Case review vs. usual care in primary care patients with depression: a pilot study

This paper reports on the results of a pilot study comparing the efficacy of an experimental case review program between psychiatrists and primary care physicians (PCPs) with PCPs' usual care on the outcome of depressive disorders at 1-year. The secondary aim of the paper is to identify correlates of remission of depressive disorders at the 1-year follow-up. The experimental case review program consisted of 12 biweekly meetings of primary care physicians with a psychiatrist. Meetings lasted two hours and were based on review of cases identified at the interview as suffering from full-blown or subthreshold conditions. Subjects were assessed at baseline, 3 months and 1 year. The baseline assessment included the Composite International Diagnostic Interview, the Hamilton Depression (HDRS) and Anxiety (HARS) Rating Scales, the Medical Outcomes Study SF-36 and some forms to collect life events, major difficulties, social support, and ongoing treatments. At 3 months patients received by mail the General Health Questionnaire (GHQ-12) and at one year the baseline clinical assessment was replicated. Assessments were conducted on eighty cases with major, minor or subsyndromal depression (SSD). The experimental case review program was similar in efficacy to usual care, with an average reduction of 5.5 points on the HAMD. Significant reduction in the severity of depression was associated with a limited number of baseline characteristics, such as being married and having minor depression as compared to major depression and SSD. On the contrary, chronic physical illness at baseline predicted a lower reduction of HAMD scores at one year. While major difficulties and life events during the one-year interval between the two assessments significantly predicted a poorer outcome, social support at home was related to a better outcome. This pilot study indicates that a case review intervention program is not efficacious in a mixed sample of patients with subsyndromal to major depression representative of the current practice of primary case physicians. Still, it might be worthwhile for "difficult" patients selected by the PCPs. In our sample, psychosocial factors seem to be important predictors of outcome. Future trials and large naturalistic studies are needed to address this key point.