The 'usual care' of major depression in primary care practice

Schulberg, Herbert C.; Block, Marian R.; Madonia, Michael J.; Scott, Chris; Lave, Judith R.; Rodríguez, Eric; Coulehan, John L.

doi:10.1001/archfami.6.4.334

Cited by 120 publications

(62 citation statements)

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“…We found no improvement in the depression recovery rate for our entire cohort, or any subgroup of it, when compared to previously reported outcomes for``usual care'' in primary care randomized clinical trials for treating major depression. 7,32,33,35 Varying the intensity of electronic feedback to study PCPs did have a statistically significant effect on the mean number of follow-up visits at 6 months. However, we found no differential impact on recovery or on various depression care process measures compared to the impact of simple screening and feedback of the diagnosis alone.…”

Section: Discussionmentioning

confidence: 87%

“…These measures were advocated by the AHCPR's Depression Panel's treatment recommendations for intensity of clinical follow-up (e.g., 3 or more contacts within a 90-day period), 26 and are similar to those recently reported by other effectiveness trials designed to improve the quality of primary care for major depression. 7,32,33 The type of depression-specific treatment recommended to the patient by the PCP and the number and timing of follow-up visits were abstracted directly from data entered into the EMR. Two trained nurses who were blinded to the randomization status of a patient's PCP reviewed each study patient's medical records.…”

Section: Patient Assessmentmentioning

confidence: 99%

“…5,6 Unfortunately, poorer than expected outcomes are consistently reported for depressed patients treated by primary care physicians (PCPs). 7,8 In part, this may be related to PCPs' low rate of recognizing depression and/or a lack of awareness about and failure to implement effective, guideline-based interventions. 9,10 With the aim of improving the quality of medical care in routine practice, automated, interactive, data-driven electronic medical record (EMR) systems are currently in use that can prompt physicians to perform empirically validated patient-specific actions according to programmable rules.…”

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confidence: 99%

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A randomized trial using computerized decision support to improve treatment of major depression in primary care

et al. 2002

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Section: Discussionmentioning

confidence: 87%

Section: Patient Assessmentmentioning

confidence: 99%

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confidence: 99%

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A randomized trial using computerized decision support to improve treatment of major depression in primary care

et al. 2002

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“…6 Thus, it is of concern that primary care physicians often prescribe these drugs at dosages too low to achieve therapeutic benefits and for periods too brief to prevent relapse. [7][8][9][10][11] The rationale guiding prescribing practices of primary care physicians has been the subject of much speculation. One possibility for why antidepressant medications, particularly of the tricyclic type, are prescribed at subtherapeutic dosages is that they produce disturbing side effects for patients who already are highly sensitive to the psychological and somatic symptoms associated with their depressive illness.…”

