• John C Fortney, Jeffrey M Pyne, Mark J Edlund, David K Williams, Dean E Robinson, Dinesh Mittal, and Kathy L Henderson.
• VA Health Services Research and Development, Center for Mental Healthcare and Outcomes Research (152/NLR), Central Arkansas Veterans Healthcare System, 2200 Fort Roots Drive, North Little Rock, AR 72114, USA. fortneyjohnc@uams.edu
• J Gen Intern Med. 2007 Aug 1; 22 (8): 108610931086-93.

BackgroundEvidence-based practices designed 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.ObjectiveThe 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.DesignMatched sites were randomized to the intervention or usual care.ParticipantsSmall 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 > or = 12 were enrolled, and followed for 12 months. Patients with serious mental illness and current substance dependence were excluded.MeasuresMedication adherence, treatment response, remission, health status, health-related quality of life, and treatment satisfaction.ResultsThe 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.ConclusionsCollaborative care can be successfully adapted for primary care clinics without on-site psychiatrists using telemedicine technologies.

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