Managed care, access to mental health specialists, and outcomes among primary care patients with depressive symptoms

OBJECTIVE: To determine whether managed care is associated with reduced access to mental health specialists and worse outcomes among primary care patients with depressive symptoms. DESIGN: Prospective cohort study. SETTING: Offices of 261 primary physicians in private practice in Seattle. PATIENTS: Patients (N = 17,187) were screened in waiting rooms, enrolling 1,336 adults with depressive symptoms. Patients (n = 942) completed follow-up surveys at 1, 3, and 6 months. MEASUREMENTS AND RESULTS: For each patient, the intensity of managed care was measured by the managedness of the patient's health plan, plan benefit indexes, presence or absence of a mental health carve-out, intensity of managed care in the patient's primary care office, physician financial incentives, and whether the physician read or used depression guidelines. Access measures were referral and actually seeing a mental health specialist. Outcomes were the Symptom Checklist for Depression, restricted activity days, and patient rating of care from primary physician. Approximately 23% of patients were referred to mental health specialists, and 38% saw a mental health specialist with or without referral. Managed care generally was not associated with a reduced likelihood of referral or seeing a mental health specialist. Patients in more-managed plans were less likely to be referred to a psychiatrist. Among low-income patients, a physician financial withhold for referral was associated with fewer mental health referrals. A physician productivity bonus was associated with greater access to mental health specialists. Depressive symptom and restricted activity day outcomes in more-managed health plans and offices were similar to or better than less-managed settings. Patients in more-managed offices had lower ratings of care from their primary physicians. CONCLUSIONS: The intensity of managed care was generally not associated with access to mental health specialists. The small number of managed care strategies associated with reduced access were offset by other strategies associated with increased access. Consequently, no adverse health outcomes were detected, but lower patient ratings of care provided by their primary physicians were found.     

Quality of care and outcomes of adults with asthma treated by specialists and generalists in managed care.

BACKGROUND: The growth of managed health care in the United States has been accompanied by controls on access to specialty physician services. We examined the relationship of physician specialty to treatment and outcomes of patients with asthma in managed care plans. METHODS: We conducted a mail survey of adult asthma patients who were enrolled in 12 managed care organizations and had at least 2 contacts for asthma (International Classification of Diseases, Ninth Revision, Clinical Modification code 493.x) during the previous 24 months; we also surveyed their treating physicians. This report concerns 1954 patients and their 1078 corresponding physicians. Treatment indicators included use of corticosteroid inhalers, use of peak flow meters, allergy evaluation, discussion of triggers, and patient self-management knowledge. Outcome measures included canceled activities, hospitalization or emergency department visits, asthma attacks, workdays lost, asthma symptoms, physical and mental health, overall satisfaction with asthma care, and satisfaction with communication with physicians and nurses. RESULTS: Significant differences were noted for patients of specialists and experienced generalists compared with those of generalist physicians. Peak flow meter possession was reported by 41.9% of patients of generalists, 51.7% of patients of experienced generalists, and 53.8% of patients of pulmonologists or allergists. Compared with patients of generalists, outcomes were significantly better for patients of allergists with regard to canceled activities, hospitalizations and emergency department visits for asthma, quality of care ratings, and physical functioning. Patients of pulmonologists were more likely to rate improvement in symptoms as very good or excellent. CONCLUSIONS: In a managed health care setting, physicians' specialty training and self-reported expertise in treating asthma were related to better patient-reported care and outcomes.     

Managed care, professional autonomy, and income

CONTEXT: Career satisfaction among physicians is a topic of importance to physicians in practice, physicians in training, health system administrators, physician organization executives, and consumers. The level of career satisfaction derived by physicians from their work is a basic yet essential element in the functioning of the health care system. OBJECTIVE: To examine the degree to which professional autonomy, compensation, and managed care are determinants of career satisfaction among physicians. DESIGN: Cross-sectional analysis using data from 1996-97 Community Tracking Study physician telephone survey. SETTING AND PARTICIPANTS: A nationally representative sample of 12,385 direct patient care physicians. The survey response rate was 65%. MAIN OUTCOME MEASURE: Overall career satisfaction among U.S. physicians. RESULTS: Bivariate results show that physicians with low managed care revenues are significantly more likely to be "very satisfied" than are physicians with high managed care revenue (P < .05), and that physicians with low managed care revenues are significantly more likely to report higher levels of clinical freedom than are physicians with high managed care revenue (P < .05). Multivariate analyses demonstrate that, among our measures, traditional core professional values and autonomy are the most important determinants of career satisfaction after controlling for all other factors. Relative income is also an important independent predictor. Multiple dimensions of professional autonomy hold up as strong, independent predictors of career satisfaction, while the effect of managed care does not. Managed care appears to exert its effect on satisfaction through its impact on professional autonomy, not through income reduction. CONCLUSIONS: Our results suggest that when managed care (or other influences) erode professional autonomy, the result is a highly negative impact on physician career satisfaction.     

