Telemedicine Surpasses On-Site Depression Treatment in Small Remote Clinics

Primary-care nurses using telemedicine may be better able to stay on message and promote behavioral activation, but results for both groups are modest.

Identifying the optimal primary-care approach to depression treatment is a priority as these clinics see most patients with clinical depression. Researchers examined telemedicine and on-site treatment in a pragmatic, randomized, comparative effectiveness study involving five rural primary-care centers, none of which employed on-site mental-health specialists.

Of 19,285 patients screened, 2863 (15%) scored as depressed on the Patient Health Questionnaire, and 364 eligible patients were randomized and followed for 18 months. Treatments were on-site collaborative care (primary-care physician plus nurse care manager) or on-site primary-care physician plus telemedicine (telephone contact with off-site nurse care managers and pharmacists; access to telepsychotherapy [17% of patients]; and telepsychiatric consultation after two failed antidepressant trials [48% of those eligible]). Telemedicine nurses were dedicated 100% to this work and received weekly supervision. The largely unemployed, impoverished, uninsured rural patients had moderately severe depression and frequent physical and psychiatric comorbidities.

Disease severity, numbers of primary-care and depression visits, and antidepressant prescriptions were similar in the groups. Most patients received therapeutic antidepressant doses; adherence was high. Although on-site and telemedicine nurses had similar training and experience, telemedicine nurses showed greater fidelity to protocol, providing more information about exercise, social activities, other rewarding self-management activities, and medication adherence. At 18 months, telemedicine had higher rates than on-site care for both response (48% vs. 22%; adjusted odds ratio, 7.74) and remission (26% vs. 10%; AOR, 12.69).

CITATION(S):

Fortney JC et al. Practice-based versus telemedicine-based collaborative care for depression in rural federally qualified health centers: A pragmatic randomized comparative effectiveness trial. Am J Psychiatry 2013 Feb 22; [e-pub ahead of print].