The pilot study of a telephone disease management program for depression Catherine J. Datto, M.D. a,b , Richard Thompson, Ph.D. a,b , David Horowitz, M.D. a,c , Maureen Disbot, R.N. c , David W. Oslin, M.D. a,b, * a University of Pennsylvania, Philadelphia, PA USA b Philadelphia VA Medical Center, Philadelphia, PA USA c University of Pennsylvania Health System, Philadelphia, PA USA Abstract Most depressed patients are seen and treated exclusively by primary care clinicians. However, primary care patients with depression are often not adequately treated. The aims of this pilot study were to measure the impact of a telephone disease management program on patient outcome and clinician adherence to practice guidelines, measure the relationship of clinician adherence to patient outcome, and explore the measurement of patient adherence to clinician recommendations and its impact on patient outcomes. Thirty-five primary care practices in the University of Pennsylvania Health System were randomized to telephone disease management (TDM) or “usual care” (UC). All patients received a baseline and a 16-week follow-up clinical evaluation performed over the telephone. Those from TDM practices also received follow-up contact at least every 3 weeks, with formal evaluations at weeks 6 and 12. These interval contacts were designed to facilitate patient and clinician adherence to a treatment algorithm based on the Agency for Health Research and Quality (AHRQ) practice guidelines. Depressive symptoms evaluated with the Community Epidemiologic Survey of Depression (CES-D) scale as well as guideline adherence were the primary outcome measures. Sixty-one patients were enrolled in this pilot project. The overall effect for CES-D scores over time was significant, (P  .001), indicating that those participating in the trial (both TDM and UC groups) showed significant improvement. The interaction between intervention condition and time was also significant (P  .05), indicating that TDM patients improved significantly more over time than did UC patients. A greater proportion of TDM patients had CES-D scores 16 by Week 16 (66.7 versus 33.3%;  2 , P  .05). The improvement in depression outcome for the TDM group was related to its impact on improving clinician adherence to depression treatment algorithms. The TDM pilot did not show a statistically significant effect on improving patient adherence to clinician recommen- dations, however. This preliminary data suggests that TDM for depression improves both clinician guideline adherence and patient outcomes in the acute phase of depression. The effect on patient outcome is at least partially explained by the effect of TDM on clinician adherence to depression treatment algorithms. © 2003 Elsevier Inc. All rights reserved. Keywords: Depression; Disease management; Primary care; Treatment algorithm; Treatment adherence 1. Introduction Depression in primary care is a pressing public health problem [1]. Depression is highly prevalent in primary care settings, and more depressed patients of all ages are seen by primary care clinicians than by specialty mental health pro- viders [2,3]. A number of efficacious treatments are avail- able to alleviate much of the symptoms, distress, and im- pairment associated with depression [4]. Still, many of the depressed patients detected in primary care are not ade- quately treated [5,6]. Although the Agency for Health Re- search and Quality (AHRQ), formerly the Agency for Health Care Policy and Research (AHCPR), has established treatment guidelines for depression in primary care based on current knowledge [7], these guidelines are seldom fol- lowed in usual practice [6,8]. Thus, even those primary care patients identified by clinicians as depressed seldom expe- rience better outcomes than do participants in clinical trials assigned to a placebo control group [9,10]. Possible limita- tions to the implementation of practice guidelines for de- pression were discussed by Cabana et al. [11]. These in- cluded lack of awareness of and familiarity with the guidelines, lack of agreement with the recommendations, inertia of previous practice, as well as external variables such as insufficient time and reimbursement. * Corresponding author. Tel.: 215-615-3083; fax: 215-349-8389. E-mail address: oslin@mail.med.upenn.edu (D.W. Oslin) General Hospital Psychiatry 25 (2003) 169 –177 0163-8343/03/$ – see front matter © 2003 Elsevier Inc. All rights reserved. doi:10.1016/S0163-8343(03)00019-7