Screening for depression in patients in long-term care facilities: a randomized controlled trial of physician response

OBJECTIVES: To determine the effect of a screening protocol using the Geriatric Depression Scale (GDS) on the frequency of primary care physicians' decisions to prescribe drug therapy or refer long-term care patients with possible depression to mental health care. DESIGN: Case-finding phase, followed by a randomized controlled trial of the effect of a physician-targeted intervention on antidepressant prescribing or referral to mental health services. SETTING: Twenty-two nonacademic long-term care facilities. PARTICIPANTS: One hundred three of 1,602 patients aged 65 and older who met criteria for cognitive function and untreated symptoms of depression. INTERVENTION: The 77 physicians of these patients were randomized as clusters into an early notification (experimental) or a delayed notification (control) group. MEASUREMENTS: Frequency of physician response (mental health consult or antidepressant therapy) at 4 and 8 weeks from notification, physician follow-up, and factors associated with physician response. RESULTS: Frequency of physician response in the early group (25%) was greater than in the delayed group (2%) (P <.005) 4 weeks from baseline. Physician response rate when the groups were combined was 36% (95% confidence interval (CI) = 26%-46%) 8 weeks from notification. Overall, there was evidence of physician action after letters of notification in 69% (95% CI = 60%-78%) of cases. Univariate logistic regression suggested that physicians' decisions were primarily associated with physician-related characteristics. CONCLUSIONS: Screening of long-term care patients for depression can increase the frequency of treatment or referral by primary care physicians.     

Behind closed doors: management of patient expectations in primary care practices

BACKGROUND: Managed care restrictions on resource use may affect communication between patients and health care professionals. METHODS: To characterize negotiations between primary care physicians and patients with expectations for new medications, tests, or referrals, this observational study combined survey data with audiotape recordings of clinical encounters. Fifty-five physicians from 20 randomly selected primary care practices in a managed care network and 211 patients who voiced specific expectations in a previsit survey were included. From the recorded clinic visits we determined modes of negotiation of patient expectations and requests. From the surveys we determined patient previsit expectations, postvisit fulfillment of expectations, satisfaction, and trust. RESULTS: Two-hundred fifty-six self-reported expectations were captured in 200 audiotape-recorded encounters. Of the previsit expectations, 97.3% were discussed during the encounter. Expectations were expressed by direct patient request (40.6%), mentioning of symptoms related to request (29.7%), or physician-initiated discussion (27.0%). Most expectations were met (66.8%); physicians suggested an alternative 21.6% of the time. Expectations for medications and tests were met more frequently than expectations for referrals (75.6% and 71.4% vs 40.8%). Patient satisfaction and trust remained high regardless of whether expectations were met. Physicians reported that they would not have ordered 62 (44.9%) of 138 requests had the patients not directly asked, and they were uncomfortable filling 8 requests (12.9%). CONCLUSIONS: Previsit expectations for medications, tests, or referrals were discussed at the visit, and physicians met or offered alternatives for nearly 90%. Patients generally received what they asked for and altered physician behavior nearly half of the time.     

Physician perceptions of HMO care for older persons. Health Maintenance Organization

OBJECTIVE: Physician attitudes may be a key factor in effective managed care for older patients. We sought to explore physicians' views of the influence of health maintenance organization (HMO) policies on the care of their older patients. DESIGN: A self-administered one-page questionnaire consisting of questions about physician demographics, the impact of HMOs on physician practice, patient care, HMO policies, and respondents' personal use of managed health care plans. PARTICIPANTS: The survey was mailed to 838 randomly selected primary care physicians affiliated with two large, nonprofit, academically-oriented, Medicare HMOs in Massachusetts. RESULTS: Completed surveys were received from 516 of 797 eligible primary care physicians, affiliated with either Secure Horizons (Tufts Associated Health Plan) or First Seniority (Harvard Pilgrim Health Care). About half (55%) of the physician respondents reported they had sufficient time to spend with their older patients. Most (81%) respondents indicated that overall, patients aged 65 and older received either better care or no change in care after joining an HMO. The majority of physicians reported that HMO affiliation had increased the frequency with which they addressed geriatric issues with their older patients. There were several patterns of response that emerged with respect to beliefs about key HMO policies. CONCLUSIONS: The majority of physicians working in two nonprofit, academically oriented Medicare HMOs in Massachusetts believed that the overall quality of care that older patients received after joining an HMO either did not change or improved.     

