Depression Management by Phone Called Win-Win

BETHESDA, Md., Sept. 25 -- An aggressive workplace program for identifying and treating depression is both good medical practice and good business, investigators here said.

Depressed workers randomized to a managed care plan emphasizing screening, telephone-based outreach, and care management had lower symptoms scores, were more likely to stay on the job, and worked about two weeks more per year than those given usual services, reported Philip S. Wang, M.D., Dr.P.H., of the National Institute of Mental Health, and colleagues.

"The results suggest that enhanced depression care of workers has benefits not only on clinical outcomes but also on workplace outcomes," the investigators wrote in the Sept. 26 issue of Journal of the American Medical Association.

The findings indicate that the added costs to employers of mental health benefits may have an even bigger payoff in terms of worker health and productivity, commented Kenneth B. Wells, M.D., M.P.H., and Jeanne Miranda, Ph.D., of the University of California at Los Angeles, in an accompanying editorial.

"The monetary value of the increased work time under the program exceeded the direct intervention costs and likely exceeded or was within the range of cost increases due to greater mental health specialty use under the intervention," they wrote.

"While formal estimates of cost-effectiveness and employer return on investment are pending, it appears to be in the business interests of many employers to implement such programs to protect their investments in the retention and productivity of workers they have hired and trained."

The intervention described by Dr. Wang and colleagues involved 604 workers from 18 companies with coverage by a managed care behavioral health program. The workers were tentatively identified through a workplace health appraisal, with those who screened positive for possible depression receiving further screening via a telephone-based structured interview.

Employees identified as having significant depression but not bipolar disorder, substance disorder, history of recent mental health treatment, or suicidality were eligible for randomization.

The patients were assigned to receive a telephone-based outreach and care-management program in which the workers were encouraged by a care manager -- a licensed master's degree-level clinical employed by the managed care company -- to enter outpatient therapy, consisting of psychotherapy and/or antidepressants.

The care managers monitored treatment quality continuity and gave recommendations to providers with the goal of improving treatment. Those patients randomized to the intervention who expressed reluctance about entering treatment were instead offered a structured telephone cognitive behavioral psychotherapy intervention. A health plan psychiatrist was also available for consultations with clinicians.

Controls -- the patients assigned to the usual care arm -- were told that their responses to the screening indicated possible depression and they were advised to consult with a clinician. These patients could receive any normally available insurance benefit or service such as medications or psychotherapy, but they did not receive the telephone-based care management services.

The investigators measured depression severity according to the Quick Inventory of Depressive Symptomatology and work performance according to the World Health Organization Health and Productivity Questionnaire, described as "a validated self-report instrument assessing job retention, time missed from work, work performance, and critical workplace incidents."

Investigators were blinded to treatment allocation and to assessment of depression severity and work performance at six and 12 months.

The authors found in an analysis of the combined data from the six- and 12-month assessments that the patients who received the care-management intervention had significantly lower self-reported depressive symptoms scores, with relative odds of recovery vs. controls of 1.4 (95% confidence interval, 1.1-2.0, P=0.009).

In addition, the care-management group was more likely to stay on the job (relative odds, 1.7, 95% CI, 1.1-3.3, P=0.02), and to work significantly more hours than controls (b=2.0, P=0.02). The patients in the intervention group worked the equivalent of two weeks more per year than those in the usual care group.

"A systematic program to identify depression and promote effective treatment significantly improves not only clinical outcomes but also workplace outcomes," Dr. Wang and colleagues wrote. "The financial value of the latter to employers in terms of recovered hiring, training, and salary costs suggests that many employers would experience a positive return on investment from outreach and enhanced treatment of depressed workers."

In their editorial, Drs. Wells and Miranda noted that the intervention approach used by the investigators has been shown to be effective in primary care settings, but cautioned that interventions in depression need to address disparities in care.

"Developers of interventions and policies should consider implications of their design for inclusion of underserved groups who may not seek behavioral health care," they wrote.

Dr. Wang and colleagues acknowledged as limitations of their study that the depression screening instrument they used could have misclassified some patients, and that the WHO Health and Productively Questionnaire might have been systematically biased.

They also noted that they could not determine whether the workers who took part in the initial screening phase had different prevalence, severity, or impairment associated with depression compared with those who did not take part, and that trial participants had less severe depression and were demographically different from a nationally representative sample.

Co-author Ronald C. Kessler, Ph.D., is a consultant for AstraZeneca, Bristol-Myers Squibb, Eli Lilly & Co, GlaxoSmithKline, Pfizer, and Wyeth and reported receiving research support for his epidemiological studies from Bristol-Myers Squibb, Eli Lilly, Ortho-McNeil, Pfizer, and the Pfizer Foundation. Co-authors Francisca Azocar, Ph.D. and Joyce McCulloch, M.S. are employees of United Behavioral Health, the managed-care plan in the study, and reported holding stocks and options from United Health Group. Neither the remaining authors nor the editorialists reported other financial conflicts of interest.