***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 
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    ***EXAMPLES*** 
    Input: Reports of cluster r and omised trials require additional information to allow readers to interpret them accurately The effective reporting of r and omised controlled trials has received useful attention in recent years . Many journals now require that reports conform to the guidelines in the Consoli date d St and ards of Reporting Trials ( CONSORT ) statement , first published in 1996 and revised in 2001 . The statement includes a checklist of items that should be included in the trial report . These items are evidence based whenever possible and are regularly review ed . The statement also recommends including a flow diagram to show the flow of participants from group assignment through to the final analysis . The CONSORT statement focused on reporting parallel group r and omised trials in which individual participants are r and omly assigned to study groups . However , in some situations it is preferable to r and omly assign groups of individuals ( such as families or medical practice s ) rather than individuals . Reasons include the threat of contamination of some interventions ( such as dietary interventions ) if individual r and omisation is used . 5 Also , in certain setting s r and omisation by group may be the only feasible method of conducting a trial . Trials with this design are variously known as field trials , community based trials , place based trials , or ( as in this paper ) cluster r and omised trials . In an earlier discussion paper we considered the implication s of the CONSORT statement for the reporting of cluster r and omised trials . Here we present up date d guidance , based on the 2001 revision of the CONSORT statement BACKGROUND Quality improvement ( QI ) programs for depressed primary care patients can improve health outcomes for 6 to 28 months ; effects for longer than 28 months are unknown . OBJECTIVE To assess how QI for depression affects health outcomes , quality of care , and health outcome disparities at 57-month follow-up . DESIGN A group-level r and omized controlled trial . SETTING Forty-six primary care practice s in 6 managed care organizations . PATIENTS Of 1356 primary care patients who screened positive for depression and enrolled in the trial , 991 ( 73 % , including 451 Latinos and African Americans ) completed 57-month telephone follow-up . INTERVENTIONS Clinics were r and omly assigned to usual care or to 1 of 2 QI programs supporting QI teams , provider training , nurse assessment , and patient education , plus re sources to support medication management ( QI-meds ) or psychotherapy ( QI-therapy ) for 6 to 12 months . MAIN OUTCOME MEASURES  Probable depressive disorder in the previous 6 months , mental health-related quality of life in the previous 30 days , primary care or mental health specialty visits , counseling or antidepressant medications in the previous 6 months , and unmet need , defined as depressed but not receiving appropriate care . RESULTS Combined QI-meds and QI-therapy , relative to usual care , reduced the percentage of participants with probable disorder at 5 years by 6.6 percentage points ( P = .04 ) . QI-therapy improved health outcomes and reduced unmet need for appropriate care among Latinos and African Americans combined but provided few long-term benefits among whites , reducing outcome disparities related to usual care ( P = .04 for QI-ethnicity interaction for probable depressive disorder ) . CONCLUSIONS Programs for QI for depressed primary care patients implemented by managed care practice s can improve health outcomes 5 years after implementation and reduce health outcome disparities by markedly improving health outcomes and unmet need for appropriate care among Latinos and African Americans relative to whites ; thus , equity was improved in the long run It is difficult to evaluate the promise of primary care quality -improvement interventions for depression because published studies have evaluated diverse interventions by using different research design s in dissimilar population s. Preplanned meta- analysis provides an alternative to derive more precise and generalizable estimates of intervention effects ; however , this approach requires the resolution of analytic challenges result ing from design differences that threaten internal and external validity . This paper describes the  four-project Quality Improvement for Depression ( QID ) collaboration specifically design ed for preplanned meta- analysis of intervention effects on outcomes . This paper summarizes the interventions the four projects tested , characterizes commonalities and heterogeneity in the research design s used to evaluate these interventions , and discusses the implication s of this heterogeneity for preplanned meta- analysis Abstract Objectives : To evaluate the long term effect of ongoing intervention to improve treatment of  depression  in primary care . Design : R and omised controlled trial . Setting : Twelve primary care practice s across the United States . Participants : 211 adults beginning a new treatment episode for major depression ; 94 % of patients assigned to ongoing intervention participated . Intervention : Practice s assigned to ongoing intervention encouraged participating patients to engage in active treatment , using practice nurses to provide care management over 24 months . Main outcome measures : Patients ' report of remission and functioning . Results : Ongoing intervention significantly improved both symptoms and functioning at 24 months , increasing remission by 33 percentage points ( 95 % confidence interval 7 % to 46 % ) , improving emotional functioning by 24 points ( 11 to 38 ) and physical functioning by 17 points ( 6 to 28 ) . By 24 months , 74 % of patients in enhanced care reported remission , with emotional functioning exceeding 90 % of population norms and physical functioning approaching 75 % of population norms . Conclusions : Ongoing intervention increased remission rates and improved indicators of emotional and physical functioning . Studies are needed to compare the cost effectiveness of ongoing depression management with other chronic disease treatment routinely undertaken by primary care BACKGROUND This article addresses whether dissemination of short-term quality improvement ( QI ) interventions for depression to primary care practice s improves patients ' clinical outcomes and health-related quality of life ( HRQOL ) over 2 years , relative to usual care ( UC ) . METHODS The sample included 1299 patients with current depressive symptoms and 12-month , lifetime , or no depressive disorder from 46 primary care practice s in 6 managed care organizations . Clinics were r and omized to UC or 1 of 2 QI programs that included training local experts and nurse specialists to provide clinician and patient education , assessment , and treatment planning , plus either nurse care