Variation in the tendency of primary care physicians to intervene

BACKGROUND: Research has documented dramatic variation in health care spending across the United States that has little relationship to health outcomes. Although high-spending areas have more physicians per capita, it is not known whether this disparity fully explains the differences in spending or whether individual physicians in high-spending regions have a greater tendency to intervene for their patients. We sought to measure the tendency of primary care physicians to intervene across regions that differ in their levels of local health care spending. METHODS: We used data from the Community Tracking Study Physician Survey, a telephone survey of a nationally representative sample of 5490 primary care physicians who provided care to adults in 1998-1999 (response rate 59%). Local health care spending in physicians' communities was determined by assigning each participating physician to 1 of 306 US hospital referral regions. The tendency of physicians to intervene was measured by evaluating their responses to 6 clinical vignettes in which they were asked how often they would order a test, referral, or treatment for the patient described. RESULTS: In 5 of the 6 vignettes, physicians in high-spending regions were more likely to recommend interventions than those practicing in low-spending regions. For example, for a 35-year-old man with back pain and foot drop, physicians in high-spending regions would recommend magnetic resonance imaging 82% of the time, compared with 69% for physicians in low-spending regions (P<.001). For a 60-year-old man somewhat bothered by symptoms of benign prostatic hypertrophy, physicians in high-spending regions would make a urology referral 32% of the time, while those in low-spending regions would do so only 23% of the time (P<.001). Our findings that physicians in high-spending regions have a greater tendency to intervene persisted in analyses stratified by physician specialty (family/general practice vs internal medicine). CONCLUSION: Varying rates of health care spending across the United States reflect the underlying tendency of local physicians to recommend interventions for their patients.     

Long-term effects of a collaborative care intervention in persistently depressed primary care patients

OBJECTIVE: A previous study described the effect of a collaborative care intervention on improving adherence to antidepressant medications and depressive and functional outcomes of patients with persistent depressive symptoms 8 weeks after the primary care physician initiated treatment. This paper examined the 28-month effect of this intervention on adherence, depressive symptoms, functioning, and health care costs. DESIGN: Randomized trial of stepped collaborative care intervention versus usual care. SETTING: HMO in Seattle, Wash. PATIENTS: Patients with major depression were stratified into severe and moderate depression groups prior to randomization. INTERVENTIONS: A multifaceted intervention targeting patient, physician, and process of care, using collaborative management by a psychiatrist and a primary care physician. MEASURES AND MAIN RESULTS: The collaborative care intervention was associated with continued improvement in depressive symptoms at 28 months in patients in the moderate-severity group (F1,87 = 8.65; P =.004), but not in patients in the high-severity group (F1,51 = 0.02; P =.88) Improvements in the intervention group in antidepressant adherence were found to occur for the first 6 months (chi2(1) = 8.23; P <.01) and second 6-month period (chi2(1) = 5.98; P <.05) after randomization in the high-severity group and for 6 months after randomization in the moderate-severity group(chi2(1) = 6.10; P <.05). There were no significant differences in total ambulatory costs between intervention and control patients over the 28-month period (F1,180 = 0.77; P =.40). CONCLUSIONS: A collaborative care intervention was associated with sustained improvement in depressive outcomes without additional health care costs in approximately two thirds of primary care patients with persistent depressive symptoms.     

Physician job satisfaction

The purpose of this study was to develop a current and comprehensive model of physician job satisfaction. Information was gathered by [1] analysis of open-ended responses from a large group practice physician survey in 1988, and (2) analysis of focus group data of diverse physician subgroups from 1995. Participants were 302 physicians from large-group practices and 26 participants in six focus groups of HMO, women, minority, and inner-city physicians. Data were used to develop a comprehensive model of physician job satisfaction. The large group practice survey data supported the key importance of day-to-day practice environment and relationships with patients and physician peers. Future concerns focused on the effect of managed care on the physician-patient relationship and the ability of physicians to provide quality care. Focus groups provided contemporary data on physician job satisfaction, reinforcing the centrality of relationships as well as special issues for diverse physician subgroups of practicing physicians. New variables that relate to physician job satisfaction have emerged from economic and organizational changes in medicine and from increasing heterogeneity of physicians with respect to gender, ethnicity, and type of practice. A more comprehensive model of physician job satisfaction may enable individual physicians and health care organizations to better understand and improve physician work life.     

