Primary care depression treatment often does not follow quality guidelines

Most patients with depression who are treated by primary care physicians do not receive care consistent with quality standards, according to a new RAND Corporation study.

Physicians had high rates of adherence to just one third of the 20 measures of quality that researchers examined and had low rates of adherence to nearly half of the treatment recommendations studied, according to the report in the September 4 edition of the Annals of Internal Medicine.

"These findings are important for patients since most cases of depression are diagnosed and treated in primary care settings," said senior author Dr. Lisa V. Rubenstein, the study's senior author, and a senior scientist at RAND, a nonprofit research organization, and a physician at the Veterans Affairs Greater Los Angeles Healthcare System. "This shows that additional efforts are needed to improve the treatment of depression."

The study also found that patients who received better-quality care reported fewer symptoms of depression up to two years after the start of treatment. The findings are among the first linking quality guidelines for depression treatment with improved patient outcomes in community settings.

"These are initial findings, but they suggest that programs that encourage doctors to follow treatment guidelines can help improve the long-term outlook for people with depression," said Rubenstein, who also is affiliated with the David Geffen School of Medicine at UCLA.

Previous studies have shown that primary care providers do a poor job following guidelines for antidepressant use or psychotherapy. The RAND study is one of the first to assess primary care providers' adherence to a comprehensive set of treatment guidelines for depression.

Researchers from RAND Health examined the experiences of health care providers and patients who took part from 1996 to 1998 in the Quality Improvement for Depression collaboration, which was designed to encourage primary care providers to adopt comprehensive depression treatment guidelines developed by the U.S. Agency for Healthcare Research and Quality.

The RAND study examined the experiences of 1,131 patients with depression who were treated in 45 primary care practices across 13 states. Study sites ranged from small private practices to large managed care organizations. About 10 percent of patients in the study were from Veterans Affairs practices.

Researchers examined whether physicians and other health providers followed 20 different measures of quality, as well as analyzing patients' reports about the status of their depression at 12, 18 and 24 months after starting treatment.

The study found that most primary care physicians did a good job of diagnosing and beginning treatment for depression, with guidelines aimed at these issues followed more than 70 percent of the time. These guidelines includes items such as talking to patients about depression and closely monitoring patients newly placed on antidepressant medication.

But researchers found that primary care clinicians did less well following up with treatment over time. Fewer than half of the patients in the study completed the minimal course of treatment for either antidepressant drugs or psychotherapy, and only slightly more than half the depressed patients who were not treated were monitored closely.

The lowest quality of care occurred among the patients who exhibited the most serious symptoms, including patients who showed evidence of suicide or substance abuse. For example, among patients who had a previous suicide attempt, just 35 percent were referred to a mental health specialist over the next six months

"Primary care physicians were good at diagnosing depression, but they did not do as good a good job of managing the sickest patients," Rubenstein said. "Right now, primary care physicians don't have the tools necessary to decide which patients to treat and which to refer on to specialized mental health care."

Receiving higher quality care did not appear to significantly impact the long-term functioning of less-sick patients, according to the study. But sicker patients who received better quality care were significantly less likely to report continuing symptoms of depression on surveys taken up to two years after their treatment began.

"For the people who were sicker, there was a closer relationship between quality and their symptoms over the long term," Rubenstein said. "This is among the first evidence that following treatment guidelines can help patients over the long term."