Clinicians' Adherence to Practice Guidelines for Depression Could Be Better

September 20, 2007 — Primary care clinicians adhered well to only one third of practice guidelines for depression care, in a 2-year observational study of more than 1100 patients. The study reports that most clinicians identified patients with depression and provided initial treatment, but they often did not assess for the risk for suicide or provide long-term treatment follow-up. Better adherence to treatment guidelines was associated with a lower persistence of depressive symptoms.
The study, with lead author Kimberly A. Hepner, PhD, at RAND Corporation, in Santa Monica, California, is published in the September 4 issue of the Annals of Internal Medicine.
Senior study author Lisa V. Rubenstein, MD, at RAND, told Medscape that the "good news" is that most primary care clinicians recognized depression, talked to their patients about it, provided them with some education, and initiated treatment. The "not so good news" is that often practitioners did not assess their patients for alcohol use or suicide risk, or adjust treatment appropriately, or follow through on long-term treatment plans. She pointed out that only 46% of the patients completed their initial treatment of depression, and only 45% of low-risk patients with resolved depression had a trial discontinuation of depressant therapy.
"These findings are important for patients, since most cases of depression are diagnosed and treated in primary care settings," she said in a press release issued by RAND.
The group writes that few studies have assessed clinician adherence to practice guidelines for treatment of depression or looked at the relationship between guideline adherence and depression outcomes. They aimed to investigate this, using observational data gleaned from 3 clinical trials conducted from 1996 to 1998 as part of the Quality Improvement for Depression (QID) collaboration. In the QID studies, primary care clinicians were encouraged to adopt collaborative care guidelines for the treatment of depression.
The current study analyzed data from 1131 patients seen in 45 primary care practices in 13 states. Study sites ranged from small private care practices to large managed care organizations.
The investigators, with a panel of experts, developed 20 indicators of quality of care for depression, which were based on Agency for Healthcare Research and Quality guidelines for depression care. The researchers also looked at how adherence to guidelines was related to depressive symptoms and depression at 12, 18, and 24 months.
Good Detection and Initial Treatment of Depression, Suboptimal Follow-up Care
The primary care clinicians performed well in recognizing depression and monitoring initial treatment. All adhered to recommendations for basic patient education (100% adherence), and most adhered to the guidelines for attention to depression during the acute phase (88%), matching treatment to patient preferences and symptoms (84%), performing adequate 6-month follow-up with new antidepressant therapy (80%), providing appropriate treatment of comorbid anxiety or panic (80%), detecting depression (79%), and providing appropriate intensity of acute-phase treatment (73%).
Less than 60% of primary care clinicians adhered to guidelines about longer-term follow-up such as monitoring vulnerable patients (59% adherence), monitoring untreated patients (53%), ensuring that initial treatment was completed (46%), and discontinuing antidepressant therapy in low-risk patients (45%). Only 55% of psychotherapy provided by mental health specialists met quality indicators.
Few primary care clinicians met depression treatment guidelines for treating patients who were nonresponsive (38%), ensuring minimal care in elderly patients with depression (26%), assessing alcohol use (23%), and referring depressive patients with panic symptoms or alcohol use to a mental health specialist (30%). In a similar fashion, few clinicians met the recommended guidelines for management of suicidality: referral of patients who are suicidal to mental health specialists (36%), treatment of suicidal ideation (28%), and assessment of suicide (24%).
Quality of care for depression predicted depressive symptoms at 12, 18, and 24 months, and persistent depression at 18 and 24 months.
Limitations of the study include the fact that the data on depression is based on patients' self-reports, and changes in practice since 1998 may limit the generalizability of the findings, the study authors write.
The study authors summarize that they found "notable strengths" in how primary care clinicians recognize and respond to depressive symptoms. However, they add that they identified a pressing need for clinicians to "better detect and manage poorly responding patients, encourage collaboration with mental heath specialists, and increase treatment completion, especially among elderly patients."
Editorial: Study Will Help Inform Practice Decisions
In an accompanying editorial, Harlan M. Krumholz, MD, at Yale University School of Medicine in New Haven, Connecticut, writes that the research by Hepner and colleagues is well done. He notes that this is an example of the type of research needed to inform clinical decisions, because it demonstrates the link between adherence to guidelines and patient health outcomes in the real world.
Drs. Hepner and Rubenstein have disclosed no relevant financial relationships. The complete list of disclosures of the other study authors is available in the original article. Dr. Krumholz has disclosed no relevant financial relationships.
Ann Intern Med. 2007;147:320-329, 342-343.