***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: Background Evidence -based practice s design ed for large urban clinics are not necessarily portable into smaller isolated clinics . Implementing practice -based collaborative care for depression in smaller primary care clinics presents unique challenges because it is often not feasible to employ on-site psychiatrists . Objective The purpose of the Telemedicine Enhanced Antidepressant Management ( TEAM ) study was to evaluate a telemedicine-based collaborative care model adapted for small clinics without on-site psychiatrists . Design Matched sites were r and omized to the intervention or usual care . Participants Small VA Community-based outpatient clinics with no on-site psychiatrists , but access to telepsychiatrists .  In 2003–2004 , 395 primary care patients with PHQ9 depression severity scores ≥12 were enrolled , and followed for 12 months . Patients with serious mental illness and current substance dependence were excluded .  Measures Medication adherence , treatment response , remission , health status , health-related quality of life , and treatment satisfaction . Results The sample comprised mostly elderly , white , males with substantial physical and behavioral health comorbidity . At baseline , subjects had moderate depression severity (  Hopkins Symptom Checklist , SCL-20 = 1.8 ) , 3.7 prior depression episodes , and 67 % had received prior depression treatment . Multivariate analyses indicated that intervention patients were more likely to be adherent at both 6 ( odds ratio [ OR ] = 2.1 , p = .04 ) and 12 months ( OR = 2.7 , p = .01 ) . Intervention patients were more likely to respond by 6 months ( OR = 2.0 , p = .02 ) , and remit by 12 months ( OR = 2.4 , p = .02 ) . Intervention patients reported larger gains in mental health status and health-related quality of life , and reported higher satisfaction . Conclusions Collaborative care can be successfully adapted for primary care clinics without on-site psychiatrists using telemedicine technologies Background Treatments and organizational changes supported by eHealth are beginning to play an important role in improving disease treatment outcome and providing cost-efficient care management . “ Improvehealth.eu ” is a novel eHealth service to support the treatment of patients with depressive disorder . It offers active patient engagement and collaborative care management by combining Web- and mobile-based information and communication technology systems and access to care managers . Objectives Our objective was to assess the feasibility of a novel eHealth service . Methods The intervention — the “ Improvehealth.eu ” service — was explored in the course of a pilot study comparing two groups of patients receiving treatment as usual and treatment as usual with eHealth intervention .  We compared patients ’ medication adherence and outcome measures between both groups and additionally explored usage and overall perceptions of the intervention in intervention group . Results The intervention was successfully implemented in a pilot with 46 patients , of whom 40 were female . Of the 46 patients , 25 received treatment as usual , and 21 received the intervention in addition to treatment as usual . A total of 55 % ( 12/25 ) of patients in the former group and 45 % ( 10/21 ) in the latter group finished the 6-month pilot . Available case analysis indicated an improvement of adherence in the intervention group ( odds ratio [ OR ] = 10.0 , P = .03 ) . Intention-to-treat analysis indicated an improvement of outcome in the intervention group ( ORs ranging from 0.35 to 18 ; P values ranging from .003 to .20 ) , but confidence intervals were large due to small sample sizes . Average duration of use of the intervention was 107 days . The intervention was well received by 81 % ( 17/21 ) of patients who reported feeling actively engaged , in control of their disease , and that they had access to a high level of information . In all , 33 % ( 7/21 ) of the patients also described drawbacks of the intervention , mostly related to usability issues . Conclusions The results of this pilot study indicate that the intervention was well accepted and helped the patients in the course of treatment . The results also suggest the potential of the intervention to improve both medication adherence and outcome measures of treatment , including reduction of depression severity and patients becoming “ healthy . Context Few studies have evaluated whether health care assistants can improve care for depressed patients .  Contribution Patients who were r and omly assigned to receive telephone case management by health care assistants  reported slightly greater improvements in depression symptoms , better adherence to antidepressant therapies , and more favorable assessment s of the quality of their care than did patients r and omly assigned to receive usual care .  