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Partners in Care

Partners in Care (PIC) is an intervention for use in managed primary care settings to improve the treatment of depression. PIC is based on collaborative care models, in which mental health is integrated with primary care. The program supports the detection, assessment, treatment choice, and management of patients with major depression or dysthymia by increasing collaboration among primary care clinicians, mental health specialists, nurses, and patients. For the managed care provider, the intervention goal is to increase the percentage of patients receiving appropriate treatment for depression. For patients, the program aims to improve quality of life and reduce depression symptoms. PIC is suitable for use with most age groups, from teenagers through older adults, although the study reviewed for this summary included only individuals 18 and older.

The core elements of PIC include teamwork between specialists and generalists, case management by nurses, and patient education and empowerment. The intervention educates clinicians on the treatment of depression in the primary care setting while also giving them access to psychotherapists who can provide consultation on difficult cases and take referrals when needed. Health care organizations participating in PIC receive a package of materials designed to help them implement their own collaborative care model. These materials include:

  • The Clinician Guide to Depression Assessment and Management in Primary Care, which gives primary care physicians the information they need to assess and treat patients, as well as key references on patient education, medications, and psychotherapy
  • Pocket-sized Quick Reference Cards, which summarize key points from the Guide and include information on antidepressants, including doses, side effects, and typical costs
  • Individual and group cognitive-behavioral therapy (CBT) manuals
  • Guidelines and Resources for the Depression Nurse Specialist, containing instructions, forms, and materials needed to carry out case management
  • Patient education brochures, suitable for use with patients with major depression as well as patients who feel sad but do not have the full-blown illness

Health care organizations implementing PIC should nominate a set of individuals who will serve as depression care improvement leaders, including a primary care provider, a mental health specialist, and a nursing clinician. At least one of these individuals should have experience in practice redesign or quality improvement methods. This leadership team uses the PIC materials to educate primary care and mental health specialist clinicians about the program, hires and trains nurse care managers, and provides the necessary space, support, and monitoring to conduct the program. Nurse care managers are usually experienced registered nurses; they can also be clinical nurse specialists or social workers who are willing to do brief, targeted, proactive care for a large caseload rather than carry out psychotherapy.

Descriptive Information

Areas of Interest Mental health treatment
Outcomes Review Date: November 2009
1: Depressive symptoms
2: Mental health-related quality of life
3: Health service utilization
4: Quality of care for depression
5: Employment
Outcome Categories Employment
Mental health
Quality of life
Treatment/recovery
Ages 26-55 (Adult)
55+ (Older adult)
Genders Male
Female
Races/Ethnicities Black or African American
Hispanic or Latino
White
Race/ethnicity unspecified
Settings Outpatient
Geographic Locations Urban
Suburban
Rural and/or frontier
Implementation History PIC was field-tested in a large trial from 1997 through 1999. Forty-six primary care clinics in 6 U.S. managed care organizations participated, and 1,265 patients completed the study. One hundred and twelve primary care physicians contributed patients to the study; 80% of these participated in educational sessions. Since that time, other projects have been undertaken using direct adaptations of PIC materials. These include the IMPACT study for elderly depressed patients; Youth Partners in Care for adolescents; and the Translating Initiatives in Depression into Effective Solutions (TIDES) project in the Department of Veterans Affairs (VA). Across these various projects, the basic PIC model has been implemented in hundreds of primary care venues in all 50 States. In addition, PIC researchers have worked in partnership with other researchers through a joint National Institute of Mental Health grant to test a similar model in networked small primary care practices using trained office staff to function as depression care managers. PIC itself has generated over 30 articles.
NIH Funding/CER Studies Partially/fully funded by National Institutes of Health: Yes
Evaluated in comparative effectiveness research studies: Yes
Adaptations All materials are available in Spanish and English. The Clinician Guide also includes a section on cultural adaptations for specific groups.
Adverse Effects No adverse effects, concerns, or unintended consequences were identified by the developer.
IOM Prevention Categories IOM prevention categories are not applicable.

Quality of Research
Review Date: November 2009

Documents Reviewed

The documents below were reviewed for Quality of Research. The research point of contact can provide information regarding the studies reviewed and the availability of additional materials, including those from more recent studies that may have been conducted.