managers for medication follow-up ( QI-meds ) or access to trained psychotherapists ( QI-therapy ) . Outcomes were assessed every 6 months for 2 years . RESULTS For most outcomes , differences between intervention and UC patients were not sustained for the full 2 years . However ,  QI-therapy reduced overall poor outcomes compared with  UC by about 8 percentage points throughout 2 years , and by 10 percentage points compared with QI-meds at 24 months . Both interventions improved patients ' clinical and role outcomes , relative to UC , over 12 months ( eg , a 10 - 11 and 6 - 7 percentage point difference in probable depression at 6 and 12 months , respectively ) . CONCLUSIONS While most outcome improvements were not sustained over the full 2 study years , findings suggest that flexible dissemination of short-term , QI programs in managed primary care can improve patient outcomes well after program termination . Models that support integrated psychotherapy and medication-based treatment strategies in primary care have the potential for relatively long-term patient benefits BACKGROUND The diagnosis and treatment of depression constitutes a significant component of a general practitioner 's workload . A pilot study has suggested that the practice nurse may have an important contribution to make in the care of patients with depression . AIM To evaluate an extended role for practice nurses in improving the outcome of depression through two specially- design ed interviews running in parallel . METHOD Two naturalistic , r and om allocation studies took place concurrently over four months . Study 1 evaluated the effectiveness of  st and ardized psychiatric assessment by a practice nurse and feedback of information to the general practitioner ( GP ) . Study 2 evaluated the above assessment and feedback combined with nurse-assisted follow-up care .  Twenty general practice s participating in the Medical Research Council General Practice Research Framework took part in the study . Subjects included general practice attenders identified as depressed by their GP . The main outcome measures were a change in Beck Depression Inventory ( BDI ) scores and in the proportion of patients fulfilling DSM-III criteria for major depression . RESULTS A total of 577 patients were recruited ; 516 [ 89 % ( 95 % CI = 86 - 92 % ) ] were rated as depressed on the BDI and 474 [ 82 % ( 95 % CI = 79 - 85 % ) ] met criteria for DSM-III major depression . Altogether , 524 ( 91 % ) patients completed follow-up at four months . All groups of patients showed improvement , but no difference in the rate of improvement was shown for the nurse intervention groups . BDI mean scores fell from 18.54 ( 95 % CI = 17.53 - 20.06 ) to 11.53 ( 95 % CI = 10.02 - 13.04 ) in Study 1 , and from 21.01 ( 95 % = CI 20.26 - 21.86 ) to 10.62 ( 95 % CI = 9.73 - 11.51 ) in Study 2 . The proportion of patients fulfilling criteria for DSM-III major depression in Study 1 fell from 80 % ( 95 % CI = 73 - 87 % ) to 30 % ( 95 % CI = 22 - 38 % ) , and in Study 2 from 80 % ( 95 % CI = 76 - 84 % ) to 27 % ( 95 % CI = 23 - 31 % ) . Prescription rates of antidepressant medication were higher than expected , ranging between 63 % and 76 % in the two studies . CONCLUSION There was an increase in the rate of antidepressant prescription , but no additional benefit could be adduced for patients who received a nurse intervention BACKGROUND Despite improvements in the accuracy of diagnosing depression and use of medications with fewer side effects , many patients treated with antidepressant medications by primary care physicians have persistent symptoms . METHODS A group of 228 patients recognized as depressed by their primary care physicians and given antidepressant medication who had either 4 or more persistent major depressive symptoms or a score of 1.5 or more on the Hopkins Symptom Checklist depression items at 6 to 8 weeks were r and omized to a collaborative care intervention ( n = 114 ) or usual care ( n = 114 ) by the primary care physician . Patients in the intervention group received enhanced education and increased frequency of visits by a psychiatrist working with the primary care physician to improve pharmacologic treatment . Follow-up assessment s were completed at 1 , 3 , and 6 months by a telephone survey team blinded to r and omization status . RESULTS Those in the intervention group had significantly greater adherence to adequate dosage of medication for 90 days or more and were more likely to rate the quality of care they received for depression as good to excellent compared with usual care controls . Intervention patients showed a significantly greater decrease compared with usual care controls in severity of depressive symptoms over time and were more likely to have fully recovered at 3 and 6 months . CONCLUSIONS A multifaceted program targeted to patients whose depressive symptoms persisted 6 to 8 weeks after initiation of antidepressant medication by their primary care physician was found to significantly improve adherence to antidepressants , satisfaction with care , and depressive outcomes compared with usual care 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 Most depressed patients are seen and treated exclusively by primary care clinicians . However , primary care patients with depression are often not adequately treated . The aims of this pilot study were to measure the impact of a telephone disease management program on patient outcome and clinician adherence to practice guidelines , measure the relationship of clinician adherence to patient outcome , and explore the measurement of patient adherence to clinician recommendations and its impact on patient outcomes . Thirty-five primary care practice s in the University of Pennsylvania Health System were r and omized to telephone disease management ( TDM ) or " usual care " ( UC ) .  All patients received a baseline and a 16-week follow-up clinical evaluation performed over the telephone . Those from TDM practice s also received follow-up contact at least every 3 weeks , with formal evaluations at weeks 6 and 12 . These interval contacts were design ed to facilitate patient and clinician adherence to a treatment algorithm based on the Agency for Health Research and Quality ( AHRQ ) practice guidelines . Depressive symptoms evaluated with the Community Epidemiologic Survey of Depression ( CES-D ) scale as well as guideline adherence were the primary outcome measures . Sixty-one patients were enrolled in this pilot project . The overall effect for CES-D scores over time was significant , ( P < .001 ) , indicating that those participating in the trial ( both TDM and UC groups ) showed significant improvement . The interaction between intervention condition and time was also significant ( P < .05 ) , indicating that 
    Output:
    
ConclusionS ystem level interventions implemented in the USA with patients willing to take anti-depressant medication leads to a modest increase in recovery from depression .