Physician follow-up visits after acute care hospitalization for elderly Medicare beneficiaries discharged to noninstitutional settings

The purpose of this study was to assess the effect of posthospital physician follow-up on readmissions in older adults. Physician follow-up visits after discharge have been promoted as a way to improve outcomes and reduce readmissions, but the evidence base for this recommendation is limited. A retrospective analysis of data from the Medicare Current Beneficiary Survey (MCBS) was conducted for 2001 to 2003. Data were extracted on elderly Medicare beneficiaries with an index hospitalization in 2002, and physician follow-up visits and readmissions within 90 days of discharge were identified. Analysis was conducted with multivariable logistic regression modeling to assess the independent effect on 90-day readmission of any physician follow-up, timing of physician follow-up, and follow-up with only primary care physicians. A generalized linear model was used to assess the effect of physician follow-up on total health expenditures. The analytical sample included 326 beneficiaries; 79% had a physician follow-up visit within 90 days, and 28% were readmitted within 90 days. In multivariable modeling, physician follow-up was negatively associated with 90-day readmissions (odds ratio=0.23, 95% confidence interval=0.13-0.43). Follow-up visits were protective against readmissions regardless of timing of visit and when restricted to those by primary care physicians. Having a follow-up visit was associated with approximately $10,000 lower annual health expenditures. In conclusion, physician follow-up protects against readmission after adjusting for important covariates and is associated with significantly lower expenditures. Future efforts should ensure that patients have adequate physician follow-up.     

Unmet expectations for care and the patient-physician relationship

OBJECTIVE: To profile patients likely to have unmet expectations for care, examine the effects of such expectations, and investigate how physicians' responses to patients' requests affect the development of unfulfilled expectations. DESIGN: Patient and physician questionnaires were administered before and after outpatient visits. A follow-up telephone survey was administered 2 weeks post visit. SETTING: The offices of 45 family practice, internal medicine, and cardiology physicians. PATIENTS: Nine hundred nine adults reporting a health problem or concern. MEASUREMENTS AND MAIN RESULTS: Before their visits, patients rated their general health and trust in the index physician. After the visit, patients reported upon 8 types of unmet expectations and any request they made. Two weeks thereafter, patients rated their visit satisfaction, improvement, and intention to adhere to the physician's advice. They also reported any postvisit health system contacts. Overall, 11.6% of patients reported >/=1 unmet expectation. Visits in which a patient held an unmet expectation were rated by physicians as less satisfying and more effortful. At follow-up, patients who perceived an unmet expectation for care also reported less satisfaction with their visits, less improvement, and weaker intentions to adhere. Patients with an unmet expectation related to clinical resource allocation had more postvisit health system contacts. Unmet expectations were typically reported by a patient whose request for a resource was not fulfilled. CONCLUSIONS: Unmet expectations adversely affect patients and physicians alike. Physicians' nonfulfillment of patients' requests plays a significant role in patients' beliefs that their physicians did not meet their expectations for care.     

Does physician gender affect satisfaction of men and women visiting the emergency department?

OBJECTIVE: To assess the association of physician gender with patient ratings of physician care. DESIGN: Interviewer-administered survey and follow-up interviews 1 week after emergency department (ED) visit. SETTING: Public hospital ED. PATIENTS/PARTICIPANTS: English- and Spanish-speaking adults presenting for care of nonemergent problems; of 852 patients interviewed in the ED who were eligible for follow-up, 727 (85%) completed a second interview. MEASUREMENTS AND MAIN RESULTS: We conducted separate ordered logistic regressions for women and men to determine the unique association of physician gender with patient ratings of 5 interpersonal aspects of care, their trust of the physician, and their overall ratings of the physician, controlling for patient age, health status, language and interpreter status, literacy level, and expected satisfaction. Female patients trusted female physicians more (P =.003) than male physicians and rated female physicians more positively on the amount of time spent (P =.01), on concern shown (P =.04), and overall (P =.03). Differences in ratings by female patients of male and female physicians in terms of friendliness (P =.13), respect shown (P =.74), and the extent to which the physician made them feel comfortable (P =.10) did not differ significantly. Male patients rated male and female physicians similarly on all dimensions of care (overall, P =.74; friendliness, P =.75; time spent, P =.30; concern shown, P =.62; making them feel comfortable, P =.75; respect shown, P =.13; trust, P =.92). CONCLUSIONS: Having a female physician was positively associated with women's satisfaction, but physician gender was not associated with men's satisfaction. Further studies are needed to identify reasons for physician gender differences in interpersonal care delivered to women. KEY WORDS: patient satisfaction; gender; physician-patient relations; delivery of care; health care quality.     

