Objectives
Depression is one of the most common and most disabling psychiatric disorders; it was the fourth highest cause of disability and death worldwide in 1990, and is expected to move into second place by 2020. Although effective treatments for depression exist, most people with depression are reluctant to see a mental health specialist. Instead, they are seen in primary care settings, where they may present a range of emotional and physical complaints. While most physicians feel they have a responsibility to recognize depression, many are unsure of their ability to diagnose and treat it. Improving that picture hasn't been a priority in the medical community or in federal agencies.

Recognizing the importance of the problem, the Foundation launched the Initiative on Depression in Primary Care. Its charge is to enhance the quality of care and outcomes for patients with depressive disorders who are seen in primary care practices.

Approach
The Initiative's steering committee — including primary care physicians, psychiatrists, and psychologists — began by seeking a better understanding of current practice patterns. Their research revealed two major barriers to effective treatment. One is the lack of tools to improve depression management; the other is a lack of time and support in the practice setting for managing patients with depression. Primary care practices are not well organized for the purpose: they need better systems for tracking patients, for encouraging their return when necessary, and for assigning appropriate people in the practice to assist the doctor in providing long-term care.

To address these needs, the Initiative set itself four goals:

• To develop office routines and practice patterns that could improve the management of patients with depression
• To develop educational programs and tools to help primary care physicians better recognize and care for patients with depression
• To evaluate the impact of these practices, programs, and tools
• To disseminate the new ideas and materials to primary care clinicians, medical groups, specialty societies, insurance plans, and others.

In pursuing these goals, the Initiative developed its Three Component Model (TCM), an approach designed to work in a wide variety of primary care settings. Under TCM, the primary care clinician, a care manager, and a mental health professional cooperate with the patient and with one another in providing evidence-based care to patients with symptoms of depression.

The most innovative aspect of TCM is its turnkey approach to implementation. The research team has consolidated the implementation strategies and materials in a manual that can be put into practice by medical groups, health plans, and others, using only modest resources of their own. The impact of this model is currently being tested in more than 60 practices in five health care organizations. The Initiative is gradually shifting the responsibility for training providers from the research team to the partner health care organizations, allowing the organizations to help the affiliated practices implement and sustain TCM over the long term. The researchers will evaluate the success of that effort.

The group's preliminary evaluation of TCM indicates that there is a significantly larger reduction in depressive symptoms among patients receiving TCM than among those who receive "usual care," and that the difference is greatest among the most impaired people.

Progress and Plans
The work of the Initiative has become an important model of how to influence the delivery of mental health services to narrow the gap between knowledge and practice and improve access to high quality care.

The Initiative plans to expand TCM still further through new partners. In order to have a major, nationwide impact on the availability of high quality depression care, they will work with two large, national organizations: Blue Cross Blue Shield, with 46 affiliated plans and more than 30 million enrolled members; and the Federal Bureau of Primary Health Care, which supports 750 federally funded community health centers with more than 1,300 clinics. The Initiative estimates that working with these organizations over two years will allow them to reach more than 1,000 practices and at least 5,000 clinicians serving 10 million people.

In addition, the Initiative will create a self-sustaining infrastructure to support the dissemination, application, and further development of TCM over the long term, beyond the life of the Initiative itself.

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