title: Clinical effectiveness and cost-effectiveness of collaborative care for depression in UK primary care (CADET): a cluster randomised controlled trial.
abstract: BACKGROUND
  Collaborative care is effective for depression management in the USA. There is little UK evidence on its clinical effectiveness and cost-effectiveness.
  
  
  OBJECTIVE
  To determine the clinical effectiveness and cost-effectiveness of collaborative care compared with usual care in the management of patients with moderate to severe depression.
  
  
  METHODS
  Cluster randomised controlled trial.
  
  
  METHODS
  UK primary care practices (n = 51) in three UK primary care districts.
  
  
  METHODS
  A total of 581 adults aged ≥ 18 years in general practice with a current International Classification of Diseases, Tenth Edition depressive episode, excluding acutely suicidal people, those with psychosis, bipolar disorder or low mood associated with bereavement, those whose primary presentation was substance abuse and those receiving psychological treatment.
  
  
  METHODS
  Collaborative care: 14 weeks of 6-12 telephone contacts by care managers; mental health specialist supervision, including depression education, medication management, behavioural activation, relapse prevention and primary care liaison. Usual care was general practitioner standard practice.
  
  
  METHODS
  Blinded researchers collected depression [Patient Health Questionnaire-9 (PHQ-9)], anxiety (General Anxiety Disorder-7) and quality of life (European Quality of Life-5 Dimensions three-level version), Short Form questionnaire-36 items) outcomes at 4, 12 and 36 months, satisfaction (Client Satisfaction Questionnaire-8) outcomes at 4 months and treatment and service use costs at 12 months.
  
  
  RESULTS
  In total, 276 and 305 participants were randomised to collaborative care and usual care respectively. Collaborative care participants had a mean depression score that was 1.33 PHQ-9 points lower [n = 230; 95% confidence interval (CI) 0.35 to 2.31; p = 0.009] than that of participants in usual care at 4 months and 1.36 PHQ-9 points lower (n = 275; 95% CI 0.07 to 2.64; p = 0.04) at 12 months after adjustment for baseline depression (effect size 0.28, 95% CI 0.01 to 0.52; odds ratio for recovery 1.88, 95% CI 1.28 to 2.75; number needed to treat 6.5). Quality of mental health but not physical health was significantly better for collaborative care at 4 months but not at 12 months. There was no difference for anxiety. Participants receiving collaborative care were significantly more satisfied with treatment. Differences between groups had disappeared at 36 months. Collaborative care had a mean cost of £272.50 per participant with similar health and social care service use between collaborative care and usual care. Collaborative care offered a mean incremental gain of 0.02 (95% CI -0.02 to 0.06) quality-adjusted life-years (QALYs) over 12 months at a mean incremental cost of £270.72 (95% CI -£202.98 to £886.04) and had an estimated mean cost per QALY of £14,248, which is below current UK willingness-to-pay thresholds. Sensitivity analyses including informal care costs indicated that collaborative care is expected to be less costly and more effective. The amount of participant behavioural activation was the only effect mediator.
  
  
  CONCLUSIONS
  Collaborative care improves depression up to 12 months after initiation of the intervention, is preferred by patients over usual care, offers health gains at a relatively low cost, is cost-effective compared with usual care and is mediated by patient activation. Supervision was by expert clinicians and of short duration and more intensive therapy may have improved outcomes. In addition, one participant requiring inpatient treatment incurred very significant costs and substantially inflated our cost per QALY estimate. Future work should test enhanced intervention content not collaborative care per se.
  
  
  BACKGROUND
  Current Controlled Trials ISRCTN32829227.
  
  
  BACKGROUND
  This project was funded by the Medical Research Council (MRC) (G0701013) and managed by the National Institute for Health Research (NIHR) on behalf of the MRC-NIHR partnership.
authors.affiliation: University of Exeter Medical School, Exeter, UK.
authors.forename: David A
authors.initials: DA
authors.lastname: Richards
authors.affiliation: Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK.
authors.forename: Peter
authors.initials: P
authors.lastname: Bower
authors.affiliation: Institute for Primary Care and Health Sciences, Keele University, Keele, UK.
authors.forename: Carolyn
authors.initials: C
authors.lastname: Chew-Graham
authors.affiliation: Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK.
authors.forename: Linda
authors.initials: L
authors.lastname: Gask
authors.affiliation: School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK.
authors.forename: Karina
authors.initials: K
authors.lastname: Lovell
authors.affiliation: Research Department of Clinical, Educational and Health Psychology, University College London, London, UK.
authors.forename: John
authors.initials: J
authors.lastname: Cape
authors.affiliation: Division of Psychology and Language Sciences, University College London, London, UK.
authors.forename: Stephen
authors.initials: S
authors.lastname: Pilling
authors.affiliation: London School of Hygiene and Tropical Medicine, London, UK.
authors.forename: Ricardo
authors.initials: R
authors.lastname: Araya
authors.affiliation: School of Social and Community Medicine, University of Bristol, Bristol, UK.
authors.forename: David
authors.initials: D
authors.lastname: Kessler
authors.affiliation: Centre for Psychological Services Research, Department of Psychology, University of Sheffield, Sheffield, UK.
authors.forename: Michael
authors.initials: M
authors.lastname: Barkham
authors.affiliation: Department of Health Sciences, University of York, York, UK.
authors.forename: J Martin
authors.initials: JM
authors.lastname: Bland
authors.affiliation: Department of Health Sciences, University of York, York, UK.
authors.forename: Simon
authors.initials: S
authors.lastname: Gilbody
authors.affiliation: University of Exeter Medical School, Exeter, UK.
authors.forename: Colin
authors.initials: C
authors.lastname: Green
authors.affiliation: Research Department of Primary Care and Population Health, University College London, London, UK.
authors.forename: Glyn
authors.initials: G
authors.lastname: Lewis
authors.affiliation: Public and Patient Advocate, Upstream Healthcare, Teddington, UK.
authors.forename: Chris
authors.initials: C
authors.lastname: Manning
authors.affiliation: Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK.
authors.forename: Evangelos
authors.initials: E
authors.lastname: Kontopantelis
authors.affiliation: School of Psychology, University of Exeter, Exeter, UK.
authors.forename: Jacqueline J
authors.initials: JJ
authors.lastname: Hill
authors.affiliation: Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK.
authors.forename: Adwoa
authors.initials: A
authors.lastname: Hughes-Morley
authors.affiliation: University of Exeter Medical School, Exeter, UK.
authors.forename: Abigail
authors.initials: A
authors.lastname: Russell
mesh_terms: D000328:Adult; D001008:Anxiety Disorders / Q000628:therapy; D003299:Cooperative Behavior; D003362:Cost-Benefit Analysis; D003695:Delivery of Health Care; D003866:Depressive Disorder / Q000191:economics / Q000628:therapy*; D005260:Female; D006801:Humans; D007407:Interviews as Topic / Q000379:methods; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team / Q000191:economics; D010353:Patient Education as Topic; D017060:Patient Satisfaction / Q000706:statistics & numerical data; D011320:Primary Health Care / Q000191:economics / Q000379:methods*; D019057:Quality-Adjusted Life Years; D016896:Treatment Outcome