Study 1

Sherbourne, C. D., Wells, K. B., Duan, N., Miranda, J., Unützer, J., Jaycox, L., et al. (2001). Long-term effectiveness of disseminating quality improvement for depression in primary care. Archives of General Psychiatry, 58(7), 696-703.  Pub Med icon

Wells, K., Sherbourne, C., Schoenbaum, M., Duan, N., Meredith, L., Unützer, J., et al. (2000). Impact of disseminating quality improvement programs for depression in managed care primary care: A randomized controlled trial. Journal of the American Medical Association, 283(2), 212-220.  Pub Med icon

Supplementary Materials

Rubenstein, L., Jackson-Triche, M., Unützer, J., Miranda, J., Minnium, K., Pearson, M. L., & Wells, K. B. (1999). Evidence-based care for depression in managed primary care practices. Health Affairs, 18(5), 89-105.  Pub Med icon

Schoenbaum, M., Unützer, J., Sherbourne, C., Duan, N., Rubenstein, L. V., Miranda, J., et al. (2001). Cost-effectiveness of practice-initiated quality improvement for depression: Results of a randomized controlled trial. Journal of the American Medical Association, 286(11), 1325-1330.  Pub Med icon

Outcomes

Outcome 1: Depressive symptoms
Description of Measures Depressive symptoms were assessed using two instruments:

  • A revised, 23-item version of the Center for Epidemiologic Studies Depression scale (CES-D)
  • The Composite International Diagnostic Interview (CIDI), which assesses probable depressive disorder in the past 6 months
The revised CES-D was used at baseline and 6-, 12-, and 24-month follow-up. The CIDI was used at 6-, 12-, and 24-month follow-up.
Key Findings Matched clinics participating in the study were randomized to an intervention group that received PIC materials or to a comparison group that received the Agency for Healthcare Research and Quality (AHRQ) depression practice guidelines by mail. All eligible patients at these clinics were screened for depression, and those with current depressive symptoms and 12-month, lifetime, or no depressive disorder were enrolled in the study.

For depressive disorder as assessed by the revised CES-D, the study found:

  • There were no significant group differences at baseline in the rate of depressive disorder.
  • At 6-month follow-up, 55.4% of intervention group patients and 64.4% of comparison group patients were reported as being depressed (p = .005).
  • At 12-month follow-up, 54.5% of intervention group patients and 61.4% of comparison group patients were still reported to be depressed (p = .04).
  • The difference between groups was still significant at 24-month follow-up (p = .04).
For probable depressive disorder as assessed by the CIDI, the study found:

  • At 6-month follow-up, 39.9% of intervention group patients and 49.9% of comparison group patients were reported as having probable depression (p = .001).
  • At 12-month follow-up, 41.6% of intervention group patients and 51.2% of comparison group patients were reported as having probable depression (p = .005).
  • The difference between groups was still significant at 24-month follow-up (p = .04).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.6 (0.0-4.0 scale)
Outcome 2: Mental health-related quality of life
Description of Measures Mental health-related quality of life was assessed using the Mental Component Summary (MCS) score from the self-administered 12-item Short-Form Health Survey (SF-12). The MCS provides an overall measurement of mental health based on factors such as vitality, social functioning, and emotional well-being. MCS scores were normalized to a general population mean of 50 (SD = 10), with higher scores indicating better health. This measure was administered at baseline and at 6-, 12-, and 24-month follow-up.
Key Findings Matched clinics participating in the study were randomized to an intervention group that received the PIC materials or to a comparison group that received the AHRQ depression practice guidelines by mail. All eligible patients at these clinics were screened for depression, and those with current depressive symptoms and 12-month, lifetime, or no depressive disorder were enrolled in the study. The study found:

  • There was no significant difference at baseline between the intervention and comparison groups in mental health-related quality of life (mean MCS scores: 35.6% vs. 36.1%).
  • At 6-month follow-up, significantly more intervention group patients than comparison group patients showed improved mental health-related quality of life (mean MCS scores: 41.6% vs. 39.8%; p = .009).
  • The difference between groups was still significant at 12-month follow-up (mean MCS scores: 40.9% vs. 39.3%; p = .04) and at 24-month follow-up (p < .05).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.6 (0.0-4.0 scale)
Outcome 3: Health service utilization
Description of Measures Health service utilization was assessed at baseline and 6- and 12-month follow-up using a self-administered patient survey that assessed whether the patient had any of the following in the past 6 months: medical visits, medical visits for emotional problems (i.e., visits at which emotional problems were discussed), and mental health specialty visits. An indicator was developed for each type of visit and the number of visits. Increased health service utilization was assumed to reflect improved quality of care for depression.
Key Findings Matched clinics participating in the study were randomized to an intervention group that received the PIC materials or to a comparison group that received the AHRQ depression practice guidelines by mail. All eligible patients at these clinics were screened for depression, and those with current depressive symptoms and 12-month, lifetime, or no depressive disorder were enrolled in the study. The study found:

