Telephone screening, outreach, and care management for depressed workers and impact on clinical and work productivity outcomes: A randomized controlled trial
Although guideline-concordant depression treatment is clearly effective, treatment often falls short of evidence-based recommendations. Organized depression care programs significantly improve treatment quality, but employer purchasers have been slow to adopt these programs based on lack of evidence for cost-effectiveness from their perspective.
The purpose of this study was to evaluate the effects of a depression outreach-treatment program on workplace outcomes.
The study was conducted over the telephone with individuals all over the U.S. with behavioral health plan coverage.
A randomized controlled trial involving 604 employees covered by a managed behavioral health plan were identified in a 2-stage screening process as having significant depression. Patient treatment allocation was concealed and assessment of depression severity and work performance at months 6 and 12 was blinded. Employees with lifetime bipolar disorder, substance disorder, recent mental health specialty care, or suicidality were excluded.
Intervention effects on depression severity were estimated using multiple imputation multiple linear regression with simulated standard errors. QIDS-SR scores at 6 and 12 months were regressed on a dichotomous predictor for randomization status. Dichotomous measures of symptom improvement (?50% reduction in QIDS-SR scores) and complete remission (QIDS-SR scores of ?5) were also examined using multiple imputation multiple logistic regression. Comparable multiple imputation regression analyses were used to estimate intervention effects on work outcomes. The primary outcome was a composite measure of the number of effective hours worked in the prior 7 days, for which participants no longer working contributed no hours and numbers of hours worked by employed respondents were weighted by job performance.
The intervention was a telephonic outreach and care management program. This program encouraged workers to enter outpatient treatment (psychotherapy and/or antidepressant medication), monitored treatment quality continuity, and attempted to improve treatment by giving recommendations to providers. Participants reluctant to enter treatment were offered a structured telephone cognitive behavioral psychotherapy.
Those assigned to usual care were informed that their responses indicated possible depression and advised to consult with a clinician; they could receive any normally available insurance benefit or service (eg, psychotherapy or pharmacotherapy), just not the additional telephone care management components provided to those in the intervention group.
The results suggest that enhanced depression care of workers has benefits not only on clinical outcomes but also on workplace outcomes. Combining data across 6- and 12-month assessments, the intervention group had significantly lower QIDS self-report scores (relative odds of recovery, 1.4; 95% confidence interval, 1.1-2.0; P = .009), significantly higher job retention (relative odds, 1.7; 95% confidence interval, 1.1-3.3; P = .02), and significantly more hours worked among the intervention (?=2.0; P=.02; equivalent to an annualized effect of 2 weeks of work) than the usual care groups that were employed.
A systematic program to identify depression and promote effective treatment significantly improves not only clinical outcomes but also workplace outcomes. The financial value of the latter to employers in terms of recovered hiring, training, and salary costs suggests that many employers would experience a positive return on investment from outreach and enhanced treatment of depressed workers.
