Briefly describe a specific question, or set of related questions, about a health care test or treatment that this program should consider.

Effectiveness of non-intensive (pharmacologic or formal psychotherapy) treatments of depressed mood in primary care. This would include self management contracts, exercise, activating social networks, and primary care phsyician provided brief supportive counseling. These could all be compared to each other and to intensive forms of therapy (as described above - antidepressant medications and psychotherapy). This must be stratified by depression diagnosis (depressed mood without clinical diagnosis versus minor depression versus major depression) and by severity of symptoms.

Does your question include a comparison of different health care approaches? (If no, your topic will still be considered.)

yes

If yes, explain the specific technologies, devices, drugs, or interventions you would like to see compared:

Intensive therapies vs non-intensive therapies (as described above) for primary care patients with different levels of severity of depression.

What patients or group(s) of patients does your question apply to? (Please include specific details such as age range, gender, coexisting diagnoses, and indications for therapy.)

Primary care patients (adults and children),and pregnant patients.

Are there subgroups of patients that your question might apply to? (For example, an ethnic group, stage or severity of a disease.)

Yes - ethnic and age sbgroups would be interesting as well as pregnant patients.

Describe the health-related benefits you are interested in. (For example, improvements in patient symptoms or problems from treatment or diagnosis.)

Reduction in depression symptomatology and increase in function.

Describe any health-related risks, side effects, or harms that you are concerned about.

 

Appropriateness for EHC Program

Does your question include a health care drug, intervention, device, or technology available (or likely to be available) in the U.S.?

yes

Which priority area(s) and population(s) does this topic apply to? (check all that apply)

EHC Priority Conditions (updated in 2008)

• Depression and other mental health disorders
• Pregnancy, including preterm birth

AHRQ Priority Populations

• Low income groups
• Minority groups
• Women
• Children

Federal Health Care Program

• Medicaid
• Medicare
• State Children's Health Insurance Program (SCHIP)

Importance

Describe why this topic is important.

Currently primary care physicians are trained only in the use of intensive therapies - medication and formal psychotherapy. Because there is a poor mental health system in the US low income and underinsured patients do not have access to providers other than primary care doctors. There is evidence that non-intensive treatments - such as those recommended in the British NICE guidelines and by US efforts such as the Macarthur initiative for depression in primary care - but there are no good reviews of evidence or comparisons of these treatments for patients in primary care. There is also evidence that intensive therapies are not useful for the majority of patients getting them (mild -moderate severity or not MDD). We need this research to guide primary care delivery of depression treatment.

What specifically motivated you to ask this question? (For example, you are developing a clinical guideline, working with a policy with large uncertainty about the appropriate approach, costly intervention, new research you have read, items in the media you may have seen, a clinical practice dilemma you know of, etc.)

I am working with primary care physicians to enhance their ability to provide effective care to low income and minority populations and there is no good assessment of evidence for non-intensive therapies for depresison in primary care.

Does your question represent uncertainty for clinicians and/or policy-makers? (For example, variations in clinical care, controversy in what constitutes appropriate clinical care, or a policy decision.)

yes

If yes, please explain:

There is total variation in the quality of depression care for patients in the US primary care and prenatal care system. Only patients in certain exemplary vertically integrated health systems have good outcomes for depression service delivery. Medicaid patients receive universally poor care. Much of the reason is the emphais currently only on intensive therapies.

Potential Impact

How will an answer to your research question be used or help inform decisions for you or your group?

If there is evidence for benefit for non intensive treatments as compared to intensive treatments we will be much better able to disseminate this model of care among primary care physicians nationally and into training programs.

Describe the timeframe in which an answer to your question is needed.

As soon as possible - within the next few years.

Describe any health disparities, inequities, or impact on vulnerable populations your question applies to.

As mentioned above low income and minority populations covered by medicaid receive mush poorer care - amply documented by our group and others - as compared to some privately insured groups.

Nominator Information

Other Information About You: (optional)

Please choose a description that best describes your role or perspective: (you may select more than one category if appropriate)

If there is evidence for benefit for non intensive treatments as compared to intensive treatments we will be much better able to disseminate this model of care among primary care physicians nationally and into training programs.

Are you making a suggestion as an individual or on behalf of an organization?

Individual

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