Stepped collaborative care for primary care patients with persistent symptoms of depression: a randomized trial

Arch Gen Psychiatry. 1999 Dec;56(12):1109-15. doi: 10.1001/archpsyc.56.12.1109.


Background: Despite improvements in the accuracy of diagnosing depression and use of medications with fewer side effects, many patients treated with antidepressant medications by primary care physicians have persistent symptoms.

Methods: A group of 228 patients recognized as depressed by their primary care physicians and given antidepressant medication who had either 4 or more persistent major depressive symptoms or a score of 1.5 or more on the Hopkins Symptom Checklist depression items at 6 to 8 weeks were randomized to a collaborative care intervention (n = 114) or usual care (n = 114) by the primary care physician. Patients in the intervention group received enhanced education and increased frequency of visits by a psychiatrist working with the primary care physician to improve pharmacologic treatment. Follow-up assessments were completed at 1, 3, and 6 months by a telephone survey team blinded to randomization status.

Results: Those in the intervention group had significantly greater adherence to adequate dosage of medication for 90 days or more and were more likely to rate the quality of care they received for depression as good to excellent compared with usual care controls. Intervention patients showed a significantly greater decrease compared with usual care controls in severity of depressive symptoms over time and were more likely to have fully recovered at 3 and 6 months.

Conclusions: A multifaceted program targeted to patients whose depressive symptoms persisted 6 to 8 weeks after initiation of antidepressant medication by their primary care physician was found to significantly improve adherence to antidepressants, satisfaction with care, and depressive outcomes compared with usual care.

Publication types

  • Clinical Trial
  • Randomized Controlled Trial
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Antidepressive Agents / therapeutic use*
  • Attitude to Health
  • Combined Modality Therapy
  • Depressive Disorder / diagnosis
  • Depressive Disorder / drug therapy*
  • Depressive Disorder / psychology
  • Evidence-Based Medicine
  • Follow-Up Studies
  • Humans
  • Patient Care Management*
  • Patient Compliance
  • Patient Education as Topic
  • Personality Inventory / statistics & numerical data
  • Primary Health Care* / methods
  • Psychiatry
  • Quality of Health Care
  • Referral and Consultation
  • Severity of Illness Index
  • Treatment Outcome


  • Antidepressive Agents