Depression is frequently underdiagnosed and undertreated by primary care doctors, who see this problem often. The good news is that quality improvement (QI) programs in which mental health specialists collaborate with primary care doctors can substantially increase rates of antidepressant treatment, according to a new study supported in part by the Agency for Healthcare Research and Quality (HS08349). Jurgen Unutzer, M.D., M.P.H., and Kenneth B. Wells, M.D., M.P.H., of the University of California, Los Angeles, and their colleagues randomized 48 managed care primary care clinics to participate in either usual care (UC) or one of two QI programs: QI-Meds or QI-Therapy.
In the QI-Meds group, nurse specialists contacted patients taking antidepressants monthly for 6 or 12 months and helped primary care providers manage antidepressant medications. The nurse had a psychiatric expert available for consultation, and patients who preferred counseling were referred to psychotherapy options available to their practice (with regular co-pay levels). Patients in the QI-Therapy group could be referred to therapists, who provided individual or group cognitive behavioral therapy (CBT) for 12 to 16 sessions at a reduced copay. They also could receive medications from their regular primary care providers or see a nonstudy therapist with usual copayments. Clinics in the usual care group were mailed clinical practice guidelines on depression.
Patients enrolled in both QI programs had significantly higher rates of antidepressant use than those in the usual care group during the initial 6 months of the study (52 percent in the QI-Meds group, 40 percent in the QI-Therapy group, and 33 percent in the UC group). Patients in the QI-Meds group also had a greater reduction in long-term use of minor tranquilizers for up to 2 years (decline from 4.6 to 2.5 percent) compared with no reduction among patients in the other two groups (which remained at 4 to 6 or 7 percent), most likely due to the active followup of patients by a depression nurse specialist.
Details are in "Two-year effects of quality improvement programs on medication management for depression," by Dr. Unutzer, Lisa Rubenstein, M.D., M.S.P.H., Wayne J. Katon, M.D., and others, in the October 2001 Archives of General Psychiatry 58, pp. 935-942.