Potential solutions for barriers to improved organization of care of depressive illness were identified. These included: (1) aligning efforts to improve depression care with broader strategies for improving care of other chronic conditions, (2) increasing the availability of depression case management services in primary care, (3) developing registries and reminder systems to ensure active follow-up of depressed patients, (4) achieving agreement on how depression outcomes should be measured to provide outcomes-based performance standards, (5) providing greater support from mental health specialists for management of depressed patients by primary care providers, (6) campaigns to reduce the stigma associated with treatment of depressive illness, (7) increased dissemination of interventions that activate and empower patients managing a depressive illness, (8) redefining the lack of time of primary care providers for high-quality depression care as issues in organization of care and provider training, and (9) development of incentives (organizational or financial) for high-quality depression care. Research needs were identified based on what has been learned to date. Identified research needs included: studies of approaches to organization of case management, research in new populations (eg, new diagnostic groups, rural populations, the disadvantaged, the elderly, and those with chronic medical illnesses), research on stepped care and relapse prevention strategies, evaluation of the societal benefits of improved depression care, and multisite trials and meta-analytic approaches that can provide adequate statistical power to assess societal benefits of improved care.
The barriers to improving care of depressive illness are well known. Patients resist mental disorder diagnoses, are not ready to accept treatment, or fail to follow through on prescribed treatments. Primary care physicians fail to recognize depression in their patients, fail to prescribe an adequate treatment regimen, or fail to follow-up with patients once treatment is initiated. Psychiatrists and other mental health professionals are not accessible to many depressed individuals (elderly, rural, medically ill, and economically disadvantaged populations). Health care systems often fail to organize mental health consultation services to support the work of primary care physicians who treat the majority of depressed patients. Insurers and employers resist adequate insurance benefits for mental health services. Given the extent and complexity of the barriers to improved care of depressive illness, it is not surprising that little progress has been made in reducing the burden of depressive illness on a population basis, despite the availability of effective treatments. The problem is not lack of effective treatments for depression but deficiencies in the organization and delivery of health and mental health services.
Although understanding the barriers to improved care is important, focusing on barriers alone can be contagious and counterproductive. The litany of barriers can easily become a rationale for inaction. Bringing potential solutions to light provides an invitation to experiment, try things out, and take action.
At our conference on improving care for depression in organized health care systems, current experimental research was presented in which possible approaches to improving care of depressive illness were tested and effects on patient outcomes were assessed. After the research presentations the participants (eg, leading researchers and persons responsible for improving the quality of care for mental disorders in systems serving of millions of people) identified possible solutions to the well-known barriers to improved depression care.
Barriers and solutions are listed in the Table 1 using the framework of the Model for Improving Chronic Illness Care described elsewhere.1 In each area we enumerate barriers and potential solutions identified by the conference participants. In the final analysis, the most significant barrier to improving the quality of care for depressive illness may be inaction, because all other barriers are insurmountable in the absence of effort to produce change.
Research needs
The conference participants also considered research needs that have not been adequately addressed by the current generation of depression research.
Case Management
The current generation of depression care studies has tested different forms of case management with generally promising results. Critical unresolved questions focus on whom case management services are needed for and how long it should be sustained. Some research suggests that case management services may need to be continued over long periods of time, but outcome data beyond 1 year are lacking. Additional research is needed to clarify the benefits of having specialist-consultants both supervise the work of case managers and provide services targeted to patients who do not achieve a favorable outcome with case management services alone. Although case managers have been used most frequently in support of pharmacotherapy, it remains unclear to what extent patients benefit from the behavioral and supportive interventions they provide. To what extent do case management services benefit patients through mobilization of hope and behavioral activation versus improved adherence to treatment regimens? Should these services be delivered by depression case managers who follow a large caseload of depressed primary care patients, or should depression be one of many chronic conditions such as diabetes, hypertension, and asthma that are managed by a generalist case manager working as part of the primary care team? Also, there is a need for development and testing of new modes of delivering case management services in addition to in-person and telephonic services (eg, telemedicine services or the Internet). New approaches are needed to increase the feasibility of sustained case management and to reduce costs.