Overview of the Partners in Care Study
PIC was a real-world trial, conducted from 1995 to 2000. Designed to improve the quality of care for depression in managed, primary care practices, PIC was carried out in 46 primary care clinics within six diverse, nonacademic managed care plans in five states in the Western, Midwestern, and Eastern United States. The study evaluated two quality-improvement (QI) programs based on previous successful collaborative care interventions, each of which cost about the same amount to implement.
The two programs shared many common materials, but had different supplemental resources. One program directed QI resources toward supporting medication treatment; the other directed resources toward supporting psychotherapy. However, both programs encouraged providers to consider patient treatment preferences in choosing a treatment plan.
The two programs proved to be about equally successful. Practices can thus choose either model and, if they wish, can add elements of the one not chosen. However, a fairly complete program may be needed to achieve a good result.
Rationale for the PIC Collaborative Care Model
Most patients with symptoms of depression are seen in primary care settings, and most are not treated effectively. The lack of successful treatment stems from a mismatch between the needs of depressed patients and the organization and processes of primary care practices.
Primary care practices depend on general medical clinicians, who often have few support staff. To ensure that physicians can see all the patients seeking care, patient visits are kept brief--usually to 15 minutes. Mechanisms for ensuring provider and patient education, guideline-adherent assessment and follow-up care for chronic illnesses, and linkages to specialists are variable in their quality and availability. Under these circumstances, care for depression poses special challenges. The PIC collaborative care QI programs are intended to address the challenges listed below.
Need for Proactive Case Detection
Fatigue, hopelessness, and passivity are part of the illness of depression. In addition, depressed patients often feel shame for having a mental condition and may not expect primary care providers to care for their depression symptoms. Unlike chronic illnesses such as diabetes, depression waxes and wanes. As a consequence, database information that a patient had depression last year is of limited help for treatment decisions this year. Active, ongoing practice-wide strategies for detecting current major depression are needed.
Need for Proactive Case Management and Patient Activation
Medications take time to improve depression symptoms, and they must be continued long after the symptoms have subsided. Medications also have side effects, and require monitoring, change, and adjustment. Brief psychotherapy requires 8 to 12 sessions for adequate improvement. Depressed patients often know little about depression and its treatments. They often find it hard to get out of bed in the morning, let alone to deal with medications or psychotherapy. Therefore, primary care practices must take an active role in ensuring that patients are knowledgeable about their condition, that they are motivated to follow treatment regimes, and that therapy is successfully completed.
Need for Time to Conduct a Thorough Clinical Assessment
In order not to overuse depression treatments, clinicians must assess patients in some depth to identify the approximately 6% requiring full treatment from among the approximately 20% of patients with some symptoms of depression. Most of the 20% require neither psychotherapy nor medications, although some will need education, further monitoring, or low-intensity psychological support (e.g., a support group). In addition, treatment guidelines stipulate the need to assess depressed patients for important common conditions, such as alcoholism, mania, or anxiety, that may affect depression treatment. Primary care practices must find ways to ensure that appropriate assessment is done.
Need for Collaboration with Mental Health Specialists
Primary care clinicians need access to psychotherapists for their patients, for consultation on difficult cases, and for ongoing education about depression. Standards of care for depression need periodic review and updating by specialists. However, mental health specialists often have less interaction with primary care providers than do, for example, medical subspecialists. Therefore, primary care practices need to develop mechanisms for ongoing, effective interaction with mental health specialists, both at the practice level and around individual patient cases.
The Partners in Care approach directly addresses these challenges through a collaborative care model. Key characteristics of this approach include collaboration between specialists and generalists, active case management, and patient empowerment.