Biomedical subjects

E Ludman

Publications and source records attributed to E Ludman.

At least 19 recordsLinked to original sources

PubMed2003

Behavioural factors associated with symptom outcomes in a primary care-based depression prevention intervention trial.

BACKGROUND: A randomized trial of a primary care-based intervention to prevent depression relapse resulted in improved adherence to long-term antidepressant medication and depression outcomes. We evaluated the effects of this intervention on behavioural processes and identified process predictors of improved depressive symptoms. METHOD: Patients at high risk for depression recurrence or relapse following successful acute phase treatment (N=386) were randomly assigned to receive a low intensity 12-month intervention or continued usual care. The intervention combined education about depression, shared decision-making regarding use of maintenance pharmacotherapy and cognitive-behavioural strategies to promote self-management. Baseline, 3, 6, 9 and 12-month interviews assessed patients' self-care practices, self-efficacy for managing depression and depressive symptoms. RESULTS: Intervention patients had significantly greater self-efficacy for managing depression (P<0.01) and were more likely to keep track of depressive symptoms (P<0.0001), monitor early warning signs (P<0.0001), and plan for coping with high risk situations (P<0.0001) at all time points compared to usual care control patients. Self-efficacy for managing depression (P<0.0001), keeping track of depressive symptoms (P=0.05), monitoring for early warning signs (P=0.01), engaging in pleasant activities (P<0.0001) and engaging in social activities (P<0.0001) positively predicted improvements in depression symptom scores. CONCLUSIONS: A brief intervention designed to target cognitive-behavioural factors and promote adherence to pharmacotherapy in order to prevent depression relapse was highly successful in changing several behaviours related to controlling depression. Improvements in self-efficacy and several self-management behaviours that were targets of the intervention were significantly related to improvements in depression outcome.

Antidepressive Agents↗

PubMed2001

Cost-effectiveness of a collaborative care program for primary care patients with persistent depression.

OBJECTIVE: The authors evaluated the incremental cost-effectiveness of stepped collaborative care for patients with persistent depressive symptoms after usual primary care management. METHOD: Primary care patients initiating antidepressant treatment completed a standardized telephone assessment 6-8 weeks after the initial prescription. Those with persistent major depression or significant subthreshold depressive symptoms were randomly assigned to continued usual care or collaborative care. The collaborative care included systematic patient education, an initial visit with a consulting psychiatrist, 2-4 months of shared care by the psychiatrist and primary care physician, and monitoring of follow-up visits and adherence to medication regimen. Clinical outcomes were assessed through blinded telephone assessments at 1, 3, and 6 months. Health services utilization and costs were assessed through health plan claims and accounting data. RESULTS: Patients receiving collaborative care experienced a mean of 16.7 additional depression-free days over 6 months. The mean incremental cost of depression treatment in this program was $357. The additional cost was attributable to greater expenditures for antidepressant prescriptions and outpatient visits. No offsetting decrease in use of other health services was observed. The incremental cost-effectiveness was $21.44 per depression-free day. CONCLUSIONS: A stepped collaborative care program for depressed primary care patients led to substantial increases in treatment effectiveness and moderate increases in costs. These findings are consistent with those of other randomized trials. Improving outcomes of depression treatment in primary care requires investment of additional resources, but the return on this investment is comparable to that of many other widely accepted medical interventions.

Adult↗

PubMed2000

Testing reminder and motivational telephone calls to increase screening mammography: a randomized study.

