"Usual care" for major depression in the 1990s: characteristics and expert-estimated outcomes.
OBJECTIVE
Motivated by the public health importance of major depression and calls to study the effectiveness of treatments frequently used in routine practice, the authors characterized the usual outpatient care of acute-phase major depression in a privately insured population as well as the effectiveness of this care.


METHODS
Upon identifying frequent antidepressant interventions from a large administrative database spanning the years 1991-1996, and after completing an exhaustive review of published efficacy evidence, the authors undertook a two-stage elicitation process. A panel of 10 experts estimated probabilities of symptom-based outcomes for 120 combinations of treatment, provider type, and patient characteristics seen in 9,054 depressive episodes. The 10 most frequent treatments, utilized in 90% of the episodes, are reported here.


RESULTS
A short course of psychotherapy delivered by specialists to healthy premenopausal women was the most frequent pattern of care. Only two prevalent treatments had adequate evidence. On the basis of expert-estimated rates of remission (Hamilton Depression Rating Scale score <8), response (score <13), and no change (score >/=18), three of the 10 most frequent treatments were highly effective, two were moderately effective, and five were minimally effective.


CONCLUSIONS
Although experts gave high marks to three commonly used treatments, the expert-estimated effectiveness for this particular system of care was quite modest. More research is needed on the outcomes associated with specific usual care practices as well as the contributors to ineffective care.
Horvitz-Lennon
Marcela
M
Department of Psychiatry, The Cambridge Hospital, Mass, USA. horvitz@hcp.med.harvard.edu
Normand
Sharon-Lise T
SL
Frank
Richard G
RG
Goldman
Howard H
HH
D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000553:Ambulatory Care / Q000592:standards; D000928:Antidepressive Agents / Q000627:therapeutic use*; D000929:Antidepressive Agents, Tricyclic / Q000627:therapeutic use; D001291:Attitude of Health Personnel; D003866:Depressive Disorder / Q000175:diagnosis / Q000523:psychology / Q000628:therapy*; D005104:Expert Testimony; D006302:Health Services Research / Q000706:statistics & numerical data*; D006801:Humans; D007344:Insurance Claim Reporting; D008094:Lithium / Q000627:therapeutic use; D015201:Meta-Analysis as Topic; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000706:statistics & numerical data*; D011569:Psychiatric Status Rating Scales; D011613:Psychotherapy / Q000379:methods*; D012108:Research Personnel; D017367:Selective Serotonin Reuptake Inhibitors / Q000627:therapeutic use; D012737:Sex Factors; D016896:Treatment Outcome
D000928:Antidepressive Agents; D000929:Antidepressive Agents, Tricyclic; D008094:Lithium; D017367:Selective Serotonin Reuptake Inhibitors