Implication Telephone case management facilitated by health care assistants may be a feasible mechanism for small primary care practice s to improve care of their patients with depression . The Editors Depression causes a substantial disease burden ( 1 ) and is responsible for annual health care costs of about $ 83.1 billion in the United States ( 2 , 3 ) . Most patients with depression are treated in primary care ( 46 ) . Collaborative care can improve depression outcomes by providing decision support and clinical information for family physicians , as well as self-management support and follow-up for patients . However , evidence regarding collaborative depression care stems mostly from academic or managed care setting s in the United States ( 711 ) . In these trials , family physicians generally relied on mental health case managers and decision support from mental health specialists ( 12 ) . Case management is a patient-centered element of collaborative care that may be effective in primary care ( 13 ) . It comprises systematic tracking of patients , support for continuing the treatment , and taking action in the case of nonadherence or lack of improvement ( 14 ) . Collaborative depression care has generally yielded positive results in diverse primary care setting s ( 7 ) . The IMPACT ( Improving MoodPromoting Access to Collaborative Treatment ) trial found that care managers who were supervised by psychiatrists and who provided education and support for medication adherence reduced depression symptoms in older patients ( 15 ) . Dietrich and colleagues ( 16 ) found that telephone support , provided by a trained , central ly based mental health care manager who was supervised by a psychiatrist , improved depression symptoms . Dobscha and colleagues ( 17 ) evaluated a primary care decision-support team for depression ( comprising a psychiatrist and a mental health nurse ) and found improved care processes but no differences in depression symptoms ( 17 ) , possibly because of less intensive follow-up of patients . Small , isolated primary care setting s often have limited re sources ( 18 ) . In the United States , 26 % of primary care practice s are solo practice s or 2-person partnerships , in which extensive collaborative models would be difficult to implement , and 22 % are located in rural areas with limited access to mental health specialists ( 19 ) . Health care assistants are established professionals in primary care setting s. They have less training than U.S. physician assistants or nurse practitioners , who provide first-contact care , and need not be college graduates ( 20 ) . In Germany , health care assistants have 3 years of on-the-job training . They are mainly responsible for administrative tasks in general practice but provide basic clinical procedures ( 21 ) . Health care assistants are a potentially important re source for enhancing patient care in primary care setting s ( 20 ) . Our aim was to evaluate whether case management by a practice -based health care assistant can reduce depression symptoms and improve the process of care for patients with major depression in small primary care practice s. Methods We design ed a pragmatic , cluster r and omized , controlled trial that used practice as the unit of r and omization to avoid contamination ( 22 ) . The institutional review board of Goethe University Frankfurt am Main , Frankfurt am Main , Germany , approved the study protocol on 25 April 2005 ( 23 ) . We used written consent procedures for family physicians and patients . We recruited practice s between February 2005 and May 2005 and patients between May 2005 and July 2006 . We carried out the intervention between June 2005 and August 2007 . We completed the last follow-up for study patients in September 2007 . Setting and Participants After calculating the sample size ( 24 ) , we informed all 1600 family physicians registered with the medical association of the state of Hesse , Germany ( m and atory registration ) , about the trial and invited them by mail to participate in information meetings . As the registration list presents only names and addresses , we checked inclusion criteria only for those who participated in the meetings . We stopped recruiting when 74 practice s had enrolled , even though more practice s were interested in participating . Inclusion criteria for the practice s were acceptance of all major health plans ( 90 % of patients are covered by this type of insurance ) ( 25 ) ; provision of a primary care service , according to the definition of Starfield and colleagues ( 26 ) ; and management by a family physician . Patients were screened on special date s and referred to the trial by the family physician in the primary care practice . Inclusion criteria for patients were diagnosis of major depression with indication for any antidepressive treatment , age 18 to 80 years , access to a private telephone , ability to give informed consent , and ability to communicate in German . The diagnosis of major depression was based on a score of more than 9 points and a categorical diagnosis in the Patient Health Question naire-9 ( PHQ-9 ) ( 27 ) , and was confirmed by the family physician by using the checklists in the Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition , and International Classification of Diseases , Tenth Edition . New patients were double-screened with the same procedure within 2 weeks . Exclusion