BACKGROUND: Prospective randomized trials have demonstrated that motivational telephone calls increase adherence to screening mammography. To better understand the effects of motivational calls and to maximize adherence, we conducted a randomized trial among women aged 50-79 years. METHODS: We created a stratified random sample of 5062 women due for mammograms within the Group Health Cooperative of Puget Sound, including 4099 women with prior mammography and 963 without it. We recruited and surveyed 3743 (74%) of the women before mailing a recommendation. After 2 months, 1765 (47%) of the 3743 women had not scheduled a mammogram and were randomly assigned to one of three intervention groups: a reminder post-card group (n = 590), a reminder telephone call group (n = 585), and a motivational telephone call addressing barriers group (n = 590). The telephone callers could schedule mammography. We used Cox proportional hazards models to estimate the hazard ratio (HR) and 95% confidence interval (CI) for documented mammography use by 1 year. RESULTS: Women who received reminder calls were more likely to get mammograms (HR = 1.9; 95% CI = 1.6-2.4) than women who were mailed postcards. The motivational and reminder calls (average length, 8.5 and 3.1 minutes, respectively) had equivalent effects (HR = 0.97; 95% CI = 0.8-1.2). After we controlled for the intervention effect, women with prior mammography (n = 1277) were much more likely to get a mammogram (HR = 3.4; 95% CI = 2.7-4.3) than women without prior use (n = 488). Higher income, but not race or more education, was associated with higher adherence. CONCLUSIONS: Reminding women to schedule an appointment was as efficacious as addressing barriers. Simple intervention groups should be included as comparison groups in randomized trials so that we better understand more complex intervention effects.

Affect↗

PubMed2000

At-risk drinking among patients making routine primary care visits.

BACKGROUND: Addressing non-alcoholic, at-risk patterns of alcohol consumption that are associated with increased morbidity and mortality is an important health care priority. OBJECTIVE: The objective was to describe the prevalence and characteristics of at-risk drinkers in a population-based sample of adults with routine primary care visits. METHODS: Three thousand four hundred thirty-nine patients with advance appointments in 23 primary care practices completed a health survey prior to their visit. At-risk drinking was defined as consuming an average of two or more drinks per day (chronic drinking), or two or more occasions of consuming five or more drinks in the past month (binge drinking), or, in the past month, one or more occasion of driving after consuming three or more drinks (drinking and driving). RESULTS: Prevalence was: 11% at-risk drinking; 63% light to moderate drinking; 26% abstinence. Abstainers differed from alcohol users on demographics (older, fewer Caucasian, lower income, more unemployed), other health behaviors (less exercise, lower rates of smoking, and marijuana and cocaine use), and family history of alcohol problems (lower). Abstainers also reported poorer physical and psychological health. Compared to light to moderate drinkers, at-risk drinkers were more likely to be male, unmarried, and to use other substances (tobacco, marijuana, and cocaine). Among at-risk drinkers, those with two or more risk factors were more likely male, consumed more alcohol per week, had higher AUDIT scores and were more motivated to change their drinking. Among those with only one risk factor, binge drinkers reported high rates of tobacco and marijuana use, relatively poor perceived health, and the highest proportion of negative consequences from drinking. CONCLUSIONS: At least 1 in 10 patients making routine primary care visits have drinking practices that place them at risk for negative consequences from drinking. Three drinking patterns that can be used to define at-risk drinking are relatively distinct.

Adult↗

PubMed2000

Predictors of outcome in a primary care depression trial.

OBJECTIVE: Previous treatment trials have found that approximately one third of depressed patients have persistent symptoms. We examined whether depression severity, comorbid psychiatric illness, and personality factors might play a role in this lack of response. DESIGN: Randomized trial of a stepped collaborative care intervention versus usual care. SETTING: HMO in Seattle, Wash. PATIENTS: Patients with major depression were stratified into severe (N = 149) and mild to moderate depression (N = 79) groups prior to randomization. INTERVENTIONS: A multifaceted intervention targeting patient, physician, and process of care, using collaborative management by a psychiatrist and primary care physician. MEASUREMENTS AND MAIN RESULTS: Patients with more severe depression had a higher risk for panic disorder (odds ratio [OR], 5.8), loneliness (OR, 2.6), and childhood emotional abuse (OR, 2.1). Among those with less severe depression, intervention patients showed significantly improved depression outcomes over time compared with those in usual care (z = -3.06, P<.002); however, this difference was not present in the more severely depressed groups (z = 0.61, NS). Although the group with severe depression showed differences between the intervention and control groups from baseline to 3 months that were similar to the group with less severe depression (during the acute phase of the intervention), these differences disappeared by 6 months. CONCLUSIONS: Initial depression severity, comorbid panic disorder, and other psychosocial vulnerabilities were associated with a decreased response to the collaborative care intervention. Although the intervention was appropriate for patients with moderate depression, individuals with higher levels of depression may require a longer continuation phase of therapy in order to achieve optimal depression outcomes.