  • There were no significant group differences at baseline for any of the three types of visits.
  • Significantly more intervention group patients than comparison group patients reported mental health specialty visits in the past 6 months at both 6- and 12-month follow-ups. The percentages of intervention and comparison group patients who reported such visits were 29.9% and 27.2% at baseline, 39.8% and 27.2% at 6-month follow-up (p = .001), and 29.1% and 22.7% at 12-month follow-up (p = .03).
  • Significantly more intervention group patients than comparison group patients also reported having medical visits for emotional problems at 6-month follow-up, but the difference was no longer significant at 12-month follow-up. The percentages of intervention and comparison group patients reporting such visits were 48.4% and 46.5% at baseline, 47.5% and 36.6% at 6-month follow-up (p = .001), and 37.4% and 35.1% at 12-month follow-up.
  • Rates of any medical visits did not differ significantly between groups in any period.
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.6 (0.0-4.0 scale)
Outcome 4: Quality of care for depression
Description of Measures Quality of care for depression was measured using a self-administered patient survey administered at baseline and 6- and 12-month follow-up. Patients were asked to report any prescription medications used in the past 30 days (for the baseline administration) and in the past 6 months (for the follow-up administration). Criteria from national guidelines (Depression Guideline Panel, 1993) were applied to each medication to assess whether the dosage was appropriate. In addition, patients reported whether they had received individual, group, or family counseling by a specialist in the past 6 months. Other survey questions were used to determine whether the patient had depressive symptoms or was free of probable disorder (see Outcome 1).

Overall care was considered appropriate if patients were free of probable disorder or had either specialty counseling or use of appropriate antidepressant medication during a given 6-month period.
Key Findings Matched clinics participating in the study were randomized to an intervention group that received the PIC materials or to a comparison group that received the AHRQ depression practice guidelines by mail. All eligible patients at these clinics were screened for depression, and those with current depressive symptoms and 12-month, lifetime, or no depressive disorder were enrolled in the study. The study found:

  • There were no significant group differences at baseline in the rates of appropriate antidepressant use, specialty counseling, or overall appropriate care.
  • The intervention group had significantly higher rates of appropriate antidepressant use relative to the comparison group at both 6- and 12-month follow-ups. The percentages of intervention and comparison group patients reporting appropriate antidepressant use were 27.6% and 27.0% at baseline, 34.7% and 25.1% at 6-month follow-up (p = .001), and 31.0% and 24.0% at 12-month follow-up (p = .01).
  • Rates of specialty counseling use were also higher in the intervention group at both follow-ups. The percentages of intervention and comparison group patients who received specialty counseling were 29.5% and 26.9% at baseline, 38.2% and 25.6% at 6-month follow-up (p < .001), and 27.3% and 20.9% at 12-month follow-up (p = .03).
  • Significantly more intervention group patients than comparison group patients received overall appropriate care for depression. The percentages of intervention and comparison group patients who received appropriate care were 44.2% and 42.5% at baseline, 50.9% and 39.7% at 6-month follow-up (p < .001), and 59.2% and 50.1% at 12-month follow-up (p = .006).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.4 (0.0-4.0 scale)
Outcome 5: Employment
Description of Measures A self-administered patient survey was used to assess whether respondents were employed at baseline. Follow-up telephone surveys assessed current employment at 6- and 12-month follow-up.
Key Findings Matched clinics participating in the study were randomized to an intervention group that received the PIC materials or to a comparison group that received the AHRQ depression practice guidelines by mail. All eligible patients at these clinics were screened for depression, and those with current depressive symptoms and 12-month, lifetime, or no depressive disorder were enrolled in the study. Results showed that among patients who were initially employed, 89.7% of those in the intervention group and 84.7% of those in the comparison group were employed at 12-month follow-up (p = .05).
Studies Measuring Outcome Study 1
Study Designs Experimental
Quality of Research Rating 3.6 (0.0-4.0 scale)

Study Populations

The following populations were identified in the studies reviewed for Quality of Research.

Study Age Gender Race/Ethnicity
Study 1 26-55 (Adult)
55+ (Older adult) 		72.3% Female
27.7% Male 		57.4% White
29.2% Hispanic or Latino
6.9% Black or African American
6.5% Race/ethnicity unspecified

Quality of Research Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the Quality of Research for an intervention's reported results using six criteria:

For more information about these criteria and the meaning of the ratings, see Quality of Research.

Outcome Reliability
of Measures 		Validity
of Measures 		Fidelity Missing
Data/Attrition 		Confounding
Variables 		Data
Analysis 		Overall
Rating
1: Depressive symptoms 3.3 3.3 3.5 4.0 3.5 4.0 3.6
2: Mental health-related quality of life 3.3 3.3 3.5 4.0 3.5 4.0 3.6
3: Health service utilization 3.3 3.5 3.5 4.0 3.5 4.0 3.6
4: Quality of care for depression 2.8 2.8 3.5 4.0 3.5 4.0 3.4
5: Employment 3.3 3.3 3.5 4.0 3.5 4.0 3.6

Study Strengths

The majority of the measures used in the study have good psychometric information and acceptable levels of reliability and validity. Fidelity was assured by steps taken prior to and during the study, including extensive training, ongoing monitoring and feedback at the clinic and clinician level, and the distribution of supporting materials. Adherence rates were reported for each part of the intervention. Attrition was relatively low, and the methods used to address attrition were clearly described for every project phase, from patient screening through survey completion at each assessment point. Baseline factors that were associated with remaining enrolled were addressed in the analyses. The study was a group-level randomized controlled trial in which clinic clusters were grouped into matched blocks based on patient demographics, clinician specialty, and distance to mental health providers. The data analyses were very appropriate for detecting effects reflecting the primary hypothesis.

