Primary Care Docs Show Mixed Results in Adhering to Depression Guidelines

A new study published in the Sept. 4 issue of Annals of Internal Medicine shows that although primary care physicians do a good job of adhering to some clinical guideline recommendations on depression, there still is room for improvement. Of 20 depression care quality measures the researchers examined, primary care physicians achieved high rates of adherence to slightly less than one-third; they demonstrated low rates of adherence to almost half of the measures.

Researchers in the study identified 20 quality-based indicators derived from depression care guidelines developed by the Agency for Healthcare Research and Quality to use in a secondary analysis of data collected through the Quality Improvement for Depression collaboration from 1996-98. Those quality indicators were applied to data from surveys of 1,131 patients from 45 primary care practices in 13 states. The practices included a multistate family practice network, two staff-model managed care organizations, and a network-model managed care organization whose patients were cared for in private practices.

Overall, the researchers found that primary care physicians do a good job of recognizing and monitoring depression in their patients for a period of several months. Participating clinicians excelled in adhering to guidelines on disseminating basic patient education, with patients receiving some form of education about depression 100 percent of the time in the practices studied. Treatments, when initiated, generally were in line with patients' needs and preferences. Primary care physicians followed up with most depressed patients on at least two occasions in the six months following the diagnosis, and patients with newly started antidepressant therapy were followed by the primary care physician or a mental health specialist at least three times in six months. Most patients who had symptoms of anxiety or panic received appropriate antidepressant therapy or psychotherapy, and most clinicians did not start long-term benzodiazepine therapy.

Primary care physicians did less well on other aspects of depression care. Only 45 percent to 59 percent of clinicians appropriately followed clinical quality indicators for treatment during the six months after the initial diagnosis. Only about 46 percent of patients completed minimum treatment with antidepressants (at least two months) or psychotherapy (at least four visits). This rate was slightly higher (51 percent) when researchers considered only patients who were amenable to receiving treatment.

About 59 percent of clinicians whose patients had completed treatment successfully and in whom symptoms had resolved followed up by discussing depression with those patients during the succeeding six months. About 47 percent of clinicians caring for patients with depression who were not treated did not monitor them closely. About 55 percent of the time, primary care clinicians did not try to discontinue antidepressant therapy in patients whose depression had resolved after appropriate treatment and who were at low risk for recurrence.

Treatment guidelines that were followed least often (23 percent to 38 percent of the time) included those pertaining to treatment adjustment in patients who did not respond during the first six months of therapy and those that involved managing suicidality, comorbid conditions and depression in elderly patients. Only 38 percent of clinicians who had patients who remained depressed at six months adjusted treatment. Only 26 percent of clinicians caring for elderly depressed patients ensured that those patients completed a minimal course of appropriate treatment.

The study researchers included three indicators for suicidality management, and on all three, clinicians participating in the study were found lacking. Only 24 percent of clinicians assessed suicidality, 26 percent treated suicidal patients with appropriate medications or psychotherapy, and 36 percent ensured patients with suicidal ideation received consultation with mental health specialists. Of 144 patients who had made a previous suicide attempt or who had some indication of a suicide plan, only 51 (35 percent) saw any mental health specialist during the succeeding six months.

In addition, only 23 percent of clinicians assessed alcohol use in patients with depression, and only 30 percent of clinicians recommended consultation with a mental health specialist for patients who had panic episodes or who abused alcohol and remained depressed at six months.

To determine whether compliance with guidelines actually helps patients who experience depression, the researchers interviewed those patients who said they received either higher or lower quality care from their primary care clinicians. Among patients with average or poor prognoses (i.e., patients with an elevated risk for persistent depression), those who said they received higher quality of depression care reported decreasing depressive symptoms. Rates of persistent depression were higher among patients who received the lowest quality care, compared with those who received the highest quality care.