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Letters to the Editor

Practice-Based or Telemedicine-Based
Collaborative Care for Depression

The author reports no nancial relationships with commercial interests.

To the Editor: In the editorial (1) accompanying the


interesting article (2) on practice-based compared with
telemedicine-based collaborative care for depression in the
April issue of the Journal, Drs. Simon and Ludman frame
the question explored by the study as: Which is better,
locally grown or factory-farmed?
The study may have answered a rather different question:
Which is more effective, supervised or unsupervised mental
health treatment? The intervention used nurses with no
prior mental health experience as depression care managers.
Both the practice-based and the telemedicine-based nurses
received an initial 1 day of training and a training manual.
Thereafter, the telemedicine-based nurses received weekly
supervision, which included a discussion of patients who were
not responding to treatment. In contrast, the practice-based
depression care managers received no clinical supervision.
The use of unsupervised nurses deviates from the standard
practice of collaborative care of depression, which rests on the
principle of collaboration between a depression care manager, the primary care provider, and a consulting psychiatrist
(3, 4). The IMPACT Intervention Manual species that The
[depression care manager] should receive clinical supervision
and consultation from a liaison primary care physician and
from a team psychiatrist during a weekly team meeting at
the primary care clinic (5). The treatment provided by the
unsupervised practice-based depression care managers was
by no means equivalent to that of the supervised telemedicinebased depression managers.
It is premature, therefore, to conclude that factoryfarmed is better than locally grown. Indeed, the study
can be seen to demonstrate the unsurprising nding that
providing weekly supervision and consultation to nurses
with no prior mental health experience leads to more effective
treatment and better outcomes.

This letter (doi: 10.1176/appi.ajp.2013.13040471) was accepted


for publication in May 2013.

References
1. Simon GE, Ludman EJ: Should mental health interventions be locally grown or factory-farmed? Am J Psychiatry 2013; 170:362365
2. Fortney JC, Pyne JM, Mouden SB, Mittal D, Hudson TJ, Schroeder
GW, Williams DK, Bynum CA, Mattox R, Rost KM: Practice-based
versus telemedicine-based collaborative care for depression in
rural federally qualied health centers: a pragmatic randomized
comparative effectiveness trial. Am J Psychiatry 2013; 170:414425
3. Untzer J, Katon W, Callahan CM, Williams JW Jr, Hunkeler E,
Harpole L, Hofng M, Della Penna RD, Nol PH, Lin EH, Aren PA,
Hegel MT, Tang L, Belin TR, Oishi S, Langston C; IMPACT Investigators; Improving Mood-Promoting Access to Collaborative
Treatment: Collaborative care management of late-life depression
in the primary care setting: a randomized controlled trial. JAMA
2002; 288:28362845
4. Improving Mood-Promoting Access to Collaborative Treatment:
IMPACT key components. http://impact-uw.org/about/key.html
5. Untzer J, Oishi S; IMPACT Investigators: IMPACT Intervention
Manual. Los Angeles, Center for Health Services Research, UCLA
Neuropsychiatric Institute, 1999

HENRY WHITE, M.D.

From the Brookline Community Mental Health Center,


Brookline, Mass.

926

ajp.psychiatryonline.org

Response to White
To the Editor: Dr. White correctly states that collaborative
care models have traditionally involved collaboration between primary care providers, care managers, and consulting
psychiatrists. This collaboration typically includes weekly
supervisory meetings between care managers and psychiatrists to discuss patients failing treatment, followed by
treatment recommendations to the primary care provider
when appropriate. We agree with Dr. White that psychiatric
supervision and consultation are integral elements of effective
mental health programs. In the telemedicine-based collaborative care arm of our study, we adapted this traditional model
for small rural primary care clinics by establishing an off-site
multidisciplinary depression care team (psychiatrist, psychologist, pharmacist, and care manager) to collaborate with the
on-site primary care providers.
Dr. White is also correct that in the practice-based collaborative care intervention arm of our study, depression treatment
was delivered by an on-site primary care provider and an onsite care manager, without the involvement of a consulting
psychiatrist. This comparison group was chosen for three
reasons. First, most primary care practices do not have access
to an on-site psychiatrist. Second, two high-quality randomized trials had previously demonstrated that depression
outcomes can be improved in small primary care clinics
lacking on-site mental health specialists by training depression care managers (without psychiatric supervision) to
support primary care providers (1, 2). Third, this comparison
group replicated the Depression Health Disparities Collaborative that was being disseminated in federally qualied
health centers by the Health Resources and Services Administration (HRSA). For the depression collaborative, HRSA specifically recommended: Establish linkages with key specialists
to assure that primary care providers have access to expert
support, and our practice-based care managers were encouraged to use mental health resources available in the community (e.g., community mental health centers). However, for
federally qualied health centers located in medically underserved areas, access to psychiatric care is challenging, and
obtaining psychiatric consultation and care manager supervision is especially difcult.
Because this was a pragmatic rather than an explanatory
trial, we cannot isolate the mechanism(s) of action that led to
better clinic outcomes in the telemedicine-based arm compared with the practice-based arm. Certainly, the depression
care manager in the telemedicine-based arm exhibited higher
delity to the care manager protocol than the care managers
in the practice-based arm. Higher delity may well have
been better in the telemedicine-based arm because of the
psychiatric supervision and the expectation that the care
manager would be required to report patient outcomes to
the psychiatrist on a weekly basis. Ideally, we believe that

Am J Psychiatry 170:8, August 2013

Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.

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