Study Weaknesses

Psychometric information was not presented for one of the scales used to measure depression symptoms, the abbreviated adaptation of the CES-D. Similarly, psychometric information was lacking for the measures and methods used to gauge quality of care for depression (i.e., receipt of specialty counseling or use of appropriate antidepressant medication).
Readiness for Dissemination
Review Date: November 2009

Materials Reviewed

The materials below were reviewed for Readiness for Dissemination. The implementation point of contact can provide information regarding implementation of the intervention and the availability of additional, updated, or new materials.

Munoz, R. F., & Miranda, J. (2000). Group therapy manual for cognitive-behavioral treatment of depression. Santa Monica, CA: RAND.

Munoz, R. F., & Miranda, J. (2000). Individual therapy manual for cognitive-behavioral treatment of depression. Santa Monica, CA: RAND.

Partners in Care program materials, http://www.rand.org/pubs/monograph_reports/MR1198/index.html

Partners in Care Web site, http://www.rand.org/health/surveys_tools/pic.html

RAND. (2000). Partners in Care quick reference cards. Santa Monica, CA: Author.

Rubenstein, L. V., Unützer, J., Miranda, J., Katon, W. J., Wieland, M., Jackson-Triche, M., et al. (2000). Clinician guide to depression assessment and management in primary care. Santa Monica, CA: RAND.

Rubenstein, L. V., Unützer, J., Miranda, J., Simon, B., Katon, W. J., Jackson-Triche, M., et al. (2000). Guidelines and resources for the depression nurse specialist. Santa Monica, CA: RAND.

Readiness for Dissemination Ratings by Criteria (0.0-4.0 scale)

External reviewers independently evaluate the intervention's Readiness for Dissemination using three criteria:

  1. Availability of implementation materials
  2. Availability of training and support resources
  3. Availability of quality assurance procedures

For more information about these criteria and the meaning of the ratings, see Readiness for Dissemination.

Implementation
Materials 		Training and Support
Resources 		Quality Assurance
Procedures 		Overall
Rating
3.3 2.8 3.0 3.0

Dissemination Strengths

The program materials provide valuable guidance for evaluating patient needs, developing care plans, and monitoring patient progress. Both patient education materials and materials for use by practices are included. Thoughtful, written guidance is provided on how to train the clinicians and others involved in implementation. Each training session is coherently described in general terms before details are presented, facilitating understanding of each phase of the program. Quality assurance is supported through the use of assessment tools, patient self-reports, and team meetings. Forms, worksheets, and procedures for collecting data on patients and assessing their progress are provided. Many of the measures in these materials have been validated by research and offer a reliable way to monitor program quality.

Dissemination Weaknesses

The program materials, most of which were developed in the 1990s, mention that implementers may want to revise the manuals to take into account recent advances (e.g., in psychotropic medications and informatics support for documenting case management), but no specific guidance on how to update the materials and procedures is offered. Certain inconsistencies in the materials may be confusing, and the language used, while appropriate for a research study, may not be practical in a primary care setting. The developer no longer provides training or support to implementers, although training on the basic PIC model is available through related projects. CBT training materials are presented as training for therapists but are focused only on the content of CBT sessions, not on the skills required to administer them, and the level of competence in CBT expected of therapists is unclear. There is little discussion of the role of team meetings and supervision and how this aspect of the program should be conducted. Since the recommended quality assurance procedures for the program were developed for the original research study, they may require more data collection than is feasible for some implementers.
Costs

The cost information below was provided by the developer. Although this cost information may have been updated by the developer since the time of review, it may not reflect the current costs or availability of items (including newly developed or discontinued items). The implementation point of contact can provide current information and discuss implementation requirements.

Item Description Cost Required by Developer
All program materials (electronic) Free Yes, one option is required
All program materials (hard copy) $275 per set Yes, one option is required
Replications

No replications were identified by the developer.
Contact Information

To learn more about implementation or research, contact:
Lisa Rubenstein, M.D., M.S.P.H.
(310) 393-0411 ext 6303
lisar@rand.org

Consider these Questions to Ask (PDF, 54KB) as you explore the possible use of this intervention.

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