***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Abstract OBJECTIVE : To determine the incremental cost-effectiveness of a quality improvement depression intervention ( enhanced care ) in primary care setting s relative to usual care . DESIGN : Following stratification , we r and omized 12 primary care practice s to enhanced or usual care conditions and followed patients for 12 months . SETTING : Primary care practice s located in 10 states across the United States . PATIENTS / PARTICIPANTS : Two hundred eleven patients beginning a new treatment episode for major depression . INTERVENTIONS : Training the primary care team to assess , educate , and monitor depressed patients during the acute and continuation stages of their depression treatment episode over 1 year . MEASUREMENTS AND MAIN RESULTS : Cost-effectiveness was measured by calculating incremental ( enhanced minus usual care ) costs and quality -adjusted life years ( QALYs ) derived from SF-36 data . The mean incremental cost-effectiveness ratio in the main analysis was $ 15,463 per QALY . The mean incremental cost-effectiveness ratios for the sensitivity analyses ranged from $ 11,341 ( using geographic block variables to control for pre-intervention service utilization ) to $ 19,976 ( increasing the cost estimates by 50 % ) per QALY . CONCLUSIONS : This quality improvement depression intervention was cost-effective relative to usual care compared to cost-effectiveness ratios for common primary care interventions and commonly cited cost-effectiveness ratio thresholds for intervention implementation Abstract BACKGROUND : Major depression is common in older adults and is associated with increased health care costs . Depression often remains unrecognized in older adults , especially in primary care . OBJECTIVE : To evaluate the cost-effectiveness of a disease management program for major depression in elderly primary care patients compared with usual care . DESIGN : Economic evaluation alongside a cluster r and omized-controlled trial . PARTICIPANTS : Consecutive patients of 55 years and older were screened for depression using the Geriatric Depression Scale and the PRIME-MD was used for diagnosis . INTERVENTIONS : General practitioners in the intervention group received training on how to implement the disease management program consisting of screening , patient education , drug therapy with paroxetine , and supportive contacts . General practitioners in the usual care group were blind to the screening results . Treatment in this group was not restricted in any way . MEASUREMENTS : Severity of depression , recovery from depression , and quality of life . Re source use measured over a 12-month period using interviews and valued using st and ard costs . RESULTS : Differences in clinical outcomes between the intervention and usual care group were small and statistically insignificant . Total costs were $ 2,123 in the intervention and $ 2,259 in the usual care group ( mean difference −$136 , 95 % confidence interval : −$1,194 ; $ 1,110 ) . Cost-effectiveness planes indicated that there were no statistically significant differences in cost-effectiveness between the 2 groups . CONCLUSIONS : This disease management program for major depression in elderly primary care patients had no statistically significant relationship with clinical outcomes , costs , and cost-effectiveness . Therefore , based on these results , continuing usual care is recommended BACKGROUND General practitioners ( GPs ) can be provided with effective training in the skills to manage depression . However , it remains uncertain whether such training achieves health gain for their patients . METHOD The study aim ed to measure the health gain from training GPs in skills for the assessment and management of depression . The study design was a cluster r and omized controlled trial . GP participants were assessed for recognition of psychological disorders , attitudes to depression , prescribing patterns and experience of psychiatry and communication skills training . They were then r and omized to receive training at baseline or the end of the study . Patients selected by GPs were assessed at baseline , 3 and 12 months . The primary outcome was depression status , measured by HAM-D. Secondary outcomes were psychiatric symptoms ( GHQ-12 ) quality of life ( SF-36 ) , satisfaction with consultations , and health service use and costs . RESULTS Thirty-eight GPs were recruited and 36 ( 95 % ) completed the study . They selected 318 patients , of whom 189 ( 59 % ) were successfully recruited . At 3 months there were no significant differences between intervention and control patients on HAM-D , GHQ-12 or SF-36 . At 12 months there was a positive training effect in two domains of the SF-36 , but no differences in HAM-D , GHQ-12 or health care costs . Patients reported trained GPs as somewhat better at listening and underst and ing but not in the other aspects of satisfaction . CONCLUSIONS Although training programmes may improve GPs ' skills in managing depression , this does not appear to translate into health gain for depressed patients or the health service Abstract Objective : To assess the effectiveness of teaching general practitioners skills in brief cognitive behaviour therapy . Design : Parallel group , cluster r and omised , controlled trial of an educational package on cognitive behaviour therapy . Setting : General practice s in north London . Participants : 84 general practitioner principals and 272 patients