***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: Among a sample of 119 distressed high-utilizers of primary care , 45 % of patients evaluated by a psychiatrist as needing antidepressant treatment had been treated in the year before the examination . However , only 11 % of the patients needing antidepressants had received adequate dosage and duration of pharmacotherapy . In the year following the intervention , study patients whose physicians were advised regarding treatment during a psychiatric consultation  were more likely to receive  antidepressant medications  ( 52.7 % ) relative to a r and omized control group ( 36.1 % ) . However , the intervention did not significantly increase the provision of adequate antidepressant therapy  ( 37.1 % vs 27.9 % ) . Among study patients using antidepressants , patient characteristics did not differentiate patients who received adequate dosage and duration of antidepressant medications from those who did not . Analysis of data on the duration of antidepressant therapy for all health maintenance organization enrollees initiating use of antidepressants showed that only 20 % of patients who had been given prescriptions for first-generation antidepressants ( amitriptyline , imipramine , or doxepin ) filled four or more prescriptions in the following six months , compared to 34 % of patients who had prescriptions for newer antidepressants ( nortriptyline , desipramine , trazodone and fluoxetine ) . Experimental research evaluating whether these newer medications ( with more favorable side effect profiles ) improve adherence , and thereby patient outcome , is needed 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 The object of the study was to evaluate outcomes of a r and omized clinical trial ( RCT ) of a pharmacist intervention for depressed patients in primary care ( PC ) . We report  antidepressant ( AD ) use and depression severity outcomes at 6-months . The RCT was conducted between 1998 and 2000 in 9 eastern Massachusetts PC practice s. We studied 533 patients with major depression and /or dysthymia as determined by a screening test done at the time of a routine PC office visit . The majority of participants had recurrent depressive episodes ( 63.5 % with > /=4 lifetime episodes ) , and 49.5 % were taking AD medications at enrollment . Consultation in person and by telephone was performed by a clinical pharmacist who assisted the primary care practitioner ( PCP ) and patient in medication choice , dose , and regimen , in accordance with AHCPR depression guidelines . Six-month AD use rates for intervention patients exceeded controls ( 57.5 % vs. 46.2 % , P = .03 ) . Furthermore , the intervention was effective in improving AD use rates for patients not on ADs at enrollment ( 32.3 % vs. 10.9 % , P = .001 ) . The pharmacist intervention proved equally effective in subgroups traditionally considered difficult to treat : those with chronic depression and dysthymia . Patients taking ADs had better modified Beck Depression Inventory ( mBDI ) outcomes than patients not taking ADs , ( -6.3 points change , vs. -2.8 , P = .01 ) but the outcome differences between intervention and control patients were not statistically significant ( 17.7 BDI points vs. 19.4 BDI points , P = .16 ) . Pharmacists significantly improved rates of AD use in PC patients , especially for those not on ADs at enrollment , but outcome differences were too small to be statistically significant . Difficult-to-treat subgroups may benefit from pharmacists ' care Background : Depression is undertreated in primary care setting s. Little research investigates the impact of patient involvement in decisions on guideline -concordant treatment and depression outcomes . Objective : The objective of this study was to determine whether patient involvement in decision-making is associated with guideline -concordant care and improvement in depression symptoms . Design : Prospect i ve cohort study . Setting : Multisite , nationwide r and omized clinical trial of quality improvement strategies for depression in primary care . Subjects : Primary care patients with current symptoms and probable depressive disorder . Measurements : Patients rated their  involvement in decision-making ( IDM )  about their care on a 5-point scale from poor to excellent 6 months after entry into the study . Depressive symptoms were measured every 6 months for 2 years using a modified version of theCenter for Epidemiologic Studies –Depression ( CES-D ) scale . We examined probabilities ( Pr ) of receipt of guideline -concordant care and resolution of depression across IDM groups using multivariate logistic regression models controlling for patient and provider factors . Results : For each 1-point increase in IDM ratings , the probability of patients ’ report of receiving guideline -concordant care increased 4 % to 5 % ( adjusted Pr 0.31 vs. 0.50 for the lowest and highest IDM ratings , respectively , P < 0.001 ) . Similarly , for each 1-point increase in IDM ratings , the probability of depression resolution increased 2 % to 3 % ( adjusted Pr 0.10 vs. 0.19 for the lowest and highest IDM ratings respectively , P = 0.004 ) . Conclusions : Depressed patients with higher ratings of involvement in medical decisions have a higher probability of receiving guideline -concordant care and improving their symptoms over an 18-month period . Interventions to increase patient involvement in decision-making may be an important means of improving care for and outcomes of depression OBJECTIVE This study evaluated the effectiveness of a structured telephone-based care management program for patients in a prepaid health plan receiving new antidepressant prescriptions from psychiatrists . METHODS Potential participants were identified with computerized medical records and contacted by telephone . Eligible and consenting participants were r and omly assigned to continued usual care ( N=104 ) or to a three-session telephone care management program ( N=103 ) . Care management contacts included assessment of depressive symptoms , medication adherence , and medication side effects with structured feedback to treating psychiatrists . Effectiveness was assessed three and six months after r and omization by blinded telephone assessment s ( depression scale on the Hopkins Symptom Checklist [ SCL ] and patient-rated global improvement ) . Computerized records were used to assess medication adherence and frequency of in-person follow-up visits . RESULTS Compared with usual care , the care management intervention had no significant effect on the mean score of the SCL depression scale at six months , on the probability of 50 percent improvement in depressive symptoms ( 41 percent for care management and 37 percent for usual care ) , or on the probability of patient-rated improvement ( 57 percent