Targeting Quality Improvement Activities for Depression

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Original Research

Targeting Quality Improvement Activities for Depression

J Fam Pract. 2000 August;49(8):721-728

References

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All statistical analyses were completed using the SAS software, version 6.12 (SAS Inc, Cary, NC) or STATA, version 6.0 (Stata Corp, College Station, Tex).

Results

Enrollment

A total of 418 patients were identified as eligible for study participation; 397 were identified through PCP encounter forms and 21 through the psychiatrist’s encounter diagnoses. All patients identified by the psychiatrist had been referred by clinic PCPs.

Research staff requested permission from PCPs to contact the 389 patients identified as depressed on encounter forms. PCPs responded to 245 (63%) of these requests, with responding physicians giving permission for research staff to contact 200 patients (82%). Of those, 135 (68%) were contacted by telephone. Eighty-four (62%) agreed to participate. Eight patients who had been identified through PCP encounter forms were referred to the psychiatrist shortly after the PCP encounter. These 8 patients and the 21 patients identified through the psychiatrist were directly referred to the research staff for recruitment. Nineteen (66%) agreed to participate. Thus, a total of 103 patients (25% of all patients identified in the administrative data) were enrolled in our study ([Figure 1]).

Demographic characteristics of enrolled patients are summarized in [Table 1]. The majority were white (92%) and women (72%), with a mean age of 42 (±10) years.

Differences in Enrolled and Nonenrolled Patients

There were no significant differences between eligible patients who enrolled or did not enroll in sex, clinic site, or encounter diagnosis. Patients who enrolled in the study were slightly older than patients who did not enroll (mean age = 41.8 years and 39.4 years, respectively; t=-1.9; P=.054). Not surprisingly, because of the shorter recruitment pathway, patients seen by the psychiatrist were more likely to enroll than patients recruited only through PCP encounter forms (c2=27.3; P <.001).

Patient Diagnosis at Enrollment

Most patients identified as depressed by their PCPs in administrative data had a current depressive diagnosis on structured psychiatric interview (the PRIME-MD). Fifty-one percent had a primary diagnosis of current major depressive disorder (MDD); 31% had MDD in partial remission or recurrence; 3% had a dysthymic disorder; and 1% had a minor depression. Many patients (43%) had “double depression” with a primary diagnosis of MDD and a secondary diagnosis of dysthymia. Ten percent of the patients did not meet criteria for any PRIME-MD psychiatric diagnosis; however, these patients usually had significant depressive or anxiety symptoms on the SCL-25. Only 2 patients did not have a PRIME-MD psychiatric diagnosis or significant symptoms on the SCL-25 (scores Ž1.75).

Clinical Characteristics

Eighty-five percent of the patients had significant depressive symptoms and 69% had severe depressive symptoms on the SCL-25 (scores Ž1.75 or Ž2.10, respectively) at enrollment; 61% had significant anxiety symptoms. Almost all patients reported having at least 1 previous episode of a depressed or sad mood lasting 2 or more weeks; 77% reported 3 or more such episodes; and most patients (55%) indicated having such an episode by the age of 18. The majority of the patients (60%) reported being depressed most days during the previous 2 years. Although enrolled patients were fairly young, they reported having an average of 3 concurrent medical conditions at the time of enrollment. The majority (68%) also had more than one psychiatric diagnosis on the PRIME-MD.

Not surprisingly, patients had significant functional limitations on the SF-36. Their scores were significantly below United States norms on all 8 functional domains (P <.001 for all domains) and were comparable with the scores of MOS patients with depression ([Table 2]). The MOS sample included depressed patients seen by mental health providers (MHPs), in addition to those seen in primary care.

Previous Treatment

Enrolled patients reported high rates of previous treatment for psychiatric conditions; 83%, previous counseling or psychotherapy; 91%, previous medication for depression; and 16%, previous psychiatric hospitalization. Thirty-three percent reported that they were currently in treatment with a MHP in addition to their PCP. When patients seen by the psychiatrist in proximity to enrollment were excluded these figures did not greatly change: 86% reported previous counseling or psychotherapy; 94%, previous medication; and 28%, concurrent MHP treatment.

Patient Follow-Up

Eighty-three patients (81%) returned follow-up questionnaires between 5 and 12 months (median=7 months) after enrollment. Patients who returned questionnaires did not differ from nonreturners in age, sex, education, presence of a PRIME-MD diagnosis, baseline SCL depression scores, AUDIT scores, or most SF-36 domains. They did have lower physical functioning (t=2.15; P=.03) and lower vitality scores (t=2.62; P=.01) at baseline than nonreturners.

Patients continued to report high rates of treatment during the months following their identification in administrative data. Ninety percent had a medication prescribed; 35% were in concurrent treatment with a MHP at the time of follow-up; and 3% were hospitalized for depression during the follow-up period. When patients identified by the psychiatrist were excluded, 92% received medications, and 30% were in concurrent MHP treatment at follow-up.