patient information; and explicit partnerships between various agencies to ensure access to and receipt of needed services (NICE, 2004).
An estimated 5–9 percent of patients in primary care settings meet criteria for having major depression (Pignone et al., 2002), and many people with depression are treated in primary care as opposed to mental health settings (Kessler et al., 2005). In addition to its direct effects on health and well-being, depression affects the utilization of and adherence to treatment for general medical conditions (discussed in Chapter 2). Although treatment of depression does not encompass all psychosocial health services, problems encountered in providing high-quality mental health care for depression in primary care settings are similar to problems encountered in detecting and managing the broader array of psychosocial health problems seen in oncology settings. Both situations involve an attempt to provide for specialty services in an environment not intended primarily for the delivery of those services. Models for ensuring care for depression in primary care settings have been developed and tested through research and a number of major initiatives. These models can inform strategies for delivering the broader array of psychosocial health services.
Although the term “collaborative care” is used to refer to a variety of types of interventions, one model of collaborative care developed by Katon and colleagues that has been tested in randomized controlled trials consists of a systematic approach to the structured involvement of mental health specialists in primary care. This approach employs (1) a negotiated definition of the clinical problem in terms that both patient and physician understand; (2) joint development of a care plan with goals, targets, and implementation strategies; (3) provision of support for self-management training and cognitive and behavioral change; and (4) active sustained follow-up using visits, phone calls, e-mail, and web-based monitoring and decision-support systems (Katon, 2003). In an initial randomized controlled trial of this intervention (supplemented by increased frequency of primary care visits in the first 6 weeks of treatment and scheduled visits with psychiatrists) involving 199 patients with depression seen at a primary care clinic over a 12-month period, intervention patients with major depression (but not those with minor depression) showed significantly greater improvement in symptoms than patients who received usual care (Katon et al., 1995). These findings were repeated in successive trials (Katon et al., 1996, 1999).