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Phone is key to novel psychiatric approach

Reach out and touch someone" ran a 1980s Bell System jingle that urged phone customers to call a loved one. Using the phone to connect people is also at the heart of a new treatment for depression that was developed by Dartmouth family physician Allen Dietrich, M.D., and a team of researchers across the country.

The new approach is called RESPECTDepression—short for Re-Engineering Systems for the Primary Care Treatment of Depression. It integrates work by a primary-care clinician, who diagnoses and manages the patient; a care manager, who provides telephone support; and a psychiatrist, who supervises the care manager and offers treatment suggestions to the clinician.

Trial: Five U.S. health-care organizations, encompassing 60 affiliated practices, participated in a clinical trial that compared the new model to standard care. After six months, 60% of RESPECT-Depression patients (106 out of 177) had responded substantially to treatment, versus 47% of standard- care patients (68 out of 146). In addition, 90% of patients treated using the new model rated their care as good to excellent (they noted that they especially appreciated the telephone support), compared to only 75% of patients in the control group. All five organizations have taken steps to sustain use of the new model, and one, Highmark Blue Cross Blue Shield of Pittsburgh, Pa., decided to make the changes permanent. The trial results were published in the British Medical Journal in September 2004.

"This is a big step forward for patients, for clinicians, and for insurers," says Dietrich, who was the lead author of the paper. "Other studies have provided guidance on steps to enhance primary care of depression. But this study shows how to translate such actions from the page to routine practice." The model was developed by the MacArthur Initiative on Depression and Primary Care, a national collaborative that Dietrich cochairs, with John Williams, M.D., of Duke. Dartmouth


Family physician Allen Dietrich is helping primary-care colleagues nationwide treat depressed patients.

psychiatrist Thomas Oxman, M.D., is its associate chair.

Under the new model, if a patient shows warning signs of depression—such as daily fatigue, eating disorders, low self-esteem, or thoughts of suicide—the clinician administers a patient health questionnaire, the PHQ9, to assess the severity of the depression. The clinician then talks with the patient about how the treatment plan will be structured in terms of psychiatric counseling, use of antidepressants, and interactions with the care manager. The primary-care clinician also does a suicide assessment and introduces the patient to the idea that the process will take at least a few months.

A care manager then calls all patients monthly to help them stay on their medication, answer questions about side effects, help them schedule counseling visits, and support them in taking self-management steps such as planning

exercise and social activities. "Patients with depression often have trouble showing initiative or being active, and so the follow-up [by the care manager] to make sure they're moving forward and to give them emotional support I think is very important," says Dietrich.

Process: The care managers are nurses, social workers, or people with backgrounds in public health and most often are hired from within the sponsoring health-care organization. Care managers administer the PHQ9 each month and report to the supervising psychiatrist, who then gives suggestions to the clinician about changes in treatment. This process continues monthly until the patient achieves remission.

Magellan Health Services, Inc., one of the largest national behavioral-health managedcare organizations, is in the pilot phase of applying the new model and is working with other health plans to develop the use of it in community primary-care practices. In addition, RESPECT-Depression is being adapted by the Department of Defense for a pilot program at Fort Bragg, to treat soldiers who return from Iraq and Afghanistan with symptoms of post-traumatic stress disorder (PTSD). The New England Journal of Medicine reported in July 2004 that rates of PTSD and major depression were much higher among returning troops in 2003 than in earlier military campaigns.

Depression: According to the World Health Organization, depression was the fourthhighest cause of disability and premature death worldwide in 1990 and will be the second- highest by 2020. In the U.S., clinical depression affects more than 19 million people each year, yet fewer than half of them seek treatment. Dietrich and Oxman believe that the new approach can help. "Family physicians are good at treating depression," explains psychiatrist Oxman. "The problem is they are so busy. . . . But when you have a system for them, then people don't fall through the cracks."

—Matthew C. Wiencke

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