criteria were confirmed pregnancy , severe alcohol or illicit drug consumption , or acute suicidal ideation assessed by the family physician . R and omization and Interventions The data safety and monitoring board stratified the practice s according to the size of the city and performed computer-based r and omization . Patient r and om assignment status was nested within the practice status . The data safety and monitoring board was responsible for allocation concealment by keeping the r and omization results in a secure data base . Because of the practice staff training required for the behavioral intervention , patients , health care assistants , family physicians , and research ers were not blinded to assignment once the trial was started . We design ed our case management intervention in accordance with the Chronic Care Model ( 28 , 29 ) , which emphasizes proactive support for the patient by the entire practice team . We trained 1 health care assistant from each practice assigned to the intervention group in 2 workshops ( an 11-hour and a 6-hour workshop ) . This interactive training included information on depression , communication skills , telephone monitoring , and behavioral activation for the patient ( 3032 ) . The health care assistants contacted their patients by telephone twice a week in the first month and than once a month for the following 11 months . They monitored depression symptoms and adherence to medication by using the Depression Monitoring List ( 33 ) . Health care assistants also encouraged patients to follow self-management activities , such as medication adherence and activation for pleasant or social activities . The assistants provided this information to the family physician in a structured report that stratified the urgency of the contact by a robot scheme . Family physicians in both the intervention and control groups received training on evidence -based depression treatment guidelines ( 34 ) . During the trial , other forms of disease or case management programs were uncommon in Germany ( 35 ) . No study practice carried out case management for any other diseases . Outcomes and Follow-up Self-rating question naires were h and ed out to the patients at baseline and at 6 and 12 months after baseline . Patients filled in the question naires at home and sent them back to the practice . We collected the question naires in the practice s and collected data from patient records ( number of family physician and specialist contacts , hospitalization , and prescribed medication ) . Research staff carried out data input and management ( 36 ) . Serious adverse events were reported to the data safety and monitoring board . Clinical Outcomes The primary outcome was depression symptoms , which we assessed by using the primary carevali date d PHQ-9 ( 37 ) . Each item is scored from 0 ( not at all ) to 3 ( nearly every day ) , for a total score that ranges from 0 to 27 ( high scores indicate more severe depression ) . We assessed response ( 50 % improvement in PHQ-9 score ) and remission status ( PHQ-9 score<5 ) as secondary outcomes . We also report data for the following secondary outcomes : quality of life , patient assessment of chronic illness care , and medication adherence . We measured health-related quality of life by using the  Medical Outcomes Study Short Form 36 ( SF-36 ) ( 38 , 39 ) and the  EuroQol-5D  ( 40 ) . The SF-36 allows the calculation of scores for physical health and mental health ( range , 0 to 100 ; higher scores indicate better status ) . The EuroQol-5D is a generic instrument that measures health-related quality of life with a visual analogue scale ( range , 0 to 100 ; higher ratings indicate higher quality of life ) . We determined the number of physical comorbid conditions by counting the documented diagnoses from different diagnostic groups listed in the Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition , and International Classification of Diseases , Tenth Edition , excluding all psychiatric diagnoses in the patient record . We assessed severity of chronic physical diseases by using the Chronic Disease Score , on the basis of prescription data from the patient record ( 41 ) . Process-of-Care Outcomes We assessed the number of family physician and mental health specialist contacts , as well as prescriptions for PURPOSE We wanted to examine whether integrating depression treatment into care for hypertension improved adherence to antidepressant and antihypertensive medications , depression outcomes , and blood pressure control among older primary care patients . METHODS Older adults prescribed pharmacotherapy for depression and hypertension from physicians at a large primary care practice in West Philadelphia were r and omly assigned to an integrated care intervention or usual care . Outcomes were assessed at baseline , 2 , 4 , and 6 weeks using the Center for Epidemiologic Studies Depression 
    Output:
    
Adherence improved most notably in studies that included sustainable system and patient-targeted changes .
Primary care providers are often positioned to impact patients ' adherence ; however , practice constraints can limit their implementation