Adult↗

PubMed2000

Are there detectable differences in quality of care or outcome of depression across primary care providers?

OBJECTIVE: The objective of this work was to determine whether there are detectable differences among primary care physicians in measures of quality of care or clinical outcome for depressed patients during the first 2 months of treatment with antidepressant medication. METHODS: We studied 1,599 depressed primary care patients initiating antidepressant treatment from 63 family physicians in 4 primary care clinics of a staff-model health maintenance organization. Patients were interviewed 6 to 8 weeks after initiating antidepressant medication with a telephone structured interview that included the Structural Clinical Interview for DSM-IV Diagnoses (SCID). Automated databases of the HMO were used to examine 3 quality-of-care measures: (1) the percentage of patients who had a refill of their antidepressant by 6 weeks, (2) the percentage of patients who had a return visit by 3 weeks, and (3) the percentage of patients having a return visit by 6 weeks. The percentage of patients in each primary care physician panel who had > or =4 persistent DSM-IV depressive symptoms at 6 to 8 weeks was the main clinical outcome variable. To adjust for case-mix differences between physician panels, patient age, gender, and medical comorbidity were controlled for in the analyses. Two covariates were used to adjust for differences in patients' clinical severity: self-report of > or =2 prior depressive episodes and an SCID diagnosis of major depression during the patient's worst episode in the last 2 years. Physician age, gender, and part-time versus full-time practice were also used as covariates. RESULTS: The wide observed range of variability in quality-of-care and clinical outcome measures by physician practice decreased markedly in the statistical model that controlled for patient-level covariates and differences in the number of patients seen per provider. We did not detect differences in physician practice for the percentage of patients who had a return visit by 3 or 6 weeks, the percentage of patients who had a refill of their antidepressant prescription by 6 weeks, or the percentage of patients with an adverse clinical outcome of depression. CONCLUSIONS: We did not find important differences in measures of quality of care or patient outcomes by physician. These results may have implications for the use of physician profiling and other forms of physician report cards.

Adolescent↗

PubMed2000

The design, implementation, and acceptance of a primary care-based intervention to prevent depression relapse.

OBJECTIVE: This article describes the conceptual underpinnings, implementation, and participation rates of a twelve-month low-intensity primary care-based intervention to prevent depression relapse. The intervention was designed to address the inherent problems in delivery of effective maintenance treatment in a population based sample of primary care patients. METHODS: Patients at high risk of relapse based on psychiatric history who recovered from depression six to eight weeks after initiation of pharmacotherapy by their primary care physician were eligible; 194 were randomized to receive the intervention. The intervention combined education about depression, motivation-enhancing shared decision-making regarding the use of maintenance pharmacotherapy, and cognitive-behavioral strategies. The program included two visits with a Depression Prevention Specialist working in tandem with the primary care physician at the primary care clinic, with supervision and back up from a consulting psychiatrist, proactive follow-up telephone calls and mailed personalized feedback. RESULTS: Ninety-three percent of patients attended both in-person visits; 97 percent attended one visit. Eighty percent of patients completed all three follow-up telephone calls, and 85 percent returned at least one mailed feedback form; 48 percent returned all four forms. Offered a menu of options for self-management, most patients chose medication as well as a variety of behavioral strategies. At six months, 72 percent ofpatients and at twelve months 62 percent of patients remained on antidepressant medication. CONCLUSIONS: We conclude that it is feasible to integrate a low intensity, twelve-month relapse prevention intervention for depression into a primary care clinic.

Antidepressive Agents↗

PubMed1999

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

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.

Antidepressive Agents↗

PubMed1999

Evaluation of a minimal self-help smoking cessation intervention following cervical cancer screening.

