title: Resolving disparities in antidepressant treatment and quality-of-life outcomes between uninsured and insured primary care patients with depression.
abstract: BACKGROUND
  Efforts to improve primary care depression treatment should penetrate to vulnerable uninsured populations.
  
  
  OBJECTIVE
  To assess a primary care intervention's impact on treatment and quality-of-life outcomes in uninsured and insured depressed patients during the acute treatment phase.
  
  
  METHODS
  Twelve community primary care practices were randomized to 'enhanced' (intervention) and usual care conditions. Physicians, nurses and administrative staff in enhanced care practices received training to improve detection and management of depression.
  
  
  METHODS
  In 1996 to 1997, 383 nonelderly depressed patients who were either uninsured or covered by private insurance/Medicaid were enrolled; 343 (89.6%) completed six-month follow-up.
  
  
  METHODS
  Adequate pharmacotherapy (>or=3 months of antidepressants at therapeutic doses); adequate psychotherapy (>or=8 counseling visits); improvement in mental-health-related-quality-of-life (MHQOL), assessed by Mental Component Summary scale for SF-36.
  
  
  RESULTS
  Multivariate results showed that 54.6% of uninsured enhanced care (UEC) patients received adequate pharmacotherapy, compared with 14.3% of uninsured usual care (UUC) patients (P = 0.0005); however, receipt of adequate psychotherapy was comparable between these two groups (18.2% UEC, 11.9% UUC; P = 0.42). Intervention effects on insured patients' treatment were modest to minimal. Among usual care patients, the insured had 5.4 points greater improvement in MHQOL at 6 months than the uninsured (12.4 points insured, 7.0 points uninsured; P = 0.02); however, among patients receiving the intervention, the insured and uninsured had comparable MHQOL improvement (12.3 points insured, 11.6 points uninsured; P = 0.76).
  
  
  CONCLUSIONS
  The intervention improved antidepressant treatment rates in uninsured patients and helped resolve quality-of-life outcome disparities observed between insured and uninsured patients receiving usual care.
authors.affiliation: Center for Studies in Family Medicine, Department of Family Medicine, University of Colorado Health Sciences Center, Denver 80220, USA. Jeff.Smith@uchsc.edu
authors.forename: J L
authors.initials: JL
authors.lastname: Smith
authors.forename: K M
authors.initials: KM
authors.lastname: Rost
authors.forename: P A
authors.initials: PA
authors.lastname: Nutting
authors.forename: C E
authors.initials: CE
authors.lastname: Elliott
mesh_terms: D000328:Adult; D000928:Antidepressive Agents / Q000627:therapeutic use; D016009:Chi-Square Distribution; D003376:Counseling; D003866:Depressive Disorder / Q000188:drug therapy / Q000451:nursing / Q000628:therapy*; D005260:Female; D006302:Health Services Research; D006801:Humans; D008297:Male; D017057:Medically Uninsured / Q000706:statistics & numerical data*; D008605:Mental Health Services / Q000191:economics / Q000592:standards*; D008875:Middle Aged; D015999:Multivariate Analysis; D010043:Outcome and Process Assessment, Health Care / Q000706:statistics & numerical data*; D011320:Primary Health Care / Q000191:economics / Q000592:standards*; D011788:Quality of Life; D012044:Regression Analysis; D017749:Total Quality Management / Q000379:methods*; D014481:United States
chemical_list: D000928:Antidepressive Agents