Collaborative Care

img_0228Treating depression often works best with a team approach. In busy agencies, no one person has the time or expertise to do everything necessary for treating depression. For example, physicians are needed to write prescriptions for individuals who want to take medicines to improve their mood. Psychotherapists are necessary for those who want talk therapy to treat their depression. Both medicines and talk therapy are helpful for many people who are depressed.

Medicines and talk therapy are the cornerstone treatments for depression. However, a team beyond a physician and psychotherapist are often needed to make depression treatment really work. First, it is helpful to have someone to spend extra time with a depressed person to help her understand depression and treatments that can help. This often takes more time than a physician has in a busy schedule.

A service provider such as a nurse, social worker, case manager, or outreach worker can often spend time with a depressed person to teach about depression and depression treatment options, and to help her get an appointment with a physician or therapist. This same provider is also essential for following up with the person. Through a series of phone calls, this provider is often able to keep the depression treatment on track.

One other person is necessary for a team approach to depression treatment. A psychiatrist needs to be available to general physicians, nurses, or psychotherapists to help them care for clients who don’t respond to medication or psychotherapy within six to eight weeks. The psychiatrist might suggest other medicines or treatments and can be an important resource for helping those who don’t respond at first to depression treatment.

For depression treatment to be truly successful, a team approach is often best.

In the collaborative care model, the team is composed of a primary care provider, a therapist, a depression care manager, and a psychiatrist. Many different kinds of providers may play the care manager role and ensure that a client is connected with the other types of providers needed to treat depression within a single agency or across many agencies, through referrals.

Depression Care Managers

Care managers help clients take an active role in their own care and coordinate care with other providers to help manage their clients’ depression.

Tasks and activities for the depression care manger include:

  • Screening – using a tool to identify people with depression and stress
  • Education – providing and explaining materials about depression and stress
  • Help make and follow up on referrals if a client’s screening shows that they may have depression and stress. This involves using resource materials or existing referral processes at your agency
  • Provide support through behavioral activation and problem solving skills
  • Advocacy – promoting and encouraging positive health behaviors; possibly working closely with clinical care managers to check on client’s progress and coordinating care for patients
  • Follow-up – checking client progress and continue providing assistance to connect to services if needed, within the scope outlined by your organization

These activities may take place in settings such as clinics, churches, schools, and community centers.

Overall goals for the Care Manager:

  • Promote mental health and wellness of community-at-large
  • Reduce stigma of mental disorders and symptoms, and of seeking help
  • Reduce risk or severity of mental disorders among underserved clients
  • Assist in making and following up on referrals for treatment and care
  • Assist those who are experiencing stress to change the way they deal with problems and to help themselves
  • Strengthen ability of individuals to cope more effectively with stressful life situations
  • Provide outreach and care in a culturally competent/sensitive manner
  • Use knowledge of language, cultural practices, beliefs, etc., to structure plan of care and strengthen relationship with client

The care management toolkit contains a care management manual and forms to assist the depression care manager in coordination and in helping clients manage their depression.

Download Resource: Care Manager Toolkit

Primary Care Provider

Primary care providers are a diverse group of people including physicians, nurse practitioners, physician assistants, and nurses. In the collaborative care model, primary care providers may use the evaluation algorithm in the Clinician Toolkit for evaluating people with symptoms of depression. This algorithm takes account of the wide variety of comorbidities and diagnoses in individuals presenting symptoms of depression. The algorithm helps providers to manage depressed patients efficiently while staying focused on the main therapeutic problems of treating major depression and dysthymia.

Tasks and activities of the primary care provider treating depression in the collaborative care model include:

  • Assess patient/client screened positive for potential depression
  • Reduce severity of depression by treatment, medication, referrals
  • Provide care in a culturally competent/sensitive manner
  • Strengthen ability of patient/client to cope more effectively
  • Communicate patient/client status to case manager for appropriate follow-up

Download Resource: Clinician Toolkit


The providers implementing collaborative care for depression benefit from consultation with a psychiatrist. A psychiatrist can help primary care providers, care managers, and therapists when clients don’t seem to respond to treatment

Tasks and activities include:

  • Oversee medication management
  • Provide educational sessions and consultations to primary care providers and therapists
  • Provide antidepressant prescription if requested by a client’s primary care provider
  • Have in-person consultations with clients if necessary
  • Respond to emergency situations with clients
  • Make treatment plans for clients with co-morbid depression and anxiety disorders

Download Resource: Therapist Toolkit


Therapists will learn more about or Cognitive Behavioral Therapy (CBT) for depression. Talk therapy has been shown to improve depression, particularly CBT. Therapists will hold individual and group CBT sessions for depressed clients.

Therapist tasks and activities in CPIC also include:

  • Reduce stigma of depression and of seeking help
  • Reduce risk or severity of depression through treatment and referrals
  • Strengthen ability of patient/client to cope more effectively
  • Provide care in a culturally competent/sensitive manner
  • Complete contact reports and monitor outcomes
  • Using contact reports, provide the Council with aggregated client outcome data
  • Improve care for depression utilizing available unit/site resources

Download Resources:
Therapist Toolkit
Bright SA Manual