Characteristics of effective collaborative care for treatment of depression: a systematic review and meta-regression of 74 randomised controlled trials

Peter A Coventry, Joanna L Hudson, Evangelos Kontopantelis, Janine Archer, David A Richards, Simon Gilbody, Karina Lovell, Chris Dickens, Linda Gask, Waquas Waheed, Peter Bower, Peter A Coventry, Joanna L Hudson, Evangelos Kontopantelis, Janine Archer, David A Richards, Simon Gilbody, Karina Lovell, Chris Dickens, Linda Gask, Waquas Waheed, Peter Bower

Abstract

Background: Collaborative care is a complex intervention based on chronic disease management models and is effective in the management of depression. However, there is still uncertainty about which components of collaborative care are effective. We used meta-regression to identify factors in collaborative care associated with improvement in patient outcomes (depressive symptoms) and the process of care (use of anti-depressant medication).

Methods and findings: Systematic review with meta-regression. The Cochrane Collaboration Depression, Anxiety and Neurosis Group trials registers were searched from inception to 9th February 2012. An update was run in the CENTRAL trials database on 29th December 2013. Inclusion criteria were: randomised controlled trials of collaborative care for adults ≥18 years with a primary diagnosis of depression or mixed anxiety and depressive disorder. Random effects meta-regression was used to estimate regression coefficients with 95% confidence intervals (CIs) between study level covariates and depressive symptoms and relative risk (95% CI) and anti-depressant use. The association between anti-depressant use and improvement in depression was also explored. Seventy four trials were identified (85 comparisons, across 21,345 participants). Collaborative care that included psychological interventions predicted improvement in depression (β coefficient -0.11, 95% CI -0.20 to -0.01, p = 0.03). Systematic identification of patients (relative risk 1.43, 95% CI 1.12 to 1.81, p = 0.004) and the presence of a chronic physical condition (relative risk 1.32, 95% CI 1.05 to 1.65, p = 0.02) predicted use of anti-depressant medication.

Conclusion: Trials of collaborative care that included psychological treatment, with or without anti-depressant medication, appeared to improve depression more than those without psychological treatment. Trials that used systematic methods to identify patients with depression and also trials that included patients with a chronic physical condition reported improved use of anti-depressant medication. However, these findings are limited by the observational nature of meta-regression, incomplete data reporting, and the use of study aggregates.

Conflict of interest statement

Competing Interests: The authors have been/are involved in the conduct of trials of collaborative care in the United Kingdom funded by the Medical Research Council and the National Institute for Health Research. PC can confirm (on behalf of all authors) that the involvement of some of the study team in collaborative care trials funded by MRC/NIHR does not alter adherence to all PLOS ONE policies on sharing data and materials.

Figures

Figure 1. PRISMA Flow Diagram.
Figure 1. PRISMA Flow Diagram.

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