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Depression is often a recurrent or persistent disorder. Since the majority of depressed patients are treated in primary care, it is clear that to improve long-term outcomes more effective treatments in this setting are needed. The goal of this study was to review the strategies used for improvement of routine treatment in terms of their effects on patient outcome. Methods: We conducted a systematic literature search to identify improvement strategies tested in randomized controlled trials in primary care, reporting at least six months effects on depression course and outcome. Results: Four strategies were identified: (1) training primary care physicians (PCPs) - this appears ineffective (2) supporting PCPs by other professionals - this produces better short term outcomes but does not prevent recurrence (3) organisational quality improvement - this shows improved outcomes at 6 months, and there is some evidence of longer term effectiveness; and (4) recurrence - and chronicity prevention strategies - these have not been shown to be effective. Conclusion: Since effects of the reviewed strategies generally do not seem to persist over time and no clear superiority over usual care has been demonstrated, we conclude that for improving long-term outcome of depression in primary care new directions or even a novel paradigm is needed.
