Research Networks

Initiative on Depression & Primary Care

The Foundation launched the Initiative on Depression in Primary Care to enhance the quality of care and outcomes for patients with depressive disorders who are seen in primary care practices.

Supported by MacArthur from 1995 to 2006

About This Network

Depression is one of the most common and disabling of psychiatric disorders.  According to the World Health Organization, in 1990 it was the fourth highest cause of disability and death worldwide; by 2020, it expected to be the second highest cause.  Despite the seriousness of the threat, many persons who could benefit from treatment are reluctant to approach mental health specialists for help.  However, these patients do consult their primary care physicians.  In 1995 the MacArthur foundation established its Initiative on Depression and Primary Care to identify opportunities for enhancing the quality of care and outcomes for patients with depressive disorders who are seen in primary care settings.

This ambitious endeavor involved a multi-step, multi-disciplinary approach.  The Initiative’s initial research indicated that primary care clinicians lacked the tools, time, and support within their practices to improve their management of patients with depression. Thus, the Initiative’s steering committee focused on designing a turnkey, evidence-based clinical model that can be implemented in diverse primary care settings and an effective “process of change” strategy to encourage the model’s adoption for dissemination to primary care clinicians. The Initiative also developed the MacArthur Depression Toolkit, which provides resources vital to improving depression care.  

RESPECT-Depression and The Three-Component Model

The Re-Engineering Systems for Primary Care Treatment of Depression project–or RESPECT-Depression—developed by the Initiative integrates the efforts of a primary care clinician, a care manager, and a mental health professional, all of whom work collaboratively with the patient and each other to provide care. Under the RESPECT-Depression’s Three Component Model (3CM), the care manager follows up with the patient via telephone a week after the initial office visit and on a monthly basis thereafter to evaluate the patient’s response to treatment and conveys this information to the clinician.  The clinician receives treatment suggestions from the mental health professional on the patient’s condition as needed to ensure good quality of care.

Clinical Trials  

Five health care organizations in the United States, including three large medical groups and two insurance plans along with 60 of their affiliated practice, took part in a clinical trial of RESPECT-Depression, in which researchers randomly assigned 400 patients diagnosed with depression to treatment using either the RESPECT-Depression approach or usual care practices. This initial trial indicated that patients treated under the RESPECT-Depression approach showed significant improvement and increased satisfaction compared with the control group over a six-month period. Subsequent trials have examined the sustainability over time of the RESPECT-Depression approach and the use of the 3CM model with specific patient groups (e.g., patients who may suffer post-partum depression).

On-Going Efforts

Although the MacArthur Initiative on Depression and Primary Care has completed its initial charge, its work continues to have a life of its own.  The MacArthur Toolkit has been downloaded from the network’s website more than 20,000 times by clinicians and administrators from 100 countries, and the website continues to draw significant traffic.  In addition, the U.S. military has adopted its own version of RESPECT-Depression with assistance from network members under a grant from the Henry M. Jackson Foundation for the Advancement of Military Medicine.  RESPECT-Mil screens active-duty personnel for depression and post-traumatic stress disorder using the three component model.

Key Research

Publication: Re-engineering systems for the treatment of depression in primary care: cluster randomized controlled trial, by Allen J. Dietrich, Thomas E. Oxman, John W. Williams, Jr., et al., in the British Medical Journal Sep 2004.  

This article describes the initial clinical trial of RESPECT-Depression in five health care organizations in the United States.

Publication: A Fidelity Measure for Integrated Management of Depression in Primary Care, by Thomas E. Oxman, Herbert C. Schulberg, Rebecca L. Greenberg, Allen J. Dietrich, John W. Williams, Jr., Paul A. Nutting, and Martha L. Bruce, Medical Care, November 2006.  

This article examines how adhering to the RESPECT-Depression approach without omitting key components maintains the effectiveness of the approach.

Publication: Sustainable impact of primary care depression intervention, by Pamela W. Lee, Allen J. Dietrich, Thomas E. Oxman, John W. Williams, Jr., and Sheila Barry, Journal of the American Board of Family Medicine, Sep-Oct 2007.  

This article examines the experiences of the health care organizations that participated in the initial trial several years later.

Publication: RESPECT-Mil: Feasibility of a Systems-Level Collaborative Care Approach to Depression and Post-Traumatic Stress Disorder in Military Primary Care, by Charles C. Engel; Thomas Oxman, Christopher Yamamoto, Darin Gould, Sheila Barry, Patrice Stewart, Kurt Kroenke, John W. Williams, Jr., Allen J. Dietrich, Military Medicine, October 2008.  

This article describes the U.S. Military’s efforts to integrate the 3CM model into the care of military personnel through the RESPECT-Mil program.

Network Chair

John W. Williams, Jr., M.D., M.H. S.
Duke University School of Medicine
Durham, NC

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