OBJECTIVE: This study was undertaken to evaluate a smoking cessation intervention provided to women smokers as follow-up to cervical cancer screening. METHODS: Women who had had a Pap test in the prior month (N = 4,053) were called to complete a survey that assessed smoking status; 580 identified smokers were randomized to receive Usual care (n = 292) or a Self-help intervention (n = 288) that included a self-help booklet, a smoking and reproductive health information card, and three telephone counseling calls. Women were followed up at 6 and 15 months post-base line. RESULTS: Cessation rates in the Usual care (UC) and Self-help (SH) groups did not differ at the 6-month (UC 10.5% vs SH 10.9%, P = 0.56) or 15-month follow-up (UC 15.5% vs SH 10.6%, P = 0.17). Among women with an abnormal Pap test result there were no differences by study group in cessation rates at 6-month (UC 9.8% vs SH 11.0%, P = 0.71) or 15-month follow-up (UC 14.6% vs SH 13.4%, P = 0.96). CONCLUSION: Integrating interventions into the clinical setting and involving providers at the point of care may have greater potential for capitalizing on this "teachable moment."

Adolescent↗

PubMed1999

The association between cigarette smoking and low-grade cervical abnormalities in reproductive-age women.

OBJECTIVE: To evaluate the association between smoking and the occurrence of low-grade cervical cytological abnormalities. METHODS: We conducted a population-based cross-sectional study of smoking and other exposures in reproductive-age women with normal and abnormal cytology results (Class 1-4 Pap tests). Participants (n = 2,448) were enrollees of the Group Health Cooperative of Puget Sound, a health maintenance organization (HMO) in Washington state, USA. Non-pregnant women were selected monthly from the HMO's cytology database during 1995-6, with over-sampling of women with low-grade abnormalities. All participants completed a structured telephone-administered survey. RESULTS: Of the 2,448 participants, 19% (n = 465) had Class 2 Pap results, and 5% (n = 117) had Class 3-4 results. Forty percent of the sample (n = 975) reported ever smoking. Women reporting current/recent smoking (n = 514, 21%) had an increased likelihood of cervical abnormalities (adjusted odds ratio (OR) 1.4, 95% confidence interval (CI 1.1-1.8). Women who had never smoked but who reported recent passive smoking exposure also had a greater likelihood of abnormal test results (OR 1.4, 95% CI 1.0-2.0). Prior smoking was not associated with cytology status. CONCLUSIONS: Our results, examining low-grade cervical abnormalities, are compatible with those from studies of more severe cervical lesions, lending added support to the hypothesis that smoking predisposes to development of a spectrum of cervical abnormalities. Thus, even cytologic screening visits represent an opportunity to counsel women smokers about their health risks, particularly the more proximal risks of cervical abnormalities and cancer.

Adolescent↗

PubMed1999

Patterns of care for depressed older adults in a large-staff model HMO.

The authors examined automated pharmacy and visit data for 502 members of a large-staff model health maintenance organization (HMO) who had been diagnosed with depression and started on antidepressants by their primary-care providers. Older patients (age >/=60; n=110) were less likely than younger adults (age 18-59, n=110) to receive adequate doses of antidepressant medications for 30 or 90 days. Older adults were also less likely than younger adults to receive more than two primary-care visits for depression in the 12 weeks after receiving a new antidepressant prescription and were less likely to receive specialty mental health care in the 6 months after receiving a new antidepressant prescription.

Adolescent↗

PubMed1998

Impact of improved depression treatment in primary care on daily functioning and disability.

BACKGROUND: Few data are available regarding the impact of improved depression treatment on daily functioning and disability. METHODS: In two studies of more intensive depression treatment in primary care, patients initiating antidepressant treatment were randomly assigned to either usual care or to a collaborative management programme including patient education, on-site mental health treatment, adjustment of antidepressant medication, behavioural activation and monitoring of medication adherence. Assessments at baseline as well as 4 and 7 months included several measures of impairment, daily functioning and disability: self-rated overall health, number of bodily pains, number of somatization symptoms, changes in work due to health, reduction in leisure activities due to health, number of disability days and number of restricted activity days. RESULTS: Average data from the 4- and 7-month assessments in both studies, intervention patients reported fewer somatic symptoms (OR 0.68, 95% CI 0.46, 0.99) and more favourable overall health (OR 0.50, 95% CI 0.28, 0.91). While intervention patients fared better on other measures of functional impairment and disability, none of these differences reached statistical significance. CONCLUSIONS: More effective acute-phase depression treatment reduced somatic distress and improved self-rated overall health. The absence of a significant intervention effect on other disability measures may reflect the brief treatment and follow-up period and the influence of other individual and environmental factors on disability.

