Numerous studies have established the efficacy and effectiveness of collaborative care for depression. However, implementing collaborative care in small rural primary care practices presents unique challenges because it is typically not economically feasible to employ mental health specialists on site. This project will evaluate telemedicine-based collaborative care adapted for small rural VA Community Based Outpatient Clinics (CBOCs). The Telemedicine Enhanced Antidepressant Management (TEAM) collaborative care intervention is implemented by offsite personnel including a Nurse Depression Manager, Clinical Pharmacist, and Consult Psychiatrists. The TEAM intervention has seven main components targeting the CBOC Primary Care Provider (PCP) and the patient: 1) academic detailing, 2) screening to establish caseness for major depressive disorder (MDD), 3) patient education/activation and barrier assessment/resolution, 4) outcomes monitoring and feedback, 5) medication management, 6) psychiatric consultation, and 7) treatment recommendations. All of these components are implemented using telemedicine technologies. Screening, patient education/activation and barrier assessment/resolution, symptom and medication monitoring, and medication management are conducted by telephone. Patient educational materials and provider toolkits are available on the TEAM website (http://www.va.gov/team/). Academic detailing and psychiatric consultations are conducted via interactive video. Feedback and treatment recommendations are provided to PCPs using electronic medical records (CPRS).

Specific Aim 1: Determine whether the TEAM intervention improves quality and outcomes compared to usual care. Specific Aim 2: Determine whether the TEAM intervention will be cost-effective in routine practice settings. Seven CBOCs in MS, AR, LA and TX are participating in the study. CBOCs were included if they 1) treated >1,000 and <5,000 unique veterans, 2) had no on-site psychiatrists, and 3) had interactive video equipment. CBOCs were pair-matched by parent VAMC and then randomized to receive the intervention or usual care. To date, 18,227 (74% of CBOC patients) were screened for MDD. Six percent of patients refused to be screened. To date, 470 patients have been eligibile to particpate in the study, and 394 (84%) were successfully enrolled and attended their primary care appointment. Seven percent of eligible patients refused to provide informed consent. Patients were considered ineligible if they were already being seen in mental health, had acute suicide ideation, schizophrenia, mania, substance dependence (but not abuse), cognitive impairment, bereavement, were pregnant, had a guardian, or did not expect to receive treatment at the clinic during the course of the next year.

Condition	Treatment or Intervention
Depression	Behavior: Telemedicine intervention

Further Study Details: 

Expected Total Enrollment:  400

Telephone research interviews were conducted at baseline, six and twelve months. The baseline telephone interview asked about demographics, depression history, depression diagnostic criteria (major depressive disorder, minor depressive disorder, dysthymia), depression symptom severity, psychiatric comorbidity, physical comorbidity, depression health beliefs, depression treatment preferences, social support, and health related quality of life. The follow-up interviews reassessed depression diagnostic criteria, depression symptom severity, and health related quality of life. In addition, the follow-up interviews assessed medication adherence, satisfaction with care, and utilization of non-VA service use. Use and cost of VA services will be collected from ACC, VISTA, and DSS. Medication possession ratios will be determined from VA pharmacy databases.

Hypotheses for Specific Aim 1 will be tested using an intent-to-treat analysis with patients defined as the unit of analysis. Random effects regression models will be used to account for the potential nesting of patients within providers and facilities. Assuming zero intra-class correlation among subjects within study sites, there will be 98% power to detect a 20% difference in the proportion of patients responding to treatment (i.e., meeting diagnostic criteria for MDD) and 97% power to detect a decrease in depression severity equivalent to a small effect size. The cost-effectiveness analysis will be conducted from the perspective of both the VA and society, and will include intervention costs, encounter/ancillary costs, and patient costs.

Ages Eligible for Study:  18 Years and above,  Genders Eligible for Study:  Both

Criteria

• Primary care patients who screen positive for depression and do not already see a mental health provider.

Arkansas
      Central Arkansas VHS Eugene J. Towbin Healthcare Ctr, Little Rock, No Little Rock,  Arkansas,  72114-1706,  United States
      Central Arkansas VHS Eugene J. Towbin Healthcare Ctr, Little Rock, No Little Rock,  Arkansas,  72114-1706,  United States
Louisiana
      VA Medical Center, Shreveport,  Louisiana,  71101,  United States
Mississippi
      VA Medical Center, Jackson,  Mississippi,  39216,  United States
Washington
      VA Puget Sound Health Care System, Seattle,  Washington,  98109,  United States

Study ID Numbers:  IIR 00-078
Record last reviewed:  March 2005
Last Updated:  March 16, 2005
Record first received:  March 16, 2005
ClinicalTrials.gov Identifier:  NCT00105690
Health Authority: United States: Federal Government
ClinicalTrials.gov processed this record on 2005-04-08