Treating Major Depression in Primary Care Practice

Abstract

The Depression Guideline Panel of the Agency for Health Care Policy and Research in 1993 published recommendations for treating major depression in primary care practice that were often based on studies of tertiary care psychiatric patients. We reviewed reports of randomized controlled trials in primary care settings published between 1992 and 1998. This evidence indicates that both antidepressant pharmacotherapy and time-limited depression-targeted psychotherapies are efficacious when transferred from psychiatric to primary care settings. In most cases, the choice between these treatments should depend on patient preference. Studies to date suggest that improving treatment of depression in primary care requires properly organized treatment programs, regular patient follow-up, monitoring of treatment adherence, and a prominent role for the mental health specialist as educator, consultant, and clinician for the more severely ill. Future research should focus on how guidelines are best implemented in routine practice, since conventional dissemination strategies have little impact.

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

“…For example, although encouraged by the investigators not to do so, study PCPs may have discussed our treatment advice with each other. Still, the recovery rate of UC patients was similar to that experienced by the UC cohort in a report from Schulberg et al 47 Patients may also have seen a PCP on the date of the PRIME-MD who was not their usual PCP, may have switched providers within the group practice, or may have seen another PCP, who had been randomized to a different study condition, when their own PCP was unavailable (e.g., on vacation). However, we found that just 8% of study patients saw a PCP other than their usual provider on the date of the PRIME-MD's administration, and switching PCPs while remaining within the group practice was uncommon (<10%).…”

Lessons from recent research on depression in primary care

“…The resulting treatment, however, was not sufficient to affect clinical outcomes. In contrast with results of these scree-ning interventions, programs of screening followed by systematic treatment have been clearly demonstrated to improve patient outcomes (Schulberg et al, 1996;Katzelnick et al, 2000). We conclude that increasing recognition of depression is a necessary, but not sufficient, step .toward providing effective depression treatment in primary care.…”

“…In a randomized trial among US urban primary care patients, Schulberg et al (1996) found that manual-based Interpersonal Psychotherapy was clearly superior to Epidemiologia e Psichiatria Sociale, 9, 3, 2000 usual primary care. In the Edinburgh Primary Care Depression Study, clinical improvement during cognitive therapy was similar to that seen in specialty trials (Scott & Freeman, 1992).…”

“…In contrast with these unsuccessful efforts directed at physicians, several patient-directed interventions have been proven superior to usual primary care management. Schulberg et al (1996) evaluated a program of guideline-based pharmacotherapy provided by specially trained primary care physicians following a structured protocol -including frequent visits and blood level monitoring. Clinical outcomes for patients in the structured pharmacotherapy program were clearly superior to those for patient receiving usual care (many of whom went untreated).…”

“…Some of the randomized trials cited earlier regarding the effectiveness of psychotherapy in primary care might also be viewed as studies of implementation. Schulberg et al (1996) found that 14% of patients randomized to Interpersonal Psychotherapy did not attend the initial session and an additional 31% dropped out prior to completing 16 sessions. Katon et al (1996) found that 6% of patients randomized to the psychologist Collaborative Care program did not attend the initial session and an additional 6% dropped out prior to Epidemiologia e Psichiatria Sociale, 9, 3, 2000 completion of four sessions.…”