Treating Depression in Primary Care: Practice Applications of Research Findings

,

Original Research

Treating Depression in Primary Care: Practice Applications of Research Findings

J Fam Pract. 2001 June;50(6):535-537

By

Herbert C. Schulberg, PhD

References

1. Depression Guideline Panel. Clinical practice guideline number 5: depression in primary care. Volume 2: treatment of major depression. Rockville, Md: US Department of Health and Human Services, Agency for Health Care Policy and Research; 1993. AHCPR publication no. 93-0550.

2. Schulberg H, Block M, Madonia M, Scott C, Lave J, Rodriguez E, Coulehan J. The “usual care” of major depression in primary care practice. Arch Fam Med 1997;61:334-39.

3. Lin E, Katon W, Simon G, et al. Achieving guidelines for the treatment of depression in primary care: is physician education enough? Med Care 1997;35:831-42.

4. American Psychiatric Association. Practice guideline for major depressive disorder In adults. Am J Psychiatry 1993;150 (suppl):S1-26.

5. American Psychiatric Association. Practice guideline for the treatment of patients with major depressive disorder (revision). Am J Psychiatry 2000;157 (suppl):1-45.

6. Schulberg H, Katon W, Simon G, Rush A. Treating major depression in primary care practice: an update of the AHCPR practice guidelines. Arch Gen Psychiatry 1998;55:1121-27.

7. Schulberg H, Pilkonis P, Houck P. The severity of major depression and choice of treatment in primary care practice. J Consult Clin Psychol 1998;66:932-38.

8. Wells K, Sherbourne C, Schoenbaum M, et al. Impact of disseminating quality improvement programs for depression in managed primary care: a randomized controlled trial. JAMA 2000;283:212-20.

9. Callahan C, Hendrie H, Dittus R, Brater C, Hui S, Tierney W. Improving treatment of late-life depression in primary care: a randomized clinical trial. J Am Geriatr Soc 1994;42:839-46.

10. Schulberg H, Magruder K, deGruy F. Major depression in primary medical care practice: research trends and future priorities. Gen Hosp Psychiatry 1996;18:395-406.

11. Brown C, Schulberg H, Sacco D, Perel J. Effectiveness of treatments for major depression in primary medical care practice: a post hoc analysis of outcomes for African American and white patients. J Affect Disord 1999;53:185-92.

12. Katzelnick D, Simon G, Pearson S, et al. Randomized trial of a depression management program in high utilizers of medical care. Arch Fam Med 2000;9:345-51.

13. Katon W, Von Korff M, Lin E, et al. Collaborative management to achieve treatment guidelines: impact on depression in primary care. JAMA 1995;273:1026-31.

14. Katon W, Robinson P, Von Korff M, Lin E, et al. A multifaceted intervention to improve treatment of depression in primary care. Arch Gen Psychiatry 1996;53:924-32.

15. Katon W, Von Korff M, Lin E, et al. A randomized trial of stepped collaborative care for primary care patients with persistent symptoms of depression. Arch Gen Psychiatry 1999;56:1109-15.

16. Simon G, Von Korff M, Rutter C, Wagner E. Randomised trial of monitoring, feedback, and management of care by telephone to improve treatment of depression in primary care. BMJ 2000;320:550-54.

17. Hunkeler E, Meresman J, Hargreaves W, et al. Efficacy of nurse telehealth care and peer support in augmenting treatment of depression in primary care. Arch Fam Med 2000;9:700-08.

18. Rubenstein L, Jackson-Triche M, Unutzer J, et al. Evidence-based care for depression in managed primary care practices. Health Aff 1999;18:89-105.

19. Schulberg H, Bryce C, Chism K, et al. Managing late-life depression in primary care practice: a case study of the health specialist’s role. Int J Geriatr Psychiatry. In press.

20. Rost K, Nutting P, Smith J, Werner J, Duan N. Improving depression outcomes in community primary care practice: a randomized trial. J Gen Intern Med. In press.