attending their practice s who scored above the threshold for psychological distress on the hospital anxiety and depression scale . Intervention : A training package of four half days on brief cognitive behaviour therapy . Main outcome measures : Scores on the depression attitude question naire ( general practitioners ) and the Beck depression inventory ( patients ) . Results : Doctors ' knowledge of depression and attitudes towards its treatment showed no major difference between intervention and control groups after 6 months . The training had no discernible impact on patients ' outcomes . Conclusion : General practitioners may require more training and support than a basic educational package on brief cognitive behaviour therapy to acquire skills to help patients with depression . What is already known on this topic Trained professionals can deliver effective cognitive behaviour therapy to depressed patients presenting to general practitioners Limited evidence shows that cognitive behaviour therapy is effective when delivered by general practitioners who have received extensive instruction Most doctors do not have the time or inclination to carry out such comprehensive training What this study adds Basic training in brief cognitive behaviour therapy has little effect on general practitioners ' attitudes to the identification and treatment of depression or the outcome of their patients with emotional problems General practitioners may require more extensive training and support if they are to acquire skills in brief cognitive behaviour therapy that will have a positive impact on their Objectives : Screening is advocated to improve the recognition of patients with major depression in primary care . Furthermore , disease management programmes are advocated to improve the quality of care and outcome for these patients . But is screening and the subsequent implementation of a disease management programme more effective than usual care ? Methods : Review of the literature on the effects of disease management programmes that include screening for major depression in general practice . Results : Six r and omised controlled trials were identified in which the effectiveness of disease management programmes were studied in patients with major depression in primary care and compared with usual care .  The majority of these , and especially the largest , showed positive effects on the recognition , diagnosis , treatment and outcome of patients . Population s in the US seem to benefit most . Conclusion : The results of disease management programmes for depression in primary care that include screening are positive and are more effective than usual care . Therefore , if preceded by screening , attention to the whole process of care for patients with major depression instead of paying attention to isolated elements of the process is justified Complex interventions , which have been shown to improve primary care depression outcomes , are difficult to disseminate to routine practice setting s. To address this problem , we developed a brief intervention to train primary care physicians and nurses employed by the practice to improve the detection and management of major depression . Before recruitment began , the research team conducted academic detailing conference calls with primary care physicians and nurses , and provided in-person training with nurses and administrative staff . Administrative staff screened over 11,000 patients before their visits to identify those with probable major depression . Primary care physicians delegated increased responsibility to office nurses , who educated over 90 % of patients about effective depression treatment and systematic ally monitored their progress over time . Early results demonstrate that community primary care practice s can rebundle traditional team roles over the short-term to provide more systematic mental health treatment without adding additional personnel . A rigorous evaluation of this effort will reduce time-consuming , expensive , and often unsuccessful efforts to " translate " research intervention findings into everyday practice Abstract Objective : To evaluate the effectiveness of a population based , multifaceted shared care intervention for  late life depression in residential care . Design : R and omised controlled trial , with control and intervention groups studied one after the other and blind follow up after 9.5 months . Setting : Population of residential facility in Sydney living in self care units and hostels . Participants : 220 depressed residents aged ≥65 without severe cognitive impairment . Intervention : The shared care intervention included : ( a ) multidisciplinary consultation and collaboration , ( b ) training of general practitioners and carers in detection and management of depression , and (c)depression related health education and activity programmes for residents . The control group received routine care . Main outcome measure : Geriatric depression scale . Results : Intention to treat analysis was used . There was significantly more movement to “ less depressed ” levels of depression at follow up in the intervention than control group ( Mantel-Haenszel stratification test , P=0.0125 ) . Multiple linear regression analysis found a significant intervention effect after controlling for possible confounders , with the intervention group showing an average improvement of 1.87 points on the geriatric depression scale compared with the control group ( 95 % confidence