Texas Medication Algorithm Project, phase 3 (TMAP-3): rationale and study design.
BACKGROUND
Medication treatment algorithms may improve clinical outcomes, uniformity of treatment, quality of care, and efficiency. However, such benefits have never been evaluated for patients with severe, persistent mental illnesses. This study compared clinical and economic outcomes of an algorithm-driven disease management program (ALGO) with treatment-as-usual (TAU) for adults with DSM-IV schizophrenia (SCZ), bipolar disorder (BD), and major depressive disorder (MDD) treated in public mental health outpatient clinics in Texas.


CONCLUSIONS
The disorder-specific intervention ALGO included a consensually derived and feasibility-tested medication algorithm, a patient/family educational program, ongoing physician training and consultation, a uniform medical documentation system with routine assessment of symptoms and side effects at each clinic visit to guide ALGO implementation, and prompting by on-site clinical coordinators. A total of 19 clinics from 7 local authorities were matched by authority and urban status, such that 4 clinics each offered ALGO for only 1 disorder (SCZ, BD, or MDD). The remaining 7 TAU clinics offered no ALGO and thus served as controls (TAUnonALGO). To determine if ALGO for one disorder impacted care for another disorder within the same clinic ("culture effect"), additional TAU subjects were selected from 4 of the ALGO clinics offering ALGO for another disorder (TAUinALGO). Patient entry occurred over 13 months, beginning March 1998 and concluding with the final active patient visit in April 2000. Research outcomes assessed at baseline and periodically for at least 1 year included (1) symptoms, (2) functioning, (3) cognitive functioning (for SCZ), (4) medication side effects, (5) patient satisfaction, (6) physician satisfaction, (7) quality of life, (8) frequency of contacts with criminal justice and state welfare system, (9) mental health and medical service utilization and cost, and (10) alcohol and substance abuse and supplemental substance use information. Analyses were based on hierarchical linear models designed to test for initial changes and growth in differences between ALGO and TAU patients over time in this matched clinic design.
Rush
A John
AJ
Department of Psychiatry, University of Texas Southwestern Medical Center, Dallas, 75390-9086, USA. john.rush@utsouthwestern.edu
Crismon
M Lynn
ML
Kashner
T Michael
TM
Toprac
Marcia G
MG
Carmody
Thomas J
TJ
Trivedi
Madhukar H
MH
Suppes
Trisha
T
Miller
Alexander L
AL
Biggs
Melanie M
MM
Shores-Wilson
Kathy
K
Witte
Bradley P
BP
Shon
Steven P
SP
Rago
William V
WV
Altshuler
Kenneth Z
KZ
D000293:Adolescent; D000328:Adult; D000465:Algorithms; D001714:Bipolar Disorder / Q000188:drug therapy / Q000523:psychology; D003155:Community Mental Health Centers / Q000706:statistics & numerical data; D003866:Depressive Disorder / Q000188:drug therapy / Q000523:psychology; D005260:Female; D017048:Health Care Costs; D006302:Health Services Research / Q000379:methods*; D006801:Humans; D008297:Male; D001523:Mental Disorders / Q000188:drug therapy* / Q000523:psychology; D017063:Outcome Assessment, Health Care; D017410:Practice Guidelines as Topic; D011619:Psychotropic Drugs / Q000191:economics / Q000627:therapeutic use*; D011787:Quality of Health Care; D012107:Research Design; D012559:Schizophrenia / Q000188:drug therapy; D013781:Texas; D016896:Treatment Outcome
D011619:Psychotropic Drugs