For those with mild depression, stepped and collaborative care models may improve care and adherence to guidelines, according to a study recently published in PLOS One. This adherence differs with acuteness of depression. Deficits in treating severe depression may be because of failed treatment initialization rather than insufficient selections of treatments.
This study included data of 569 individuals with depression who were treated in stepped and collaborative care intervention. This intervention included a number of components, among them optimized procedures for diagnosis, a network of professionals trained in treating depression and guideline-based diagnosis, and standardized methods for monitoring.
Participants were categorized as having mild, moderate, or severe depression, with analysis performed on agreement between chosen treatment and initialized treatment and on guideline-adherent selections and initializations of treatment selections. A multiple mixed logistic regression model was used, with fixed effects including acuteness and type of depression, treatment status, and interactions.
Those with mild depression had the highest rates of guideline-adherent selection (91%) and initialization (85%) of treatment. Among those with moderate depression, there was 68% guideline-adherent treatment selection and 54% initialization. Those with severe depression had the lowest rates of selection (59%) and adherence (19%). In those with moderate depression, there was an odds ratio (OR) of 1.8 (95% CI, 1.30-2.59; P =.0006) between treatment adherent selection and initialization, while for severe depression, it was 6.9(95% CI, 4.24-11.25; P <.0001). With mild depression, this difference was not significant (OR, 1.8; 95% CI,0.68-4.56; P =.24).
Limitations to this study include a lack of diagnostic validation, as well as a definition of guideline adherence based solely on degree of severity.
The study researchers concluded that “[stepped and collaborative care models] are feasible and capable of improving diagnostic processes, treatment selection, adequate treatment of mildly depressed patients and application of low-intensity interventions in depression care. Furthermore, this study described the important difference of treatment selection and treatment initialization regarding guideline-adherence. … The low rate of guideline-adherent first treatments in severely depressed patients was not primarily a problem of inadequate treatment selection or lack of knowledge, but rather a matter of failed implementation.”
Heddaeus D, Steinmann M, Daubmann A, Härter M, Watzke B. Treatment selection and treatment initialization in guideline-based stepped and collaborative care for depression [published online December 26, 2018]. PLoS One. doi: 10.1371/journal.pone.0208882