Setting the revisit interval in primary care

OBJECTIVE: Although longitudinal care constitutes the bulk of primary care, physicians receive little guidance on the fundamental question of how to time follow-up visits. We sought to identify important predictors of the revisit interval and to describe the variability in how physicians set these intervals when caring for patients with common medical conditions. DESIGN: Cross-sectional survey of physicians performed at the end of office visits for consecutive patients with hypertension, angina, diabetes, or musculoskeletal pain. PARTICIPANTS/SETTING: One hundred sixty-four patients under the care of 11 primary care physicians in the Dartmouth Primary Care Cooperative Research Network. MEASUREMENTS: The main outcome measures were the variability in mean revisit intervals across physicians and the proportion of explained variance by potential determinants of revisit intervals. We assessed the relation between the revisit interval (dependent variable) and three groups of independent variables, patient characteristics (e.g., age, physician perception of patient health), identification of individual physician, and physician characterization of the visit (e. g., routine visit, visit requiring a change in management, or visit occurring on a "hectic" day), using multiple regression that accounted for the natural grouping of patients within physician. MAIN RESULTS: Revisit intervals ranged from 1 week to over 1 year. The most common intervals were 12 and 16 weeks. Physicians' perception of fair-poor health status and visits involving a change in management were most strongly related to shorter revisit intervals. In multivariate analyses, patient characteristics explained about 18% of the variance in revisit intervals, and adding identification of the individual provider doubled the explained variance to about 40%. Physician characterization of the visit increased explained variance to 57%. The average revisit interval adjusted for patient characteristics for each of the 11 physicians varied from 4 to 20 weeks. Although all physicians lengthened revisit intervals for routine visits and shortened them when changing management, the relative ranking of mean revisit intervals for each physician changed little for different visit characterizations-some physicians were consistently long and others were consistently short. CONCLUSION: Physicians vary widely in their recommendations for office revisits. Patient factors accounted for only a small part of this variation. Although physicians responded to visits in predictable ways, each physician appeared to have a unique set point for the length of the revisits interval.     

Depression and panic disorder as predictors of health outcomes for patients with asthma in primary care

INTRODUCTION: Depression and panic disorder are widely acknowledged as complicating factors in asthma patients. However, their impact on health outcomes in primary care patients is less well examined. This study prospectively evaluated the impact of depression and panic disorder on outcomes of primary care patients with asthma over 1 year. METHODS: At baseline, 256 asthma patients from 43 primary care practices completed self-report questionnaires including the Patient Health Questionnaire (PHQ), the Asthma Quality of Life Questionnaire (AQLQ), and a structured questionnaire evaluating asthma severity, hospitalisation and emergency visits. One year later, 185 (72.3%) patients completed the same questionnaire. RESULTS: At baseline, 3.9% of patients suffered from major depressive disorder, 22.7% from minor depressive disorder, and 7.8% from panic disorder. In the year under evaluation, 17 patients (9.2%) received emergency home visits and 10 patients (5.4%) were admitted to a hospital. Depression at baseline predicted hospitalisation within the subsequent year (OR 6.1; 95% CI 1.5-24.6) and panic disorder predicted unscheduled emergency home visits (OR 4.8; 95% CI 1.3-17.7). Depression but not panic disorder predicted the AQLQ scales activity (p=0.001), symptoms (p=0.001), emotions (p=0.001) and environment (p=0.001) at follow-up. CONCLUSIONS: Although rates of hospitalisation and emergency visits in primary care are low, the impact of psychiatric comorbidity on health outcomes for patients with asthma is substantial. It might be helpful to identify patients with psychiatric comorbidity by analysing reasons for hospitalisation and emergency visits. For these patients, intensifying care with psychiatric interventions might help to reduce inappropriate healthcare utilisation and avoid adverse outcomes.     

