Incremental benefit and cost of telephone care management and telephone psychotherapy for depression in primary care.

CONTEXT Effectiveness of organized depression care programs is well established, but dissemination will depend on the balance of benefits and costs. OBJECTIVES To estimate the incremental benefit, incremental cost, and net benefit of 2 depression care programs. DESIGN Randomized trial comparing 2 interventions with continued usual care, conducted between November 2000 and June 2004. SETTING Seven primary care clinics of a prepaid health care plan in Washington. PARTICIPANTS Consecutive primary care patients starting antidepressant treatment were invited to a telephone assessment 2 weeks later. Of 634 patients with significant depressive symptoms, 600 consented and were randomized. INTERVENTIONS The telephone care management intervention included up to 5 outreach calls for monitoring and support, feedback to treating physicians, and care coordination. The care management plus telephone psychotherapy intervention added an 8-session structured cognitive behavioral therapy program with up to 4 additional calls for reinforcement. MAIN OUTCOME MEASURES Independent, blinded telephone assessments at 1, 3, 6, 9, 12, and 18 months included the Symptom Checklist 90 depression scale. Health services costs were measured using health care plan accounting records. RESULTS Over 24 months, telephone care management led to a gain of 29 depression-free days (95% confidence interval, -6 to +63) and a $676 increase in outpatient health care costs (95% confidence interval, $596 lower to $1974 higher). The incremental net benefit was negative even if a day free of depression was valued up to $20. Care management plus psychotherapy led to a gain of 46 depression-free days (95% confidence interval, +12 to +80) and a $397 increase in outpatient costs (95% confidence interval, $882 lower to $1725 higher). The incremental net benefit was positive if a day free of depression was valued at $9 or greater. CONCLUSION Compared with current primary care practice, a structured telephone program including care management and cognitive behavioral psychotherapy has significant clinical benefit with only a modest increase in health services cost.