Two-year effects of quality improvement programs on medication management for depression.
BACKGROUND
Significant underuse of evidence-based treatments for depression persists in primary care. We examined the effects of 2 primary care-based quality improvement (QI) programs on medication management for depression.


METHODS
A total of 1356 patients with depressive symptoms (60% with depressive disorders and 40% with subthreshold depression) from 46 primary care practices in 6 nonacademic managed care organizations were enrolled in a randomized controlled trial of QI for depression. Clinics were randomized to usual care or to 1 of 2 QI programs that involved training of local experts who worked with patients' regular primary care providers (physicians and nurse practitioners) to improve care for depression. In the QI-medications program, depression nurse specialists provided patient education and assessment and followed up patients taking antidepressants for up to 12 months. In the QI-therapy program, depression nurse specialists provided patient education, assessment, and referral to study-trained psychotherapists.


RESULTS
Participants 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% in the QI-medications group, 40% in the QI-therapy group, and 33% in the usual care group). Patients in the QI-medications group had higher rates of antidepressant use and a reduction in long-term use of minor tranquilizers for up to 2 years, compared with patients in the QI-therapy or usual care group.


CONCLUSIONS
Quality improvement programs for depression in which mental health specialists collaborate with primary care providers can substantially increase rates of antidepressant treatment. Active follow-up by a depression nurse specialist in the QI-medications program was associated with longer-term increases in antidepressant use than in the QI model without such follow-up.
Unützer
J
J
Center for Health Services Research, Neuropsychiatric Institute, University of California, Los Angeles, 10920 Wilshire Blvd, Suite 300, Los Angeles, CA 90024, USA. unutzer@ucla.edu
Rubenstein
L
L
Katon
W J
WJ
Tang
L
L
Duan
N
N
Lagomasino
I T
IT
Wells
K B
KB
D000328:Adult; D014151:Anti-Anxiety Agents / Q000627:therapeutic use; D000928:Antidepressive Agents / Q000627:therapeutic use*; D003866:Depressive Disorder / Q000188:drug therapy* / Q000628:therapy; D019317:Evidence-Based Medicine / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D016015:Logistic Models; D008297:Male; D008329:Managed Care Programs / Q000458:organization & administration / Q000592:standards; D009722:Nurse Practitioners / Q000706:statistics & numerical data; D010353:Patient Education as Topic; D010821:Physicians, Family / Q000706:statistics & numerical data; D017410:Practice Guidelines as Topic; D011320:Primary Health Care / Q000379:methods / Q000592:standards*; D011613:Psychotherapy / Q000379:methods / Q000592:standards; D011785:Quality Assurance, Health Care / Q000379:methods*; D055502:Secondary Prevention; D016896:Treatment Outcome; D000078329:Workforce
D014151:Anti-Anxiety Agents; D000928:Antidepressive Agents