Research in New Populations
A logical next step is to test the care models proven useful for depressed patients in diverse patient populations. Research on care of other common psychiatric illnesses such as anxiety disorders, somatoform disorders, and bipolar disorder is needed. Adapting the new care models and testing their effectiveness in the care of rural, economically disadvantaged, and elderly populations would also be useful. Future research might test provision of case management and specialist consultation services through telemedicine connections for patient populations lacking direct access to such services in their primary care setting (eg, rural practices, network model practices). Finally, the management of treatment-resistant patients was identified as a critically important issue that has not been resolved. Will treatment-resistant patients benefit more from referral for specialty mental health care, or can they be effectively managed in the primary care setting with effective organization of treatment and support services? Surprisingly little is known about the care of depression among patients with comorbid medical disease (eg, diabetes, heart disease, chronic obstructive pulmonary disease). There is now substantial evidence that depression is associated with increased physical symptoms, increased disability, increased use of general medical services, and increased likelihood of comorbid medical illness.2 Enrolling patients with a specific chronic disease such as diabetes or coronary artery disease would enable researchers to more precisely delineate the effect of improved depression care on biologic measures of disease severity as well as physical symptoms, disability, and use of health care services. The impact of improved depression care on the ability of patients to manage a comorbid chronic disease is of considerable interest.
Stepped Care and Relapse Prevention
An emerging theme in the current generation of depression care research is the use of sequential or stepped care management strategies. In stepped care interventions, patient outcomes are monitored, and modifications in the care plan and/or more intensive management are targeted toward patients who do not have a favorable outcome by a defined time point (eg, 2 months after the initiation of treatment).3,4 It is hoped that stepped care models will enhance the cost-effectiveness of depression care programs by reserving the use of case management and specialist consultation services for those patients who cannot be effectively managed by the primary care physician alone. In general, there is a need for new research (and analyses from completed studies) that identify ways of using limited specialist and case management services to greatest effect in improving the long-term outcomes per unit cost. Effectiveness studies now need to develop and test interventions that follow patients for continuation and maintenance phases to assess their ability to prevent relapse and maximize patient functioning over extended periods of time.
Societal Benefits of Improved Depression Care
There was a sense of urgency about the need for new research that more adequately assesses the effects of treating depression on labor force participation, market and nonmarket productivity, work absenteeism, family functioning, and time off work for travel to mental health treatments. The need to evaluate the effects of treating depression on both the depressed individual and members of their families was recognized. Research in these important areas has been hampered by the lack of reliable and valid measures. In particular, the development of reliable and valid measures of work productivity and family burden were seen as critically important.
Expert panels have recommended that alternative treatments be compared using cost utility methods that explicitly incorporate patient outcome preferences.5 The evaluation of health state preferences remains uncommon in depression clinical trials because of measurement problems. Different research groups have recently attempted to indirectly measure how patient utilities vary with different dimensions of health quality of life using the 12-item Medical Outcomes Study Short Form or the 36-item Medical Outcomes Study Short Form.6-9 However, the validity of these alternative approaches is unclear. Resolution of these uncertainties was considered to be an important research area.
Multisite Trials and Meta-Analytic Approaches
As depression research increasingly focuses on assessing effects on societal costs and benefits of improved depression care, the large variance of policy-relevant outcome measures such as disability days, unemployment, and health care costs is of increasing concern. Effectiveness studies enrolling even 200 to 300 patients are underpowered to detect clinically significant differences in many of these outcomes,10 even though even modest beneficial effects of treatment could have substantial social significance on a population basis. This suggests the need for large-scale multisite trials of depression care programs. The effects of depression care programs on these outcomes might also be assessed through meta-analyses of completed trials or new intervention studies that are designed to vary components of the intervention strategy.