Despite the development of cost-effective evidence-based models for treating depression in primary care, economic and organizational barriers often impede sustainability in routine clinical practice. Under the Depression in Primary Care: Linking Clinical and System Strategies program, the Robert Wood Johnson Foundation (RWJF) funded eight demonstration grants to implement clinical changes in depression care alongside changes in contractual relationships, payment methods and other economic arrangements. The preceding articles summarize the specific economic and organizational changes implemented under four of these demonstration projects. This commentary highlights certain elements that appear critical to successfully re-align system incentives to support evidence-based depression care based in part on the experiences of these four sites.