title: Practice-based versus telemedicine-based collaborative care for depression in rural federally qualified health centers: a pragmatic randomized comparative effectiveness trial.
abstract: OBJECTIVE
  Practice-based collaborative care is a complex evidence-based practice that is difficult to implement in smaller primary care practices that lack on-site mental health staff. Telemedicine-based collaborative care virtually co-locates and integrates mental health providers into primary care settings. The objective of this multisite randomized pragmatic comparative effectiveness trial was to compare the outcomes of patients assigned to practice-based and telemedicine-based collaborative care.
  
  
  METHODS
  From 2007 to 2009, patients at federally qualified health centers serving medically underserved populations were screened for depression, and 364 patients who screened positive were enrolled and followed for 18 months. Those assigned to practice-based collaborative care received evidence-based care from an on-site primary care provider and a nurse care manager. Those assigned to telemedicine-based collaborative care received evidence-based care from an on-site primary care provider and an off-site team: a nurse care manager and a pharmacist by telephone, and a psychologist and a psychiatrist via videoconferencing. The primary clinical outcome measures were treatment response, remission, and change in depression severity.
  
  
  RESULTS
  Significant group main effects were observed for both response (odds ratio=7.74, 95% CI=3.94-15.20) and remission (odds ratio=12.69, 95% CI=4.81-33.46), and a significant overall group-by-time interaction effect was observed for depression severity on the Hopkins Symptom Checklist, with greater reductions in severity over time for patients in the telemedicine-based group. Improvements in outcomes appeared to be attributable to higher fidelity to the collaborative care evidence base in the telemedicine-based group.
  
  
  CONCLUSIONS
  Contracting with an off-site telemedicine-based collaborative care team can yield better outcomes than implementing practice-based collaborative care with locally available staff.
authors: Division of Health Services Research, Department of Psychiatry, College of Medicine, University of Arkansas for Medical Sciences, Little Rock, USA. fortneyjohnc@uams.edu
authors: John C
authors: JC
authors: Fortney
authors: Jeffrey M
authors: JM
authors: Pyne
authors: Sip B
authors: SB
authors: Mouden
authors: Dinesh
authors: D
authors: Mittal
authors: Teresa J
authors: TJ
authors: Hudson
authors: Gary W
authors: GW
authors: Schroeder
authors: David K
authors: DK
authors: Williams
authors: Carol A
authors: CA
authors: Bynum
authors: Rhonda
authors: R
authors: Mattox
authors: Kathryn M
authors: KM
authors: Rost
mesh_terms: D000928:Antidepressive Agents / Q000627:therapeutic use; D001131:Arkansas; D003863:Depression / Q000175:diagnosis / Q000188:drug therapy / Q000628:therapy*; D005260:Female; D006801:Humans; D008297:Male; D008507:Medically Underserved Area; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data; D010348:Patient Care Team / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000379:methods; D011569:Psychiatric Status Rating Scales / Q000706:statistics & numerical data; D011613:Psychotherapy; D012074:Remission Induction; D019035:Rural Health Services / Q000706:statistics & numerical data; D017216:Telemedicine / Q000379:methods*; D016896:Treatment Outcome
chemical_list: D000928:Antidepressive Agents