Much has been learned about how to effectively treat depressive disorders, but we remain less certain about how to deliver these treatments in routine primary care practice. Clinical guidelines point the way; their implementation, however, requires system change. Key issues in improving health care system capacities for effective depression care include: (1) enhancing continuity of care; (2) activating and empowering patients; (3) matching interventions to patients, including stepped care strategies; (4) improving treatment follow through; (5) monitoring clinical course outcomes; and (6) revising the structure of care so guideline-based care is feasible in routine patient care. (J Fam Pract 2001; 50:535-537)

The public health significance of depression as a prevalent disorder in primary care practice is well established, and the value of diagnosing this disorder accurately and treating it effectively is amply documented.¹ However, the benefits of treatment that are evident in research projects remain elusive in routine ambulatory practice. The outcomes of usual care are still significantly worse than those of standardized interventions carefully monitored by investigators.² Even the benefits of the latter dissipate when the research program is completed.³ The critical issue, therefore, is how to transfer efficacious treatments of depression from research settings to routine primary care practice in a manner that will permit them to flourish. Recommendations about steps pertinent to these processes are presented in this paper.

Guideline-Based Treatment Algorithms

The treatment algorithms recommended in 1993⁴ and 2000⁵ by the American Psychiatric Association and in 1993 by the Depression Guideline Panel of the Agency for Health Care Policy and Research (AHCPR)¹ are landmarks in the quest for optimal management of depressive disorders. Despite initial concerns about the effectiveness of treatments transferred from the psychiatric to the primary care sector, the guideline recommendations have proven valid and durable.⁶ It is clear that antidepressant medications produce a 60% recovery rate when prescribed within proper dosages and for adequate duration. Depression-specific time-limited psychotherapies achieve similar outcomes, even with patients experiencing moderate to severe symptomatology.⁷ Two principles emerge from this body of work: (1) major depression should not be treated with anxiolytic medications alone or with long-term psychotherapy; and (2) patient preference for a particular guideline-based treatment should be considered when it is clinically and practically feasible.

Despite this scientific progress and the extensive efforts to disseminate the AHCPR depression guidelines, few would assert that such efforts have significantly influenced routine primary care of depression. Thus, guidelines are a necessary but not sufficient condition for improving the treatment of depression; they constitute a blueprint for building rather than completing a structure. Accordingly, attention has shifted to the manner in which general principles of effective clinical care can be customized to the structural, fiscal, and sociodemographic characteristics of a particular primary care practice. The study by Wells and colleagues⁸ illustrates efforts to disseminate guidelines in the context of local circumstances and suggests that administrative support for state of the art practice can positively influence patient outcomes.

Moving Beyond the Guidelines

The dissemination of existing guidelines surely is warranted, but it should be recognized that guideline standard treatments are imperfect. Antidepressant medications and depression-specific psychotherapies produce only 70% to 75% recovery rates even in treatment-completer analyses.¹ Thus, altered strategies, like those that follow, are needed to help the significant minority of depressed patients who fail to recover.

Continunity of Care

Although case identification attracted much attention during the 1980s, various studies have demonstrated that an improved case finding by itself does not improve depression outcomes.^7,8 Inadequate attention has been directed to the fuller continuum of care on which screening and assessment are the starting points. Case identification must be followed by timely and targeted feedback to the primary care physician; appropriate treatment must be provided the patient; the patient’s clinical course must be actively monitored; and the treatment should be modified when clinically indicated. Each component of this continuum must be refined if the quality of care is to improve.

Activating and Empowering Patients

It is vital that patients with depression be actively involved in their treatment, since overcoming helplessness and hopelessness is central to recovery.¹ Strategies for activating and empowering these patients range from the educational to the social. The former include increasingly effective materials about the nature and course of mood disorders that use state of the art technologies to capture and maintain the patient’s interest. Self-care programs have been developed that permit patients to monitor beliefs and behaviors linked to clinical depression. Social strategies for activating and empowering patients are also becoming more commonplace.

Matching Patient to Intervention