Absenteeism↗

PubMed1997

Population-based care of depression: effective disease management strategies to decrease prevalence.

This paper reviews the concepts of population-based care and disease management of major depression. Population-based care and disease management strategies motivated by health care reform provide approaches for organizing health services to lower the prevalence of common medical and psychiatric illnesses in primary care populations. We apply these concepts to the organization of services for patients with major depression.

Cross-Sectional Studies↗

PubMed1997

Collaborative management to achieve depression treatment guidelines.

Two models that integrate the psychiatrist into treatment of depression in primary care have been evaluated in randomized controlled trials. In the psychiatrist/primary care model, a psychiatrist alternated visits with a primary care physician to assist in the education and pharmacologic treatment of the patient. In the psychiatrist/psychologist team model, the psychiatrist worked with a team of psychologists to improve adherence to and effectiveness of antidepressant treatment, with psychologists also providing brief behavioral treatment in the primary care clinic. Findings with the psychiatry/primary care model are reported. It was found that the collaborative model was associated with improved adherence to treatment, increased patient satisfaction with depression care, and improved depression outcome compared with usual care by primary care physicians alone. Similar results were found in the study of the psychiatrist/psychologist collaborative care model. The success of these models indicates the appropriateness of a novel role for the psychiatrist and psychologist, i.e., that of collaboration with primary care physicians in care of the depressed patient in the primary care setting.

Antidepressive Agents↗

PubMed1996

A multifaceted intervention to improve treatment of depression in primary care.

BACKGROUND: This research study evaluates the effectiveness of a multifaceted intervention program to improve the management of depression in primary care. METHODS: One hundred fifty-three primary care patients with current depression were entered into a randomized controlled trial. Intervention patients received a structured depression treatment program in the primary care setting that included both behavioral treatment to increase use of adaptive coping strategies and counseling to improve medication adherence. Control patients received "usual" care by their primary care physicians. Outcome measures included adherence to antidepressant medication, satisfaction with care of depression and with antidepressant treatment, and reduction of depressive symptoms over time. RESULTS: At 4-month follow-up, significantly more intervention patients with major and minor depression than usual care patients adhered to antidepressant medication and rated the quality of care they received for depression as good to excellent. Intervention patients with major depression demonstrated a significantly greater decrease in depression severity over time compared with usual care patients on all 4 outcome analyses. Intervention patients with minor depression were found to have a significant decrease over time in depression severity on only 1 of 4 study outcome analyses compared with usual care patients. CONCLUSION: A multifaceted primary care intervention improved adherence to antidepressant regimens and satisfaction with care in patients with major and minor depression. The intervention consistently resulted in more favorable depression outcomes among patients with major depression, while outcome effects were ambiguous among patients with minor depression.

Adult↗

PubMedDate not supplied

Relapse of depression in primary care. Rate and clinical predictors.

OBJECTIVE: To determine the clinical predictors and rate of relapse for major depression in primary care. DESIGN: A cohort study of subjects in 2 randomized trials of depressed patients diagnosed and prescribed antidepressant medicine by primary care physicians. Baseline, 7-month, and 19-month assessments were conducted. SETTING: A large primary care clinic of a staff-model health maintenance organization. PATIENTS: Two hundred fifty-one primary care patients who did not satisfy Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition (DSM-III-R) criteria for major depression at 7 months. MAIN OUTCOME MEASURES: Relapse was defined as (1) satisfying DSM-III-R criteria for major depression at 19 months, or (2) reporting an interval episode of 2 weeks or more of depressed mood and symptoms between 7 and 19 months. Predictors examined included demographic characteristics, medical comorbidity, disability, and psychological symptoms. Depressive symptoms were measured by Inventory of Depressive Symptoms and Hopkins Symptoms Checklist. RESULTS: Of the patients, 37.1% reported relapse of depression in the 12-month relapse-risk period. The 2 major risk factors associated with relapse were (1) persistence of subthreshold depressive symptoms 7 months after the initiation of antidepressant therapy (odds ratio, 3.3; 95% confidence interval, 2.74-3.93) and (2) history of 2 or more episodes of major depression, or chronic mood symptoms for 2 years (odds ratio, 2.1; 95% confidence interval, 1.41-2.76). Patients with both risk factors were approximately 3 times more likely to relapse than patients with neither. CONCLUSIONS: The relapse rate among primary care patients treated for depression approached that of specialty samples, with more than one third reporting relapse in 1 year. Clinical characteristics can help target high-risk patients for relapse prevention efforts.

