Can depression treatment in primary care reduce disability? A stepped care approach.

Objective: To assess effects of stepped collaborative care depression intervention on disability.

Design: Randomized controlled trial.

Setting: Four primary care clinics of a large health maintenance organization.

Patients: Two hundred twenty-eight patients with either 4 or more persistent major depressive symptoms or a score of 1.5 or greater on the Hopkins Symptom Checklist. Depression items were randomized to stepped care intervention or usual care 6 to 8 weeks after initiating antidepressant medication.

Intervention: Augmented treatment of persistently depressed patients by an on-site psychiatrist collaborating with primary care physicians. Treatment included patient education, adjustment of pharmacotherapy, and proactive monitoring of outcomes.

Main outcome measures: Baseline, 1-, 3-, and 6-month assessments of the Sheehan Disability Scale and the social function and role limitation subscales of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36).

Results: Patients who received the depression intervention experienced less interference in their family, work, and social activities than patients receiving usual primary care (Sheehan Disability Scale, z = 2.23; P =.025). Patients receiving intervention also reported a trend toward more improvement in SF-36-defined social functioning than patients receiving usual care (z = 1.63, P =.10), but there was no significant difference in role performance (z = 0.07, P =.94).

Conclusions: Significant disability accompanied depression in this persistently depressed group. The stepped care intervention resulted in small to moderate functional improvements for these primary care patients. Arch Fam Med. 2000;9:1052-1058