Collaborative Care Shows No Added Benefit for OUD With Depression or PTSD
Key Clinical Summary
- In a pragmatic randomized trial of 797 adults with opioid use disorder (OUD) and co-occurring depression and/or posttraumatic stress disorder (PTSD), collaborative care did not outperform enhanced usual care (EUC) at 6 months.
- Primary outcomes (buprenorphine initiation, cumulative prescribing days, and mental health symptom scores) were not significantly different between groups.
- Both groups demonstrated clinical improvement over follow-up, suggesting potential spontaneous recovery or spillover effects in low-resource settings.
A collaborative care model tailored for low-resource primary care settings did not improve outcomes beyond enhanced usual care for adults with opioid use disorder (OUD) and co-occurring depression and/or posttraumatic stress disorder (PTSD), according to a randomized clinical trial published in JAMA Internal Medicine. The findings, drawn from the Collaboration Leading to Addiction Treatment and Recovery From Other Stresses (CLARO) pragmatic study, address a key evidence gap in integrated behavioral health care for clinically complex populations.
Study Findings
The 2-group, single-masked randomized clinical trial enrolled 797 adults with probable OUD and major depression and/or PTSD across 18 primary care clinics in California and New Mexico between January 2021 and December 2023. Participants were randomized to collaborative care (n=400) or enhanced usual care (EUC; n=397). The mean age was 40.2 years, and 54.3% were female.
The collaborative care intervention lasted 6 months and involved a community health worker care manager and an addiction psychiatrist working alongside a primary care practitioner. The team delivered evidence-based treatments for OUD, depression, and PTSD, monitored biopsychosocial symptoms, and facilitated referrals for psychotherapy.
Primary outcomes at 6 months included time to first filled buprenorphine prescription, cumulative days of prescribed buprenorphine, and changes in Patient Health Questionnaire-9 (PHQ-9) and PTSD Checklist for DSM-5 (PCL-5) scores. None of these outcomes differed significantly between groups. Adjusted mean differences for collaborative care versus EUC were 7.0 days for time to first buprenorphine prescription (P=0.19), 4.3 days for cumulative buprenorphine prescribing (P=0.47), −1.0 points on the PHQ-9 (P=0.13), and −0.9 points on the PCL-5 (P=0.63).
Secondary outcomes, including days of opioid and other drug use and health-related quality of life, also showed no between-group differences. However, both groups improved from baseline across multiple measures. Exploratory as-treated analyses suggested improvements in OUD outcomes among participants who engaged with treatment as delivered.
Clinical Implications
For clinicians caring for patients with OUD and co-occurring mental illness, these findings underscore the complexity of translating collaborative care models into low-resource primary care settings. While collaborative care is an evidence-based model for treating behavioral health conditions in primary care, its added value for OUD with psychiatric comorbidity may be limited when usual care is already enhanced.
Clinicians should consider whether intensive collaborative models are feasible and appropriately matched to patient needs and local resources. The results also highlight the importance of optimizing existing care pathways and ensuring access to evidence-based OUD treatments, regardless of care model.
Expert Commentary
“Before drawing conclusions, future research is needed to assess whether the lack of impact was due to the way collaborative care was tailored for patients with clinically complex issues and/or settings with few behavioral health resources, problems with implementation, and/or spillover or spontaneous improvement,” noted Katherine E. Watkins, MD, RAND, Santa Monica, California, and study coauthors. “In addition, how to provide psychotherapy in settings with few behavioral health practitioners remains an unanswered question.”
In this large randomized trial, collaborative care offered no clear advantage over enhanced usual care for adults with OUD and co-occurring depression or PTSD. The findings highlight the need to refine integrated care strategies and tailor interventions to real-world primary care contexts.
