The effects of quality improvement for depression in primary care at nine years: results from a randomized, controlled group-level trial.
OBJECTIVE
To examine 9-year outcomes of implementation of short-term quality improvement (QI) programs for depression in primary care.


METHODS
Depressed primary care patients from six U.S. health care organizations.


METHODS
Group-level, randomized controlled trial.


METHODS
Patients were randomly assigned to short-term QI programs supporting education and resources for medication management (QI-Meds) or access to evidence-based psychotherapy (QI-Therapy); and usual care (UC). Of 1,088 eligible patients, 805 (74 percent) completed 9-year follow-up; results were extrapolated to 1,269 initially enrolled and living. Outcomes were psychological well-being (Mental Health Inventory, five-item version [MHI5]), unmet need, services use, and intermediate outcomes.


RESULTS
At 9 years, there were no overall intervention status effects on MHI5 or unmet need (largest F (2,41)=2.34, p=.11), but relative to UC, QI-Meds worsened MHI5, reduced effectiveness of coping and among whites lowered tangible social support (smallest t(42)=2.02, p=.05). The interventions reduced outpatient visits and increased perceived barriers to care among whites, but reduced attitudinal barriers due to racial discrimination and other factors among minorities (smallest F (2,41)=3.89, p=.03).


CONCLUSIONS
Main intervention effects were over but the results suggest some unintended negative consequences at 9 years particularly for the medication-resource intervention and shifts to greater perceived barriers among whites yet reduced attitudinal barriers among minorities.
Wells
Kenneth B
KB
The RAND Corporation, 1776 Main Street, Santa Monica, CA 90401, USA.
Tang
Lingqi
L
Miranda
Jeanne
J
Benjamin
Bernadette
B
Duan
Naihua
N
Sherbourne
Cathy D
CD
D000223:Adaptation, Psychological; D000328:Adult; D003863:Depression / Q000188:drug therapy*; D005260:Female; D019538:Health Care Surveys; D006301:Health Services Needs and Demand; D006801:Humans; D008297:Male; D008875:Middle Aged; D017063:Outcome Assessment, Health Care; D011320:Primary Health Care / Q000592:standards*; D011785:Quality Assurance, Health Care; D012944:Social Support; D014481:United States