A randomized trial of telemedicine-based collaborative care for depression

Background: Evidence-based practices designed for large urban clinics are not necessarily portable into smaller isolated clinics. Implementing practice-based collaborative care for depression in smaller primary care clinics presents unique challenges because it is often not feasible to employ on-site psychiatrists. Objective: The purpose of the Telemedicine Enhanced Antidepressant Management (TEAM) study was to evaluate a telemedicine-based collaborative care model adapted for small clinics without on-site psychiatrists. Design: Matched sites were randomized to the intervention or usual care. Participants: Small VA Community-based outpatient clinics with no on-site psychiatrists, but access to telepsychiatrists. In 2003-2004, 395 primary care patients with PHQ9 depression severity scores >= 12 were enrolled, and followed for 12 months. Patients with serious mental illness and current substance dependence were excluded. Measures: Medication adherence, treatment response, remission, health status, health-related quality of life, and treatment satisfaction. Results: The sample comprised mostly elderly, white, males with substantial physical and behavioral health comorbidity. At baseline, subjects had moderate depression severity (Hopkins Symptom Checklist, SCL-20=1.8), 3.7 prior depression episodes, and 67% had received prior depression treatment. Multivariate analyses indicated that intervention patients were more likely to be adherent at both 6 (odds ratio [OR]=2.1, p=.04) and 12 months (OR=2.7, p=.01). Intervention patients were more likely to respond by 6 months (OR=2.0, p=.02), and remit by 12 months (OR=2.4, p=.02). Intervention patients reported larger gains in mental health status and health-related quality of life, and reported higher satisfaction. Conclusions: Collaborative care can be successfully adapted for primary care clinics without on-site psychiatrists using telemedicine technologies.