Institute of Health Research, University of Exeter Medical School, Exeter EX1 2LU, UK.
BMJ. 2013 Aug 19;347:f4913. doi: 10.1136/bmj.f4913.
To compare the clinical effectiveness of collaborative care with usual care in the management of patients with moderate to severe depression.
Cluster randomised controlled trial.
51 primary care practices in three primary care districts in the United Kingdom.
581 adults aged 18 years and older who met ICD-10 (international classification of diseases, 10th revision) criteria for a depressive episode on the revised Clinical Interview Schedule. We excluded acutely suicidal patients and those with psychosis, or with type I or type II bipolar disorder; patients whose low mood was associated with bereavement or whose primary presenting problem was alcohol or drug abuse; and patients receiving psychological treatment for their depression by specialist mental health services. We identified potentially eligible participants by searching computerised case records in general practices for patients with depression.
Collaborative care, including depression education, drug management, behavioural activation, relapse prevention, and primary care liaison, was delivered by care managers. Collaborative care involved six to 12 contacts with participants over 14 weeks, supervised by mental health specialists. Usual care was family doctors' standard clinical practice.
Depression symptoms (patient health questionnaire 9; PHQ-9), anxiety (generalised anxiety disorder 7; GAD-7), and quality of life (short form 36 questionnaire; SF-36) at four and 12 months; satisfaction with service quality (client satisfaction questionnaire; CSQ-8) at four months.
276 participants were allocated to collaborative care and 305 allocated to usual care. At four months, mean depression score was 11.1 (standard deviation 7.3) for the collaborative care group and 12.7 (6.8) for the usual care group. After adjustment for baseline depression, mean depression score was 1.33 PHQ-9 points lower (95% confidence interval 0.35 to 2.31, P=0.009) in participants receiving collaborative care than in those receiving usual care at four months, and 1.36 points lower (0.07 to 2.64, P=0.04) at 12 months. Quality of mental health but not physical health was significantly better for collaborative care than for usual care at four months, but not 12 months. Anxiety did not differ between groups. Participants receiving collaborative care were significantly more satisfied with treatment than those receiving usual care. The number needed to treat for one patient to drop below the accepted diagnostic threshold for depression on the PHQ-9 was 8.4 immediately after treatment, and 6.5 at 12 months.
Collaborative care has persistent positive effects up to 12 months after initiation of the intervention and is preferred by patients over usual care.
ISRCTN32829227.
比较协作式护理与常规护理在管理中重度抑郁症患者中的临床效果。
整群随机对照试验。
英国三个初级保健区的 51 个基层医疗实践点。
581 名年龄在 18 岁及以上、经修订临床访谈表符合 ICD-10（国际疾病分类，第 10 版）抑郁发作标准的成年人。我们排除了有急性自杀意念的患者，以及有精神病、或 I 型或 II 型双相情感障碍的患者；心境低落与丧亲有关或主要表现问题为酒精或药物滥用的患者；以及正在接受专科心理健康服务的心理治疗的抑郁患者。我们通过在全科诊所搜索电脑病历来确定可能符合条件的参与者，以识别有抑郁的患者。
由护理经理提供协作式护理，包括抑郁教育、药物管理、行为激活、复发预防和初级保健联络。协作式护理包括在 14 周内与参与者进行 6 到 12 次接触，由心理健康专家监督。常规护理是家庭医生的标准临床实践。
四个月和十二个月时的抑郁症状（患者健康问卷 9 项；PHQ-9）、焦虑（广泛性焦虑障碍 7 项；GAD-7）和生活质量（简短 36 项问卷；SF-36）；四个月时的服务质量满意度（客户满意度问卷；CSQ-8）。
276 名参与者被分配到协作式护理组，305 名参与者被分配到常规护理组。四个月时，协作式护理组的平均抑郁评分为 11.1（标准差 7.3），常规护理组为 12.7（6.8）。调整基线抑郁后，接受协作式护理的参与者的抑郁评分比接受常规护理的参与者低 1.33 个 PHQ-9 点（95%置信区间 0.35 至 2.31，P=0.009），在 12 个月时低 1.36 个 PHQ-9 点（0.07 至 2.64，P=0.04）。四个月时，与常规护理相比，协作式护理在心理健康方面，但不是在身体健康方面，质量明显更好。焦虑两组间无差异。接受协作式护理的参与者对治疗的满意度明显高于接受常规护理的参与者。在治疗结束后，立即有 8.4 名患者需要接受治疗，使其 PHQ-9 评分降至可接受的抑郁诊断阈值以下，在 12 个月时为 6.5 名患者。
协作式护理在干预启动后长达 12 个月时仍具有持续的积极效果，并且比常规护理更受患者欢迎。
ISRCTN32829227。