Adult↗

PubMedDate not supplied

Long-term outcomes of initial antidepressant drug choice in a "real world" randomized trial.

OBJECTIVE: To compare the long-term clinical, quality-of-life, and economic outcomes after an initial prescription for fluoxetine, imipramine hydrochloride, or desipramine hydrochloride. DESIGN: Randomized, controlled trial. SETTING: Primary care clinics of a staff-model health maintenance organization in the Seattle, Wash, area. PATIENTS: Four hundred seventy-one adults beginning antidepressant drug treatment for depression. INTERVENTION: Random assignment of initial medication (desipramine, fluoxetine, or imipramine), with treatment (dosing, medication changes or discontinuation, and follow-up visits) managed by a primary care physician. MEASUREMENTS: Interviews at baseline and at 6, 9, 12, 18, and 24 months examined medication use, clinical outcomes (Hamilton Depression Rating Scale and depression subscale of the Hopkins Symptom Checklist), and quality of life (Medical Outcomes Study SF-36 Health Survey). Medical costs were assessed using the health maintenance organization's accounting data. RESULTS: Patients assigned to fluoxetine therapy were significantly more likely to continue taking the initial antidepressant but no more likely to continue any antidepressant therapy. The fluoxetine group did not differ significantly from either tricyclic drug group on any measure of depression severity or quality of life. For 24 months, antidepressant drug costs were approximately $250 higher for patients assigned to fluoxetine therapy, but total medical costs were essentially identical. CONCLUSIONS: Initial selection of fluoxetine or a tricyclic antidepressant drug should lead to similar clinical outcomes, functional outcomes, and overall costs. Differences in antidepressant prescription costs are blunted by the large minority of tricyclic-treated patients who switch to use of more expensive medications. Restrictions on first-line use of fluoxetine in primary care will probably not reduce overall treatment costs.

Adrenergic Uptake Inhibitors↗

PubMedDate not supplied

Can depression treatment in primary care reduce disability? A stepped care approach.

OBJECTIVE: To assess effects of stepped collaborative care depression intervention on disability. DESIGN: Randomized controlled trial. SETTING: Four primary care clinics of a large health maintenance organization. PATIENTS: Two hundred twenty-eight patients with either 4 or more persistent major depressive symptoms or a score of 1.5 or greater on the Hopkins Symptom Checklist. Depression items were randomized to stepped care intervention or usual care 6 to 8 weeks after initiating antidepressant medication. INTERVENTION: Augmented treatment of persistently depressed patients by an on-site psychiatrist collaborating with primary care physicians. Treatment included patient education, adjustment of pharmacotherapy, and proactive monitoring of outcomes. MAIN OUTCOME MEASURES: Baseline, 1-, 3-, and 6-month assessments of the Sheehan Disability Scale and the social function and role limitation subscales of the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36). RESULTS: Patients who received the depression intervention experienced less interference in their family, work, and social activities than patients receiving usual primary care (Sheehan Disability Scale, z = 2.23; P =.025). Patients receiving intervention also reported a trend toward more improvement in SF-36-defined social functioning than patients receiving usual care (z = 1.63, P =.10), but there was no significant difference in role performance (z = 0.07, P =.94). CONCLUSIONS: Significant disability accompanied depression in this persistently depressed group. The stepped care intervention resulted in small to moderate functional improvements for these primary care patients. Arch Fam Med. 2000;9:1052-1058

Data Collection↗