COMMENTARY

This sizeable trial builds upon previous studies of collaborative care and chronic disease management. The authors suggest that this collaborative, stepped care management intervention is more effective than usual care for depression in a wide range of people and several types of medical care organisations. The findings have important implications for clinical practice and challenges for current policy.

Several randomised trials have found improved patient outcomes in depression from various components of chronic disease management compared with usual care. Although this study focused on older people, the totality of evidence suggests that usual care for major depression or dysthymia in primary care is no longer acceptable for any age group. Beyond screening or increased case detection, all primary care providers and practice administrators should examine how they can improve depression management. Depending on the size and resources of a practice, at least some of the care management components of this intervention could be implemented. For the mental health worker, this study emphasises the importance of seeking out and being involved in consultative and supervisory roles to more effectively serve a larger number of patients.

Investigators should not be complacent that interventions of this nature will improve depression management. The number of people achieving true remission remains unacceptably small, attesting to the chronic nature of major depression and dysthymia.

For government and organisational policy makers, the results of this study mandate the need to offer fair and reasonable reimbursement for care management services and for telephone or in person supervision by mental health professionals serving primary care providers.