychological and pharmacological approach," Dr Lewis wonders. "Alternatively, the introduction of a new and innovative service might have led to non-specific treatment effects."

Dr Lewis says the researchers "should be commended" for investigating improved management for people with severe depression in secondary care.

"Their results are perhaps a little disappointing and on their own cannot justify the development of specialist teams. However, it is important to recognize that we need to develop new treatments, evaluate new approaches, and investigate older treatments in severe depression and other non-psychotic disorders in secondary care," Dr Lewis writes.

"A dearth of research exists for a relatively common problem in psychiatric services and patients are being provided with little more than guesswork supplemented with well-intentioned common sense. Further research is needed," he concludes.

Funding for the study was provided by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, the UK Medical Research Council, the Nottinghamshire Healthcare NHS Foundation Trust, the Derbyshire Healthcare NHS Foundation Trust, the Cambridgeshire and Peterborough NHS Foundation Trust, and the University of Nottingham. The authors and Dr Lewis have disclosed no relevant financial relationships.

Lancet Psychiatry. Published online August 3, 2016. Abstract, Comment

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