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confidence: 99%

Symptoms of Major Depression and Tricyclic Side Effects in Primary Care Patients

1997

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OBJECTIVE:To examine the prevalence and course of symptoms resembling side effects of tricyclic antidepressants among primary care patients experiencing major depression and receiving nortriptyline pharmacotherapy. DESIGN:Prospective cohort study. PATIENTS: Seventy-five patients meeting DSM-III-R criteria for a current major depression.SETTING: Four Pittsburgh (Pa.) ambulatory health centers affiliated with residency programs. MEASUREMENTS AND MAIN RESULTS:Symptoms resembling tricyclic side effects were assessed at baseline and at monthly intervals using the Somatic Symptoms Checklist. The Hamilton Rating Scale for Depression and Diagnostic Interview Schedule were used to assess depressive severity and history of generalized anxiety or panic disorder, respectively. Symptoms resembling tricyclic side effects, including thirst (54%), palpitations (51%), and dry mouth (48%), were commonly experienced before commencing pharmacotherapy. Patients with severe depressive episodes and those with a history of an anxiety or panic disorder had significantly more physical symptoms than those with milder episodes of depression and were more likely to drop out of care ( n ‫؍‬ 25) before completing the acute phase of pharmacotherapy. Patients who completed the acute phase of pharmacotherapy and those who entered its continuation phase ( n ‫؍‬ 43) experienced significant reductions in many depressive and physical symptoms ( p Ͻ .001). CONCLUSIONS:Symptoms resembling tricyclic side effects are common among depressed primary care patients before beginning pharmacotherapy and generally remit with the depressive episode. Better awareness of major depression's somatic effects and the consequences of therapy could result in better management of both physicians' and patents' expectations regarding antidepressant pharmacotherapy. ajor depression is experienced by 6% to 8% of primary care patients, 1 and is associated with significant psychic distress and functional disability. 2-5 A metaanalysis of randomized clinical trials by the Depression Guideline Panel of the Agency For Health Care Policy and Research concluded, however, that most episodes of this disorder can be resolved efficaciously when antidepressant medications are prescribed at proper dosages and for adequate durations. 6 Thus, it is of concern that primary care physicians often prescribe these drugs at dosages too low to achieve therapeutic benefits and for periods too brief to prevent relapse. [7][8][9][10][11] The rationale guiding prescribing practices of primary care physicians has been the subject of much speculation. One possibility for why antidepressant medications, particularly of the tricyclic type, are prescribed at subtherapeutic dosages is that they produce disturbing side effects for patients who already are highly sensitive to the psychological and somatic symptoms associated with their depressive illness. Medication-induced discomforts such as thirst, dry mouth, palpitations, and dizziness, which are most marked early in the course of treatment, could lead ...

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“…The disparity between 'best practice' and actual practice in the treatment of depression has been well documented (Bauer, 2002;Crown et al, 2001;Schulberg et al, 1997). Ornstein et al (2000), in a study of 389 primary care physicians, also found that there is a wide variation in prescribing antidepressants in primary care.…”

Section: Commentmentioning

confidence: 99%

Maximizing the Adequacy of Medication Treatment in Controlled Trials and Clinical Practice: STAR*D Measurement-Based Care

Trivedi

Rush

Gaynes

et al. 2007

Neuropsychopharmacol

145

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The success of well-developed protocols has been limited in real-world practice, where even effective strategies have not been sufficient to meet patient needs in routine clinical care owing to Axis I and III comorbidities. The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) trial required that antidepressant medication treatment be optimal regarding dose and duration, yet accommodate flexibility to ensure safety given the wide range of comorbid general medical and psychiatric disorders allowed in the trial. The objective of this study was to develop a measurement-based care (MBC) approach and an automated feedback system to ensure adequate and safe antidepressant treatment delivery suitable for both clinical research and routine practice. Ratings of depressive symptom severity and side-effect frequency, intensity, and burden were obtained at each treatment visit using the MBC system that (1) guided medication dose adjustments and treatment duration, (2) documented clinician adherence to treatment recommendations, and (3) provided prompt feedback to clinicians to enhance appropriate treatment decisions. Physician adherence to protocol-specific treatment was monitored based on measured symptoms and side-effect burden, and dose and duration of antidepressant at each critical decision point during the acute phase treatment of major depression. Feedback was provided at the point of care by the clinical coordinators, assisted by Web-based reports following each treatment visit. On the basis of the first treatment step with citalopram, over 85% of treatment encounters had appropriate fidelity to recommendations. Most deviations from treatment recommendations occurred late in treatment and were often justifiable. MBC proved to be feasible and effective in busy primary and psychiatric settings. This approach signals a paradigm shift toward the use of measurement-based clinical decisions, both at the point of care and following each visit, to deliver optimal pharmacotherapy for depression.

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The 'usual care' of major depression in primary care practice

Cited by 120 publications

References 1 publication

A randomized trial using computerized decision support to improve treatment of major depression in primary care

A randomized trial using computerized decision support to improve treatment of major depression in primary care

Symptoms of Major Depression and Tricyclic Side Effects in Primary Care Patients

Maximizing the Adequacy of Medication Treatment in Controlled Trials and Clinical Practice: STAR*D Measurement-Based Care

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