Denver Health and Hospitals Foundation
Denver, Colorado
Depression
African American, Latino

Project

Patients received depression assessment, support and counseling over the phone.

A six-session, scripted telephone counseling protocol is delivered by mental health clinicians to improve medication adherence and promote behavioral activation in ways that help patients experience reward and pleasure in their lives. Mental health clinicians receive training on how to provide culturally effective care. Additionally, bilingual mental health clinicians and culturally tailored print materials are made available to Spanish-speaking participants. After each call, patients receive a letter summarizing the discussion and a list of “homework” assignments to be completed before the next call. Primary care physicians receive feedback on their patients’ mental health diagnoses and depression severity levels, along with updated disease management recommendations after every other counseling session. Participants are Federally Qualified Health Centers (FQHCs) that are part of Denver Health and Hospitals Foundation, a public safety net health care system.

Rationale

Primary care physicians are increasingly responsible for diagnosing and treating depression, but their management of depression has been less than optimal. Their management is often characterized by low medication adherence and adjustment, low levels of mental health assessment and consultation with mental health specialists, and a lack of evidence-based psychotherapy. These problems are even more pronounced for low-income minority patients.

This study aims to improve the management of depression by providing telephone-based assessment, counseling and monitoring. The intervention is based on a Behavioral Activation approach, a relatively simple intervention that is easy for depressed patients to understand and does not require difficult or complex skills to implement. The telephone-based care management and therapy program has the potential to improve clinical outcomes, while being less costly and easier to establish than collaborative care or practice-based reorganizations. In particular, the telephone-based intervention program may increase adherence to antidepressant medications.

Summary Results

Depression assessment, support, and counseling delivered by a mental health clinician over the phone was successful in significantly improving depression symptom scores at 12 weeks (10.93 vs 12.63 on PHQ-9) for patients with depression diagnosed by their primary care physician. Patients in the intervention group were also significantly more likely to be in remission (PHQ-9 < 5) at 24 weeks (odds ratio: 2.1). However, this intervention did not affect medication persistence or  adherence. In addition, patients with severe baseline depressive symptoms (PHQ-9 > 15) had significantly greater decreases in depressive symptoms  at 6, 12, and 24 weeks, regardless of whether they received the intervention or control treatment.

Publications

Telephone Assessment, Support, and Counseling for Depression in Primary Care Medical Clinics 
Cognitive and Behavioral Practice. 2014;21(3):282–295. 
Full Article (subscription may be required)

Additional Resources

• VIDEO: Watch a 5-minute presentation

Principal Investigators

• David S. Brody, MD (Medical Director, Denver Health)
• Jeanette Waxmonsky, PhD (Assistant Professor, University of Colorado-Denver School of Medicine)