Context Depression is commonly encountered in primary care settings yet is often
missed or suboptimally managed. A number of organizational and educational
strategies to improve management of depression have been proposed. The clinical
effectiveness and cost-effectiveness of these strategies have not yet been
subjected to systematic review.
Objective To systematically evaluate the effectiveness of organizational and educational
interventions to improve the management of depression in primary care settings.
Data Sources We searched electronic medical and psychological databases from inception
to March 2003 (MEDLINE, PsycLIT, EMBASE, CINAHL, Cochrane Controlled Trials
Register, United Kingdom National Health Service Economic Evaluations Database,
Cochrane Depression Anxiety and Neurosis Group register, and Cochrane Effective
Professional and Organisational Change Group specialist register); conducted
correspondence with authors; and used reference lists. Search terms were related
to depression, primary care,
and all guidelines and organizational and educational interventions.
Study Selection We selected 36 studies, including 29 randomized controlled trials and
nonrandomized controlled clinical trials, 5 controlled before-and-after studies,
and 2 interrupted time-series studies. Outcomes relating to management and
outcome of depression were sought.
Data Extraction Methodological details and outcomes were extracted and checked by 2
reviewers. Summary relative risks were, where possible, calculated from original
data and attempts were made to correct for unit of analysis error.
Data Synthesis A narrative synthesis was conducted. Twenty-one studies with positive
results were found. Strategies effective in improving patient outcome generally
were those with complex interventions that incorporated clinician education,
an enhanced role of the nurse (nurse case management), and a greater degree
of integration between primary and secondary care (consultation-liaison).
Telephone medication counseling delivered by practice nurses or trained counselors
was also effective. Simple guideline implementation and educational strategies
were generally ineffective.
Conclusions There is substantial potential to improve the management of depression
in primary care. Commonly used guidelines and educational strategies are likely
to be ineffective. The implementation of the findings from this research will
require substantial investment in primary care services and a major shift
in the organization and provision of care.