for care management and 52 percent for usual care ) . Patients assigned to care management made significantly more medication management visits over six months ( 2.4 visits compared with 2.0 visits ; p=.035 ) , but there were no significant differences in rates of adequate medication treatment . CONCLUSIONS This study found that a low-intensity telephone care management program did not appear to significantly improve clinical outcomes for patients starting antidepressant treatment . Compared with findings from earlier primary care studies , this study found that patients receiving care from a psychiatrist received more intensive treatment , although many still experienced poor outcomes Context Most successful disease management interventions for depression care have required intensive involvement of care managers or mental health specialists . Contribution The authors r and omly assigned 41 primary care physicians from 5 clinics to receive either depression decision support or usual care . Depression decision support was provided by a team that included a psychiatrist and a nurse care manager and involved an initial telephone contact , patient education , monthly record review , and sending a progress report to primary care physicians every 3 months . Depression severity improved equally in both groups over 12 months , despite evidence that intervention clinicians delivered more depression-related services . Implication s Decision support improved processes of depression care but not outcomes . The Editors Depression is a common problem worldwide . According to projections from the World Health Organization ( WHO ) , depression will be the second leading cause of disability in the developed world by 2020 ( 1 ) . One in 10 primary care patients meets criteria for major depression ( 2 ) , yet underrecognition and undertreatment are common ( 3 , 4 ) . Untreated depression is associated with increased deaths , adverse medical outcomes , deficits in function and well-being , and increased use of health services ( 3 , 59 ) . Multifaceted , collaborative interventions have been shown to improve depression-related outcomes in primary care ( 1022 ) . These interventions include decision support for clinicians , self-management support for patients , clinical information systems modifications , and care management . Care management typically consists of patient education and activation , symptom and treatment adherence monitoring , and self-management reinforcement ( 23 ) . Most collaborative depression interventions have relied on intensive involvement of care managers and specialists , usually shifting responsibility and workload toward mental health or research teams . Clinical systems may not be capable of sustaining this level of intensity . We therefore developed a multifaceted depression decision support intervention , which was design ed to optimize primary care clinicians ' abilities to treat depression without adding substantial new re sources . We aim ed to determine the effect of depression decision support on clinical outcomes and processes of care among patients with depression in a Veterans Affairs ( VA ) primary care setting . Methods Design Overview Our clinician-level , cluster r and omized , controlled trial studied depression decision support versus usual care . We r and omly assigned clinicians to either group and nested patients within clinician group assignment . We recruited participants between July 2002 and October 2003 from 5 primary care clinics of a VA medical center and followed patients for 12 months . The local institutional review board approved the study , and all patients and clinicians gave written informed consent . Setting Approximately 25000 veterans were treated during the study period in the 5 primary care clinics ( 3 urban and 2 rural clinics ) . Mental health clinicians are available on site in all clinics to provide consultation and brief treatment . A separate , more traditional mental health clinic serves approximately 8000 patients with chronic mental illnesses . Participants Full- and part-time staff physicians , fellows , physician assistants , and nurse practitioners were eligible to participate , and 41 ( 95 % ) of 43 eligible clinicians agreed to participate . To decrease variability in baseline depression-related knowledge and skills , we invited all clinicians to participate in the MacArthur Foundation depression education program ( 2427 ) before r and omization . In two 4-hour sessions , the program addresses communication skills and knowledge related to recognizing and managing depression . All patients of participating clinicians were eligible for the study . Research assistants review ed medical records of patients with upcoming primary care appointments ( within 4 to 6 weeks ) . They excluded patients who had received treatment from mental health specialists within the previous 6 months ; who had received a diagnosis of psychotic disorder , dementia , or bipolar disorder ; or who were considered to be terminally ill . They mailed study introduction letters to nonexcluded patients . The letters informed the patients that the research team would call them within 2 weeks unless they declined screening by notifying the study office . Telephone screening measures included the  Patient Health Question naire ( PHQ-9 ) ( 28 ) and the  Short Blessed Test screening  for dementia ( 29 ) . We invited patients with PHQ-9 scores of 10 to 25 ( moderate to severe depression ) ( 30 ) to attend in-person enrollment interviews . We referred patients with PHQ-9 scores greater than 25 ( very severe depression ) or active dangerous ideation for urgent care , and we excluded them from participation . Enrollment interviews were scheduled within 2 weeks of primary care visits and usually took place the same day . The primary inclusion criterion was a repeated PHQ-9 score of 10 to 25 or a Hopkins Symptom Checklist-20 ( SCL-20 ) ( 31 ) score of 1.0 or greater at the enrollment interview . Of the 5434 patients 
    Output:
    
The interventions which showed significant improvement in outcomes were primarily multifaceted and complex , with proactive care management and involvement of mental health specialists .
The most commonly used elements of multifaceted interventions included patient educational strategies , telephone follow-up to monitor patients ' progress , as well as providing medication support and feedback to primary care providers .
Overall , educational interventions alone were ineffective in improving antidepressant medication adherence .
In conclusion , improving adherence to antidepressants requires a complex behavioural change and there is some evidence to support behavioural and multifaceted interventions as the most effective in improving antidepressant medication adherence and depression outcomes .