interval 0.76 to 2.97 , P=0.0011 ) . Conclusions : The outcome of depression among elderly people in residential care can be improved by multidisciplinary collaboration , by enhancing the clinical skills of general practitioners and care staff , and by providing depression related health education and activity programmes for residents . Key messages Large numbers of depressed elderly people live in residential care but few receive appropriate management A population based , multifaceted shared care intervention  for late life depression was more effective than routine care in improving depression outcome The outcome of late life depression can be improved by enhancing the clinical skills of general practitioners and care staff and by providing depression related health education and activity programmes for residents The intervention needs further refining and evaluation to improve its effectiveness and to determine how best to implement it in other residential care setting BACKGROUND Depression , a common disorder often treated by family physicians , may be both underdiagnosed and undertreated . The objective of this study was to determine whether the diagnosis and treatment of depression by family physicians could be improved through an educational strategy . METHODS In this study , conducted between July and December 1997 , 42 family physicians in Newfoundl and were r and omly assigned to an intervention group ( 3-hour case-based educational session on clinical practice guidelines [ CPGs ] for depression and access to a psychiatrist for consultation ) or to a control group ( receipt of CPGs without educational session or access to the psychiatrist ) . Physicians were asked to keep a log of patients with newly diagnosed depression and to record information on severity of depression , medications and referrals to mental health professionals . Patients were asked to complete the Centre for Epidemiologic Studies Depression ( CES-D ) scale before treatment and after 6 months of follow-up . The primary outcome measure was the " gain " score ( difference between first and last CES-D scores ) . RESULTS During the study period physicians in the intervention group diagnosed 91 new cases of depression ( mean 4.1 per physician ) and those in the control group diagnosed 56 ( mean 2.8 per physician ) ; the difference was not significant . Most patients ( 91.2 % in the intervention group and 89.3 % in the control group received a prescription for an antidepressant on their first visit . Similar proportions ( 46.2 % in the intervention group and 37.5 % in the control group ) took their medication for the full 6 months ; however , significantly more patients in the intervention group were taking an antidepressant at the 6-month follow-up ( 56 % v. 39.3 % , p = 0.02 ) . The mean number of visits per patient was similar in the 2 groups ( 7.7 in the intervention group and 7.6 in the control group ) . Physicians in the intervention group consulted the psychiatrist 9 times . The overall rate of referrals to psychiatrists and other mental health professionals was 10.9 % ; however , referrals were significantly higher in the intervention group ( 15.4 % v. 3.5 % , p = 0.05 ) . After 6 months of follow-up , a significant difference in gain scores was detected between the intervention and control groups for both the patient 's self-rated CES-D scores ( mean gain score 19.3 v. 15.5 respectively , p = 0.04 ) and the physicians ' ratings of depression severity before treatment and at 6 months ( mean gain 1.1 v. 0.7 respectively , p = 0.02 ) . INTERPRETATION The educational strategy had a modest beneficial effect on the outcomes of patients with depression , but there are still concerns regarding the low rates of drug treatment and referral to mental health professionals by family physicians PURPOSE Although potentially costly , enhancing primary care depression management on an ongoing basis results in substantial long-term treatment effectiveness . The purpose of this article is to compare the cost-effectiveness of this approach with that of usual care . METHODS The study was conducted in 12 community primary care practice s r and omized to enhanced or usual care after stratification by baseline practice patterns . Practice s assigned to enhanced care encouraged depressed patients to engage in active treatment , using practice nurses to provide regularly scheduled care management during the course of 24 months . We analyze outcomes for 211 adults ( 73.4 % of potential eligible patients ) beginning a new treatment episode for major depression determined by previsit screening . Outcomes included blinded estimates of days free of depression impairment as well as health care costs for 2 years . RESULTS Enhanced care significantly increased the number of days free of depression impairment for 2 years when compared with usual care ( 647 
    Output:
    
Training of providers alone ( even in a specific interventional method ) did not result in improved patient outcomes .
The additional implementation of guidelines and the use of more complex interventions in primary care yield a significant reduction in depressive symptomatology .
Provider training by itself does not seem to improve depression care ; however , if combined with additional guidelines implementation , results are promising for new-onset depression patient sample s. Additional organizational structure changes in form of collaborative care models are more likely to show effects on depression care