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Researchers examine efforts to improve primary care for depression

Despite the availability of effective treatments for depression, rates of appropriate treatment for depression remain low nationally, particularly in primary care, where only about one-fourth of depressed patients receive appropriate care. Primary care patients often resist psychiatric labeling and treatment, and primary care doctors typically have little training in depression care and may face barriers to referring patients to specialty mental health services.

Three recent studies on primary care for depression are summarized here, and all provide some indication that there is hope that the high rate of unmet need for depression treatment can be relieved. The first study demonstrates the effectiveness of quality improvement programs, even for depressed patients with comorbid medical illness; the second documents the effectiveness of guideline-concordant care; and the third shows that over time, primary care clinicians have gained increased confidence in their ability to provide such treatment.

All three studies were supported in part by the Agency for Healthcare Research and Quality. The first two studies (HS08349), which were led by Kenneth B. Wells, M.D., M.P.H., of RAND, examined the effects of two Partners in Care (PIC) quality improvement programs on primary care for depression. PIC was a randomized trial of practice-initiated QI interventions versus usual care and an observational study of outcomes of appropriate treatment. The third study (HS07649), which was led by Jonathan B. Brown, M.P.P., Ph.D., of the Kaiser Permanente Center for Health Research, examined primary care physicians' confidence in their ability to treat depression.

Koike, A.K., Unutzer, J., and Wells, K.B. (2002, October). "Improving the care for depression in patients with comorbid medical illness." American Journal of Psychiatry 159(10), pp. 1738-1745.

Patients who are depressed and have other medical problems such as severe headaches, arthritis, diabetes, or major paralysis, may have a more difficult time than other patients in dealing with their depression. The good news is that these patients can benefit from managed primary care quality improvement (QI) programs for depression that increase access to antidepressant medications and psychotherapy. However, they still are more likely to have a depressive disorder 6 and 12 months later than those who are depressed but do not have other illnesses. Care management programs that integrate the management of medical illnesses and depression may be an effective approach to treat depression in these complex patients, suggest the researchers.

They compared treatment and outcomes for 1,356 patients with mild to major depression from 46 managed primary care clinics and assessed the impact of two QI programs on their outcomes. They randomly assigned clinics to usual care or one of two QI programs for depression. Clinics in the usual care group received only written depression treatment guidelines by mail. Both QI programs included trained experts and nurse specialists to provide patient education and assessment; one also provided nurse specialists as case managers for medication followup, and the other had psychotherapists who offered individual or group cognitive behavior therapy at a reduced copayment rate. Patients in either QI program could choose treatment with antidepressant medication, psychotherapy, or no treatment.

At both 6 and 12 months, QI patients who were only depressed and depressed patients with other medical problems had less probable depressive disorders than similar usual care patients. Nevertheless, at 6 and 12 months, probable depressive disorders were significantly more likely in patients with one or more comorbid medical conditions (over 43 percent still had probable depressive disorder) than patients with depression only, even though there were no significant differences in antidepressant use or specialty counseling between the two groups.

Schoenbaum, M., Unutzer, J., McCaffrey, D., and others. (2002, October). "The effects of primary care depression treatment on patients' clinical status and employment." Health Services Research 37(5), pp. 1145-1158.

In this study, depressed primary care patients who received appropriate care for their depression were less likely to be depressed 6 months later and were more likely to be employed and have a better quality of life than depressed patients who didn't receive appropriate care. The investigators analyzed data from the PIC study on quality improvement for care of depressed primary care patients. The study included 938 adults with depressive disorder or with depressive symptoms and a lifetime history of major depression in 46 managed primary care clinics in five States. They examined the impact of appropriate depression care (that is, medication and/or psychotherapy) compared with no care or insufficient care on health outcomes and employment 6 months later.

Overall, 44 percent of patients received appropriate care during 6 months of followup. Patients in usual care practices were less likely than those in QI practices to have appropriate care. At 6 months, patients with appropriate care had lower rates of depressive disorder (24 vs. 70 percent), that is, they were less likely to still suffer from problems with sleep, fatigue, and weight; had better mental health-related quality of life; and had higher rates of employment (72 vs. 53 percent), compared with patients who did not receive appropriate care.

These findings inform public policy debates about the desirability of parity of coverage for mental health and physical health care by demonstrating the real-world effectiveness of appropriate depression care. The results of depression care on employment status may be particularly useful, since this outcome has not been examined in clinical trials. Strikingly, the estimated increase in employment due to treatment was very similar to the estimated decrease in employment due to depression reported in other studies.

Shye, D., Brown, J.B, Mullooly, J.P., and Nichols, G.A. (2002, November). "Understanding changes in primary care clinicians' satisfaction from depression care activities during adoption of selective serotonin reuptake inhibitors." American Journal of Managed Care 8(11), pp. 963-974.

A newer class of antidepressants, the selective serotonin reuptake inhibitors (SSRIs), first came into the U.S. market in 1988. They were shown to have fewer side effects and reduced risk of overdose compared with earlier antidepressants. They also were widely accepted by patients due to publicity centered on the effectiveness of Prozac and other drugs in this class. Adoption of SSRIs in a large HMO was associated with greater confidence by the HMO's primary care clinicians in their ability to successfully treat depression (especially using medication) and in their overall satisfaction from depression care activities, according to this study.

Using before and after surveys, the researchers prospectively studied change in 196 primary care clinicians' (internal medicine and family practice physicians, physician assistants, and nurse practitioners) level of satisfaction from treating depressed patients from mid-1993 to early 1995, the period when their HMO adopted use of SSRIs for primary care treatment of depression. The questionnaires addressed depression-related attitudes and self-reported practices (recognition of depression, feasibility of primary care treatment of depression, effectiveness of drug treatment, depression care self-efficacy perceptions, and depression care therapeutic activity levels).

Overall satisfaction showed a small (6 percent) but significant improvement over the study period. Satisfaction in 1995 was a function of improved perceptions about the feasibility of primary care treatment of depression (3.7 percent increase), which in turn, were related to improved perceptions about the effectiveness of drug treatment (7.3 percent increase). The significant (10 percent) decrease in self-reported referral activity levels was complemented by a 3.7 percent increase in reported treatment activity levels. This suggests that by 1995, clinicians were more willing to treat depressed patients themselves instead of referring them to mental health specialists.

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