August 31, 2015

Organized self-management support eases chronic depression

Randomized controlled trial including peer support helps patients at Group Health and Swedish Medical Center

How to reach people with chronic or recurrent depression? In a randomized trial, they benefited from a self-management support service that included regular outreach care management and a self-care group with a combined behavioral and recovery-oriented approach. Over 18 months, patients improved significantly in all four measured outcomes.  Compared to patients in usual care, they had less severe symptoms and less likelihood of having major depression, higher recovery scores, and higher likelihood of being much improved. Psychiatric Services published Organized Self-Management Support Services for Chronic Depressive Symptoms: A Randomized Controlled Trial.

“What makes this program unique is that it combines a traditional mental health model aiming to reduce symptoms with a recovery model focused on achieving life goals despite symptoms,” said study leader Evette J. Ludman, PhD, a senior research associate at Group Health Research Institute.

“When depression persists or recurs, people may start thinking that treatment will never help them to recover,” Dr. Ludman added. “But this intervention really seems effective at improving their lives, and the differences between the groups were continuing to diverge at 18 months.” You can read a blog post that Dr. Ludman wrote about the Organized Self-Management Support Services for Chronic Depressive Symptoms (Stride) trial.

Real-world setting

The randomized controlled trial enrolled more than 300 adult patients at five primary-care clinics Seattle: four at Group Health Cooperatives, and one at Swedish Medical Center. Half of the patients were randomly assigned to keep receiving usual care, including medication, psychotherapy, both, or neither. The other half, in addition to this usual care, received an 18-month intervention that included depression self-management training, recovery coaching, and care coordination. Each participant in the study intervention had regular phone or in-person contacts with an outreach care manager to improve engagement with mental health services and medication therapy. Each patient also participated in a structured group program that a professional therapist and a trained peer specialist co-led. This program was based on cognitive behavioral therapy and behavioral activation skills training. Each peer specialist had had chronic depression and completed a five-day training and certification program from the Depression and Bipolar Support Alliance.

“The care managers, peer specialists, and group program focused on coaching participants to achieve self-care goals and larger life goals for a ‘life worth living,’” Dr. Ludman said. “They emphasized that recovery is possible—while acknowledging that the participants had had disappointing experiences with treatment. The intervention had to remain flexible and geared to individual goals, because people with chronic depression have such varied experiences.”

What’s next?

Most previous attempts to improve the effectiveness of care for depression in the community has focused on people recently diagnosed with depression—not on those with chronic depression. But up to three in 10 people with depression have a chronic course, with depression that keeps recurring or doesn’t completely go away. And persistent depression is linked to poor general health, with other diseases, suicide attempts, and lost work productivity. Persistent depression has also been linked to high use of general medical services.

That’s why the research team plans to study next how the health care costs of the intervention group differ from those of the usual-care group—taking into account the cost of the intervention.

National Institute of Mental Health grant MH065530 supported this trial, which was registered at clinical (NCT01139060).

Dr. Ludman’s coauthors were Gregory Simon, MD, MPH; Louis C. Grothaus, MA; Julie Elissa Richards, MPH; and Christine Stewart, PhD; and Ursula Whiteside, PhD.

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