December 8, 2016

How Group Health’s collaborative approach transformed depression care

Drs. Michael Von Korff, Evette Ludman, Elizabeth Lin, and Greg Simon 

In a group interview, GHRI mental health scientists describe how their work with UW psychiatry researchers changed treatment worldwide.

Three decades ago, many researchers believed “if we could just recognize people with depression, they would get treated and that would solve their problems,” says Michael Von Korff, ScD, Group Health Research Institute (GHRI) senior investigator. But helping patients get relief would require a much broader strategy—one that scientists from Group Health and the University of Washington (UW) developed together over many years.

In preparation for Kaiser Permanente’s anticipated acquisition of Group Health, we’re looking back at our legacy of groundbreaking GHRI research, including our work in depression, which is the leading cause of disability, affecting 350 million people worldwide. We asked Dr. Von Korff and three of his GHRI colleagues, Senior Investigator Greg Simon, MD, MPH, Senior Research Associate Evette Ludman, PhD, and Adjunct Investigator Elizabeth Lin, MD, MPH, to tell us how their work transformed depression care globally.

“In the 1980s, an enormous amount of research was done on depression screening, but it wasn’t helping,“ Dr. Von Korff remembers. “Everyone was looking at the front end: diagnosis. But we worked with thought leaders in psychiatry, like the UW’s Wayne Katon and Jürgen Unützer, and looked at the back end: what happens after diagnosis.”

The 1990s: collaborative care

“In 1995,” Dr. Simon recalls, “we published the paper on collaborative care.” The study, reported in the Journal of the American Medical Association, was headed by the late Dr. Katon, UW professor of psychiatry and behavioral sciences and GHRI affiliate investigator. The randomized controlled trial demonstrated the superiority of a collaborative approach over usual depression care.

Collaborative care uses a primary care team to address depression. The goal is evidence-based treatment, including medication, education about lifestyle changes, and self-management support. A care manager monitors improvement using questions from a validated depression-symptom checklist. If patients need more intensive care, the team decides the next step, such as medication adjustment or specialty referral.

Since then, “the results have been replicated in almost one hundred randomized trials,” Dr. Von Korff says. “They changed depression care worldwide.” Today, the U.S. Preventive Services Task Force, which sets national guidelines, the National Institute for Health Care and Excellence, which develops U.K. guidance, and the World Health Organization all base depression recommendations on this work.

Dr. Ludman notes that collaborative care influenced the Chronic Care Model (CCM) and vice versa. The CCM was developed in the 1990s at GHRI’s MacColl Center for Health Care Innovation, by Senior Investigator Ed Wagner, MD, MPH. “Collaborative care and the CCM grew up together,” says Dr. Simon.

Collaborative care and the CCM are internationally recognized for managing chronic illness. When they were new, however, they were revolutionary. “When we first started talking about collaborative care for depression and the Chronic Care Model in the mid-90s,” Dr. Von Korff says, “people had no idea what we were talking about. It just wasn’t how they thought about things.”

At meetings now, Dr. Simon says, “People tell me all about this great idea—collaborative care for depression. I just sit back and smile.”

The 2000s: TEAMcare

In 2010, the researchers published a New England Journal of Medicine study showing that collaborative TEAMcare helped patients with depression and co-existing physical diseases of diabetes, heart disease, or both. “Collaborative care improved psychological, physiological, and functional measures,” Dr. Lin says. ”The different members of the primary care team worked optimally together to treat patients with complex problems.”

Patients expressed greater satisfaction with their care and improved quality of life. The model was proven for teens at Group Health, and adapted, tested, and disseminated across the country in the Care of Mental, Physical, and Substance Use Syndromes (COMPASS) initiative from the Center for Medicare and Medicaid Innovation.

Collaborative care works because of its simplicity. “It’s about paying attention,” Dr. Ludman says. “It’s having someone be accountable, following up with patients, using measures to check how they’re doing and if they’re not better, doing something about it.”

Dr. Von Korff adds, “It’s a simple, inexpensive, organized approach. That’s why it’s been used all over the world, from U.S. Federally Qualified Health Centers to clinics in India.”

Team care is flexible. It doesn’t require specialists and it evolves as technology advances. “We’ve seen this implemented with psychiatrists, psychologists, social workers, or lay people,” Dr. Simon says. “Care managers can be within the primary care team or centrally located and serving many teams virtually. Collaborative care now often involves electronic health records and new modes of communication like email and video visits.”

Dr. Lin recalls talking with Drs. Von Korff and Katon in the 1980s about their long-term plans. “Looking back at our 30 years of research,” she says, “we’ve always worked toward bringing physical and mental health together.” Collaborative care, Dr. Simon says, embodies the GHRI philosophy: “We say, ‘We know some practical things that will help you and your family stay healthy. So let’s do those things.’”


by Chris Tachibana