Patient–Physician Communication in the Primary Care Visits of African Americans and Whites with Depression

Background Little research investigates the role of patient–physician communication in understanding racial disparities in depression treatment. Objective The objective of this study was to compare patient–physician communication patterns for African-American and white patients who have high levels of depressive symptoms. Design, Setting, and Participants This is a cross-sectional study of primary care visits of 108 adult patients (46 white, 62 African American) who had depressive symptoms measured by the Medical Outcomes Study–Short Form (SF-12) Mental Component Summary Score and were receiving care from one of 54 physicians in urban community-based practices. Main Outcomes Communication behaviors, obtained from coding of audiotapes, and physician perceptions of patients’ physical and emotional health status and stress levels were measured by post-visit surveys. Results African-American patients had fewer years of education and reported poorer physical health than whites. There were no racial differences in the level of depressive symptoms. Depression communication occurred in only 34% of visits. The average number of depression-related statements was much lower in the visits of African-American than white patients (10.8 vs. 38.4 statements, p = .02). African-American patients also experienced visits with less rapport building (20.7 vs. 29.7 statements, p = .009). Physicians rated a higher percentage of African-American than white patients as being in poor or fair physical health (69% vs. 40%, p = .006), and even in visits where depression communication occurred, a lower percentage of African-American than white patients were considered by their physicians to have significant emotional distress (67% vs. 93%, p = .07). Conclusions This study reveals racial disparities in communication among primary care patients with high levels of depressive symptoms. Physician communication skills training programs that emphasize recognition and rapport building may help reduce racial disparities in depression care.     

Family support, living alone, and subjective health of a patient in connection with a coronary artery bypass surgery

OBJECTIVE: The study's objective was to evaluate the connections among family support, living alone, and subjective health after coronary artery bypass surgery (CABS). DESIGN: This was a prospective and comparative follow-up study. SETTING: The study took place in surgical clinics in two university hospitals in Finland. PATIENTS: A total of 279 patients underwent CABS. The sample comprised consecutive patients who were willing to participate. INTERVENTION: The patients were asked to evaluate their subjective health before surgery (initial phase) and 6 months after surgery (follow-up phase). OUTCOME MEASURES: Outcome was measured by the Chest Pain and Dyspnea Scale, Modified Beck Depression Inventory, Endler Anxiety Scale, Family Support Scale, and Hopelessness items. RESULTS: Subjective health improved significantly after CABS. Those who had lower family support before surgery had more depressive symptoms, anxiety, and hopelessness than those who had more support. In the group with low family support, the subjective health of women was poorer than that of men, and those who had no vocational education described poorer health than others. In the group with high family support, those who had no vocational education had more chest pain and dyspnea than others. Patients who were living alone had initially more depressive symptoms and hopelessness compared with patients living with someone. At follow-up, those living alone reported more chest pain and depressive symptoms than those living with someone. Patients aged less than 65 years and living alone reported more depressive symptoms, anxiety, and hopelessness than the oldest age group during the follow-up. In those patients living with someone, the subjective health of female patients, patients aged less than 65 years, and patients who had no vocational education was poorer than others. CONCLUSIONS: High family support seemed to protect health and promote recovery. In nursing it is important to take care of those who receive only limited amount of family support or who live alone. These results suggest that women, patients aged less than 65 years, and patients with no vocational education may need additional support and care.     

Improving depression care in patients with diabetes and multiple complications

BACKGROUND: Depression is common in patients with diabetes, but it is often inadequately treated within primary care. Competing clinical demands and treatment resistance may make it especially difficult to improve depressive symptoms in patients with diabetes who have multiple complications. OBJECTIVE: To determine whether a collaborative care intervention for depression would be as effective in patients with diabetes who had 2 or more complications as in patients with diabetes who had fewer complications. DESIGN: The Pathways Study was a randomized control trial comparing collaborative care case management for depression and usual primary care. This secondary analysis compared outcomes in patients with 2 or more complications to patients with fewer complications. PATIENTS: Three hundred and twenty-nine patients with diabetes and comorbid depression were recruited through primary care clinics of a large prepaid health plan. MEASUREMENTS: Depression was assessed at baseline, 3, 6, and 12 months with the 20-item depression scale from the Hopkins Symptom Checklist. Diabetes complications were determined from automated patient records. RESULTS: The Pathways collaborative care intervention was significantly more successful at reducing depressive symptoms than usual primary care in patients with diabetes who had 2 or more complications. Patients with fewer than 2 complications experienced similar reductions in depressive symptoms in both intervention and usual care. CONCLUSION: Patients with depression and diabetes who have multiple complications may benefit most from collaborative care for depression. These findings suggest that with appropriate intervention depression can be successfully treated in patients with diabetes who have the highest severity of medical problems.